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Current Reform Efforts Are Not Sustainable

by Michael Rohwer

Healthcare reform has been a persistent failure. After four decades, the future of healthcare remains economically unsustainable. The physician workforce is demoralized and at the point of leaving. Reform’s high volume of self-justified changes and activities offers little or no real value to consumers, providers, or society.

During the recent recession, the growth of per-capita health spending fell to match the overall growth of the economy. That good news is not projected to last. According to the CMS Office of the Actuary National Health Statistics Group, the United States’ already highest-in-the-world healthcare spending percentage is projected to consume 19.3% of GDP by 2023—an increase of 2.1% from 2012 .

Physicians and other practitioners are leaving the profession. The Association of American Medical Colleges estimates that the United States will be 45,000 primary-care doctors short in 2020; this is up from a 9,000 shortfall in 2010 . A 2012 Urban Institute study found that 30% of those aged 35 to 49 plan on leaving their practice within five years; the number jumped to 52% for those over 50. A 2014 Physician’s Foundation-commissioned survey found 56% of physicians describe their morale as negative .

The Affordable Care Act, the latest major reform, significantly expands coverage and that’s a good thing. One benefit is that this allows more people to avoid medical bankruptcy. But while the cost of care is being redistributed a little, it remains unsustainable.

I believe we have not attained the progress we need because the fixes are designed for the healthcare system we think we have, and not the healthcare system we actually have.

The current approach is traditional management based on the belief that efficiency will come from industrialization: Large integrated delivery systems are intended to focus accountability and reduce fragmentation; top-down evidence-based standards and guidelines are expected to reduce the variability of clinical care; high-level financial alignment is expected to enable all parties to meet financial objectives; practitioners are expected to take care of patients because that is essential for the success of the organization. These are not bad approaches and might work well if healthcare were a factory having inputs, outputs, and processes that behave predictably.

Healthcare, however, is a Complex Adaptive System . That means it will respond in a non-linear fashion and it will be unpredictable. Thus industrialization (in which known actions produce a predictive result) can be expected to create multiple unintended consequences and little real benefit.

Complex Systems are a fundamental, integral part of nature—part of its DNA. They cannot be avoided, and must be understood and embraced if we are to attain sustainable results. What I am suggesting is that management of Complex Systems is very different from traditional industrialization. We cannot create viable improvement until management aligns with the reality and nature of natural processes.

The application of Complexity Science to healthcare is a big subject. This is the first in a series of articles designed to explain and propose change, to stimulate rethinking in how we view and do business. Next: What “Complexity” Is