Aug 27 2009
In all of the discussion about health care reform today, it seems to me that we are still stuck in our thinking of trying to make a perverse system more “efficient.” This is like trying to get out of a hole by digging faster, cheeper, deeper. We have to face the fact that we are despite the overwhelmingly positive goals of individuals drawn to the healing professions, we are now dealing with a Disease Industrial Complex whose growth threatens to swamp our GDP and damage society far beyond that of the Military Industrial Complex that Eisenhower warned us about.
I was involved with an effort in health care reform called Vvaleo with Dee Hock, David Cooperrider, Rob Kolodner, Tom Garthwaite, Ken Kizer, and others. It was a wonderful learning experience, with lots of counter examples to cherish. My chief Aha! (or duhhh! ) was that gathering all the stakeholders in a perversely incentivized industry sector and asking them to self organize into a more efficient organization is simply not going to work. Who is going to offer to get off a gravy train to allow the others to continue without them in the name of “efficiency?”
I wrote a 1995 paper with Heather Wood Ion based on Jonas Salk’s vision for health care reform called for Creating an Epidemic of Health – the last paper he reviewed before his death. I had some 1999 workshops on the topic, and it became the catch-phrase of the Vvaleo effort. Since then the web has appeared, and we know a lot more about viral processes. Here’s a conversation I had with UCSD’s James Fowler and his analysis of the Framingham Heart Study data for network effects of health and happiness.
Martin Seligman, a leader in the discipline of positive psychology, has successfully flipped people’s thinking to a new balance between “positive” and “deficit” discourse in psychology, introducing an ontology of the positive in Character Strengths and Virtues to balance the disease-based model in Diagnostic and Statistical Manual of Mental Disorders.
Flipping our thinking from a disease-first to a health-first model is not asking for a trip to California lala land thinking – it is a fundamental recognition that fixing problems and amplifying resilience, adaptation, and coping are two very different things. If a toaster cord breaks, we can fix it by replacing the cord. If a cat loses its tail, trying to reattach it is not likely to be successful. The cat can still be a cat without its tail.
Toasters are systems in which the whole is equal to the sum of its parts. Understanding what’s wrong with a toaster is and how it works are equivalent forms of knowledge. However, cats are systems in which the whole is greater than the sum of its parts. Understanding a dissected cat and understanding a live cat are two very different ways of understanding this. Fixing what’s wrong with the dissected cat is not going to fix the whole cat.
So it is today with our health care system. We are applying toaster-like thinking to a cat-like problems. The whole of our health care system is far greater than any of the parts, and operates at a level far beyond anything we can appreciate with the endless catalogs of disease-fixes.
It is encouraging to see the Department of Health and Human Services’ Healthy People 2020 initiative. I hope that it takes more radical outlook than simply “preventative.”
Here’s some more of my writing on the subject in: Health People: Person-Centered, Outcomes-Driven, Virtual Health Systems I’m ashamed that this is in such an expensive, copyrighted book, so here is the opening chapter I wrote with Rob Kolodner, former head of national health IT for HHS, called Inverted Perspectives: Triggering Change.
Our current perspective is that health is what the enterprise does to the patient. If we just add up all the things doctors do to patients, then we can get a grip on expenses, add things up to maximize quality of life years, and all is good. We just need to figure out what parts of the toaster to fix, get some MBAs to do some linear programming analysis, and we have the perfect health factory with sick people coming in and healthy people coming out the other end.
But there is something wrong with this perspective. People aren’t toasters, and hospitals aren’t factories. Things that don’t happen, never triggering transactions from which outcome analyses can be performed, are the most significant part of the health process. There is no way to count the things that count the most to a happy, healthful life.