The Ecology of Health Care: in Sickness and in Health

A swamp or quagmire

Health care in America is in a horrible mess, the lair of what complexity theorists call “wicked problems”. A recent article in Wired magazine described it as “a morass, a quagmire, a slough of policy despond”. As every one knows, the US spends almost twice as much on health care as any other country (as a percentage of GNP) but with less satisfactory results. Classical indicators like infant mortality are far too high and show little sign of improvement. It is estimated that at least 30% of the resources spent on health care are wasted. And the situation is going to get worse as the population ages.

For the past thirty years I have been working in the belief that the best way to sort out complex messes is to use a theory of complex systems. Unfortunately complexity theory and systems thinking are abstract disciplines and can be as difficult to understand as the organizational messes one is trying to deal with! This is where the ecological perspective and analogical thinking come in. I use theories of complex systems to discipline analogies drawn between complex natural systems and human organizations. This way one gets all the benefits of systems thinking without having to grapple with learning a new set of abstract concepts.  This past month I have been working on the application of this approach to a US regional health care system and this past weekend I delivered a big presentation to their top people based upon my work.

Grappling with Change

The sheer complexity of the change faced by any health system is mind-boggling and the ecological approach as contained in The New Ecology of Leadership is incredibly helpful in teasing out the components in space and time. I always begin with the focal system itself – the organization one is looking at. I like to get as many different perspectives as possible. In this case I interviewed the CEO and several thought leaders on the board of governors and among the trustees to understand the issues. I also interviewed a retired CEO, who had taken the organization through its previous iteration. I read dozens of business cases on health care systems and reviewed state and local press articles. The objective was to create a compressed learning history for the organization that can be communicated and shared visually. I use a mindmap to organize everything for myself and then put the history of the organization on my ecocycle model. It shows where the organization is positioned in space and time. One can see the continuities from the past and the contingencies from the future. One can see competitors and how they are positioned. One can see the cycle of medical technology running “underneath” the organization. This is the cycle that sees the continual invention and discovery of new, more expensive treatments and techniques and the steady commoditization of old ones. This is what is driving the basic “inpatient-to-outpatient” dynamic, which results in the need for more and more patients to be treated without admission to a hospital.

“Above” the focal organization are the systems that constrain it. Prominent among these are the state and federal governments. The federal level is in turmoil because of the promulgation of Obamacare, even the broad impact of which is uncertain. As if this was not enough there is the ambiguity of the Presidential election and the fate of health care after that. At the state level, regulation is becoming increasingly important and obtrusive with capitation of payments and tiered health plans that limit consumer choice. With regulation still developing, everyone is attempting to get the inside track on what’s happening and to influence legislation, if they can. All this change is taking place against a backdrop of an aging population, many of who do not have healthy lifestyles.

Responding to Change

Organizationally the health care industry is responding to this change by integrating vertically. Individual hospitals that used to compete with each other have been joining together to form hospital groups; these hospital groups are now combining with physician groups and specialist acute care centers to form regional ecosystems. These ecosystems are beginning to creep across state boundaries and will probably grow into national ecosystems, perhaps like large retailers. Unlike large retailers, however, these health systems have to treat people as close to their homes as possible and preferably in them. It is now broadly recognized that hospitals themselves are the most expensive and the most dangerous environment in which to handle sick people.

The challenges for hospital administrators are huge. Not-for-profits are being threatened by for-profit groups, some of which are funded by private equity groups who sense that big money is to be made in what they call “industry rollups”. They are buying up hospitals and physician groups aggressively and playing all kinds of games with the coding systems used to bill for their services. They are also doing their best to keep the high margin well-insured cases for themselves and hand the rest off onto others. As if the organizational challenges were not enough, a hard, dispassionate strategic approach to this process will not work for long without equal attention being paid to the “soft” side of the organization. Organizations need plans to attract resources from suppliers, but they also need narratives – compelling stories of communities of care. This is particularly true of the physicians and their groups, who see their primary function as caring for people, rather than making money. It is also true of the multitude of hospital workers from janitors and receptionists to nurses and the physicians themselves, who collectively determine the all-important patient experience.

This is where the dynamic, ecological perspective really come into its own, giving many more insights into issues than the conventional approaches that are usually based on static, economic frameworks.  The sweet zone in particular, with the zig-zag ladder running between means and ends, and using plans and narratives, maps and compasses, is an enormously helpful perspective.  Several participants in the conference told me that the customized version of this slide alone was “worth the price of admission”.

The zigzag ladder in the sweet zone

From Sickness to Wellness

Health systems around the world know that they have to move from curing the sick to keeping people well. With its emphasis on community and economy, the ecological perspective is helpful here too. Virtuous habits are best cultivated in a social context and the ecological perspective raises all the right questions. It assumes that people act their way into better ways of thinking, rather than the other way around. Certainly lectures don’t work.  The question is how do we give people immersive experiences that will allow them to develop healthy, virtuous habits? What community-based organizations can do this and where do we see it happening already? Without good questions like these, one can’t have good answers and an ecological perspective on health care really helps generate them. Swamps and quagmires can be dangerous but they can also be fertile generators of new life!

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