#Monopoly is an interesting game – you can bankrupt other players, build hotels on properties they’ll never land on, and pretend it’s all in the name of “fun!”
Unfortunately, that is a reality in quite a few business spaces in the real world too!
For e.g., if I look at U.S. Healthcare, it seems that the game (of Monopoly!) that’s been underway for quite some time doesn’t seem to align with any clear rules – each stakeholder is fighting all over the board, one or more of them constantly change the game without seeing the long-term consequences (and nobody cares for how the system functions as a whole)!
Fragmentation and inefficiencies persist and thrive while accountabilities blur, and frustrations and #burnout rise! Meanwhile, the only thing getting "fixed" is the price tag!
Problem is……U.S. Healthcare (like most global systems of #healthcare) is an interconnected system where all parts (Payers, #Providers, Policymakers, and #Patients – the four Ps of the Value Chain in Healthcare Systems) influence each other! So, when shots get fired and specific sets of players get accused point blank, or blanket rollback of coverage gets announced, its time to address the issues as a System rather than (as) power centres fencing out on “Guilty vs Accused!”
That’s not an easy switch…..and the government MUST play its role in earnest……and that doesn’t seem to be happening especially with #DOGE, #POTUS and related taskmasters at odds with not just the patients and the value chain but even with each other!
Maybe it is time for the elected powerful to look into the Healthcare system using the lens of Systems Thinking!
Firstly, because Systems Thinking teaches us that true reform must look at the whole system and recognize the interdependencies between all its components—otherwise, its just one meaningless roll of dice (rules?) after another which keeps getting the same expensive results! In short, trying to “fix” healthcare in isolated parts will just build power struggles with momentary handing out of “Get Out of Jail Free” cards—until the system collapses under the weight of its own complexity!
Secondly, if one looks at Systems Thinking for Health System Improvement, there are seven principles to bear in Mind.
Further, IMO, if one looks to create a natural sequence or flow based on how these principles influence each other to create a theme of Cause and Effect, it would probably lead to them being numbered as you see below.
Please note that in the list below, I put in the implications for clarity and the later part as my thoughts on how they could potentially fit in context of the current state of U.S. Healthcare.
- Definition: Understanding the past is crucial to comprehending how a health system functions and how it evolved over time. The history of policies, decisions, and previous events shapes the current structure and behavior of the system.
- Implication: Knowing the history of the system helps predict future behaviors and outcomes. By recognizing patterns and past influences, we can better anticipate challenges and design effective interventions.
- Potential Context for U.S. Healthcare: The U.S. healthcare system's current structure, shaped by historical decisions like employer-based insurance and segmented public programs (Medicare, Medicaid), has led to inefficiencies and inequities. A solution is to learn from these past decisions by integrating public and private sectors more effectively. This could mean expanding public options like Medicare or simplifying the insurance market to reduce fragmentation, allowing more seamless access to care and coverage.
2. The Feedback Principle
- Definition: Feedback loops within the system shape its ongoing behavior. Positive feedback loops can reinforce certain trends, while negative feedback loops can stabilize or correct imbalances.
- Implication: The feedback principle drives ongoing change. Interventions in the system will have lasting impacts, either accelerating or mitigating trends, which must be considered when planning any modifications or reforms.
- Potential Context for U.S. Healthcare: In the U.S. system, rising healthcare costs create a feedback loop where higher premiums and out-of-pocket expenses limit access to care, worsening health outcomes. A potential solution is to focus on cost-reduction strategies such as implementing value-based care models, where providers are incentivized for delivering high-quality care at lower costs. Reducing unnecessary tests and procedures could break the cycle of escalating healthcare costs while improving overall patient health.
3. The Holistic Principle
- Definition: The health system behaves as a whole, with its components (e.g., hospitals, healthcare providers, policies, and patients) interacting in complex ways. The behavior of the system emerges from these interactions, not just from individual parts.
- Implication: To understand and improve the system, one must look at it in its entirety. Isolated changes may have unintended consequences elsewhere in the system, so comprehensive, integrated approaches are necessary.
- Potential Context for U.S. Healthcare: The U.S. healthcare system's fragmentation leads to inefficiencies. A holistic solution could involve the integration of care, where healthcare providers (hospitals, primary care, specialists) work together in coordinated networks, improving the continuity of care for patients. Programs like Accountable Care Organizations (ACOs), which incentivize cooperation among healthcare providers, could be expanded to ensure comprehensive, patient-centred care while reducing unnecessary services and costs.
- Definition: The health system resists rapid change due to slow-moving resources and established patterns. This resistance stems from the accumulation of stock (e.g., financial, human, infrastructure) that cannot be easily adjusted.
- Implication: Any proposed changes must account for the system's inertia. Transformations will take time, and efforts to drive change need to be gradual and sustainable, with recognition that the system resists swift adjustments.
- Potential Context for U.S. Healthcare: The U.S. healthcare system has long been entrenched with complex insurance structures and established industry practices. A solution is to start with incremental reforms that build momentum, such as expanding public options like Medicare for All or introducing a public option that can coexist with private insurance. These changes could offer a gradual transition toward a more unified system, while simultaneously addressing gaps in coverage and improving health equity.
5. The Surprise Principle
- Definition: Due to the complexity of the system, actions within the health system often lead to both expected and unexpected outcomes. These surprises are frequently the result of delayed effects or the unpredictable interactions between system components.
- Implication: Policymakers and health system designers must plan for uncertainty and unexpected consequences. It is important to monitor outcomes and be flexible in responding to unforeseen developments.
- Potential Context for U.S. Healthcare: In the U.S., attempts to reform the system often lead to unintended outcomes, such as the rise of high-deductible plans or network restrictions under the Affordable Care Act. A potential solution is to integrate ongoing evaluation and adaptive policy-making into reform efforts. Policymakers should implement pilot programs, collect real-time data on health outcomes, and remain open to adjusting policies as they learn from the real-world effects of their decisions.
- Definition: No individual or organization can see the entire health system in its entirety. Each actor’s perspective is limited by their role, expertise, or area of focus, leading to a fragmented understanding of the system.
- Implication: Decisions should be made with the understanding that the full complexity of the system may not be apparent to any one actor. This emphasizes the need for collaboration, input from diverse perspectives, and systems thinking to improve the overall functioning.
- Potential Context for U.S. Healthcare: The fragmented nature of U.S. healthcare, where different actors—hospitals, insurance companies, policymakers—make decisions in isolation, creates inefficiencies. A solution is to foster (enforce?) greater collaboration across these sectors, encouraging shared decision-making and data sharing. One way this could be implemented is through the expansion of multi-stakeholder committees or task forces, bringing together insurers, health providers, and government agencies to develop policies that work cohesively across the system.
7. The Collaboration Principle
- Definition: Given the complexity and interdependence of the system, collaboration across sectors and disciplines is essential. No single individual or organization can fully manage or improve the system on their own.
- Implication: Addressing health system challenges requires collective efforts. Collaboration between healthcare providers, policymakers, communities, and other stakeholders is crucial for effective system improvement.
- Potential Context for U.S. Healthcare: As stated above, to address the challenges in the U.S. healthcare system, collaboration across the private and public sectors is essential - because the end purpose of U.S. Healthcare (as a system) is to improve outcomes for anyone that the system is designed to serve (economics notwithstanding). One solution is the development of public-private partnerships to address healthcare Access, Equity, and Innovation. These partnerships can focus on areas like technology adoption for better health records, health data sharing for improved decision-making, and collaborative community health initiatives with suitable doses of #AI thrown in! By pooling resources and expertise, one can drive reforms that improve efficiency, reduce costs, and create a more inclusive healthcare system.
Closing thoughts: By aligning Systems Thinking principles with solutions for U.S. healthcare, one can (hope to) begin to craft a more cohesive, sustainable, and patient-centred system.
The focus should be on creating integrated, adaptable, and collaborative efforts to overcome the current fragmentation and inefficiencies, with a strong emphasis on long-term, gradual reforms that draw on lessons from the past.
It would be worth noting that head-on collision with stakeholders (including Payers, Providers and Patients) is likely to violate Principle #7, leading to outcomes aligned with Principle #5 because head-on collisions would likely be driven by Principle #6 (which is a sure source of bad judgment if not accounted for) bringing into effect Principle #4 (but not in a good way)!
Oh, and that would also point to how decisionmakers did not heed Principle #1 or Principle #2 probably because they couldn’t accept Principle #3! If that were true, it be bad… for the system, I mean!
(P.S. With Musk’s DOGE (which seems to emphasize government efficiency), and President Trump’s healthcare reforms (which seem to prioritize market-driven solutions) operating on fundamentally different principles, synergistic movement is both hard and crucial…..because the challenges facing U.S. Healthcare are not amenable to a linear equation (or solution) where Reducing bureaucracy (or Coverage) = improving Efficiency (or Outcomes)! Reforms MUST aspire to resolve health disparities and tackle Health Equity issues that affect vulnerable populations to produce any meaningful change!)
(P.P.S. In places, I have chosen "we" over "one".... I guess past life has a way of reinforcing itself in a narrative! :) )
