Yaneer Bar-Yam, Improving the effectiveness of health care and public health: A multi-scale complex systems analysis, American Journal of Public Health 96(3): 459-466 (2006).
The US health care system is struggling with a mismatch between the large, simple (low-information) financial flow and the complex (high-information) treatment of individual patients. Efforts to implement cost controls and industrial efficiency that are appropriate for repetitive tasks but not high-complexity tasks lead to poor quality of care.
Multiscale complex systems analysis suggests that an important step toward relieving this structural problem is a separation of responsibility for 2 distinct types of tasks: medical care of individual patients and prevention/population health. These distinct tasks require qualitatively different organizational structures. The current use of care providers and organizations for both purposes leads to compromises in organizational process that adversely affect the ability of health care organizations to provide either individual or prevention/population services.
Thus, the overall system can be dramatically improved by establishing 2 separate but linked systems with distinct organizational forms: (a) a high-efficiency system performing large-scale repetitive tasks such as screening tests, inoculations, and generic health care, and (b) a high-complexity system treating complex medical problems of individual patients.
Report Demonstrates how to Cut Health Care Costs without Sacrificing Quality
Health care costs can be reined in and quality can be improved by separating population-based and preventive care from individual care of ill patients, reports a new article in the American Journal of Public Health. Care providers can make immunizations, screening and some forms of routine treatment much more efficient and cost-effective without sacrificing quality, and doing so would give doctors more time and resources to devote to complex individualized care. According to the article, the current top-down cost control measures imposed by insurers are ineffective and even harmful. The policies made by insurers influence how doctors can treat their patients, and often have unforeseen negative impact on the quality of care. Decisions made by physicians should be based upon medical needs. However, the way doctors are paid affects how they work, how much time and attention they give to patients, and ultimately what decisions they make.
The author of the article, Professor Yaneer Bar-Yam notes that, ironically, in many parts of the country efforts to cut costs by the insurers often lead to a vicious cycle, where the first services to be cut are preventive care programs. While this saves money in the short term, the elimination of these programs ultimately has a detrimental impact on overall health and raises costs in the long term. Because this has been going on for some time, today we are paying dearly for cuts in prevention that were made years ago.
What we need, according to Bar-Yam, is to separate the complex tasks of individualized medical care from the large-scale, simple repetitive tasks of preventive and population-based care such as immunizations and screening tests. This frees up doctors to provide the best possible care for individual patients, while insurers can use top-down methods to make simple preventive measures as efficient as possible. “The overall system can be dramatically improved,” Bar-Yam concludes, “by establishing two separate but linked systems with distinct forms and organizational objectives, one to deal efficiently with the large scale, repetitive, population based care, and the other to address effectively the complex tasks of attending to the needs of medically ill patients."
There are much more general insights in the article that apply more broadly. "In order for an organization to be effective," Bar-Yam writes "there must be a match between the functional capabilities of organization and the complexity of the task to be performed."
The proposed new public health component (left box) provides efficient population-based care (+) to its customers, including employers (as shown by the upper left arrows), private insurers, government agencies, or individuals (similar to high-efficiency fast food and other mass market products or services); arrows are not shown for the latter cases. Moreover, it refers (gray arrows) those who need individualized care to the other part of the healthcare system that is focused on individualized care.