Complexity in healthcare

“Out of intense complexities, intense simplicities emerge”

- Winston Churchill

Why is healthcare so complex? Why is transformation in healthcare so hard to achieve?

The great healthcare policy mind, Dr. Paul Starr, has written extensively about healthcare. If you are not familiar with Dr. Starr’s work, please check out any of his wonderful offerings. While being somewhat biased on his work, I would encourage anyone new to healthcare policy and Dr. Starr to start with his Pulitzer winning book “The Social Transformation of American Medicine“. However, it is Dr. Starr’s most recent offering I wish to highlight here to kick off today’s post. In “Remedy and Reaction,” Dr. Starr outlines some reasons why there is complexity in healthcare and why it is hard to change:

1. High health-care costs equal high health-care incomes, which explains why special interest groups resist policies that reduce spending;
2. Those who are reasonably well-protected want to maintain the status quo;
3. The complexity of the healthcare insurance system makes it difficult for Americans to understand their own interests; and,
4. Ongoing distrust of politicians and government.

In a fascinating article entitled, “The challenge of complexity in healthcare“, Drs. Plsek and Greenhalgh write the following:

“Our learnt instinct with such issues, based on reductionist thinking, is to troubleshoot and fix things—in essence to break down the ambiguity, resolve any paradox, achieve more certainty and agreement, and move into the simple system zone. But complexity science suggests that it is often better to try multiple approaches and let direction arise by gradually shifting time and attention towards those things that seem to be working best.”

Rather than try and wrap your brain around decades of research of complexity science and apply that knowledge to healthcare, the following video does a nice job explaining what I am saying here:

So how can we begin to change some of the complexity we see in healthcare if what we currently have in healthcare is not working? Former CMS Director, Dr. Don Berwick, described the need for us to test solutions in healthcare, but he adopted a somewhat different philosophical approach grounded in the Triple Aim:

“Start at scale. There is no more time left for timidity. Pilots will not suffice. The time has come, to use Göran Henrik’s scary phase, to do everything. In basketball, they call it ‘flooding the zone.’ It’s time to flood the Triple Aim zone.”

And the Federal government has been doing this – see the Health Care Innovation Awards.

While various white papers and research articles tackle healthcare complexity and complexity science, the community is still out there caught in the middle of a big healthcare mess. And, what’s interesting about healthcare is that while all these complexities are indeed true, and we do need to address them, the simplistic variable in the equation is one that we often forget – it’s all about the relationship.

As patients, we want to feel connected; we want to know that someone understands us and is listening to what we want. Healthcare often forces providers to be less and less patient-centered not because they do not want to, but because of some of the issues raised above; complexity being just one.

In a recent book review, Dr. Starr wrote the following:

“Ideals may tell us something important about what we would like to be,” the political philosopher Avishai Margalit writes. “But compromises tell us who we are.”

It is ideal that in healthcare we would be all about the patient. And yes, there are certain compromises in healthcare we should not be willing to take regardless of their complexity. If we truly strive for a more effective and efficient patient-centered healthcare system, compromising on the relationship in care should not be an option – regardless of its complexity (and simplicity).

Dr. Miller has his doctorate in clinical psychology and is an Assistant Professor in the Department of Family Medicine at the University of Colorado Denver School of Medicine where he is the Director of the Office of Integrated Healthcare Research and Policy. His core task is to integrate mental health across all three of the department’s core mission areas: clinical, education, and research. Opinions expressed here are his own and not those of his employer.

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Posted in complexity, healthcare
  • Randall Reitz

    Ben, Another great post. It would seem to me that your #2 above (Those who are reasonably well-protected want to maintain the status quo) would require compromise when seeking to simplify complexity. As an ideological purist, what is the role for compromise in speaking truth to power and bringing health to the masses?

    • Ben Miller

      Randall, As always you are spot on and picking up on some of the challenges of change. In any effort, we want as many people to come to the table as possible; however, if we want to speak the truth sometimes compromise has to take a backseat. This is the role of leadership – to know when that truth must be spoken; to know when to disrupt. The question is in healthcare, who is the leader? Who will be “speaking up” and calling out?