JAMA: Rigid regulatory framework can't fix complex healthcare system

Imagine a mechanical healthcare system in which each component interacts predictably with another to produce a predictable output that can be adjusted by tweaking a specific component. That system does not exist and treating the existing complex system as such sets it up for failure, according to a July 18 viewpoint published in the Journal of the American Medical Association.

Efforts to control the healthcare system and its costs should refrain from relying on “levers,” such as certifications, surveys, payments and penalties, wrote Lewis A. Lipsitz, MD, of Beth Israel Deaconess Medical Center and Harvard Medical School, both in Boston.

“These mechanical approaches often lead to unintended consequences,” he wrote. “This is due to the enormous complexity of the healthcare system, both in lay terms by its complicated design and in scientific terms by its nonlinear, dynamic and unpredictable nature... In contrast to mechanical systems in which component parts interact linearly to produce a predictable output, the components of complex systems interact nonlinearly over multiple scales and produce unexpected results.”

An example of how the complex healthcare system chews up proposed solutions and spits out unintended consequences is the Medicare three-day stay rule. Introduced in 1965 to reduce expenditures, the rule requires prolonged hospitalization for beneficiaries to become eligible for extended care benefits that pay for nursing home stays. For an elderly patient who is well enough to end acute care in a hospital but not well enough to return home, a well-meaning provider might prescribe additional hospitalization, along with costly and unnecessary medical tests.

To avoid these unintended consequences, initiatives aimed at changing behavior occurring within a complex system should implement simple rules that encourage interaction among all stakeholders to reach mutual objectives and provide opportunities for stakeholders to self-organize. Recent capitation and bundled payment models are a step in the right direction, according to Lipsitz.

“The U.S. healthcare system will need to continue to depart from a mechanical, regulatory approach to healthcare policy and move toward a complex systems approach that permits creative self-organization,” Lipsitz concluded. “This may be accomplished by removing structural boundaries between healthcare professionals, aligning their goals, enabling experimentation and establishing simple rules to help limit costs."