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AAMC Reporter: August 2005
A Word from the President:
"If It Ain't Broke, Don't Try to Fix It "
The health care system is broken! How many times have you heard that refrain over the past several years? When I hear it, I wince. Why? Because "broken" is not the right image for what's wrong with the system. Words matter. They evoke well-established mental models. The word "broken" implies if we just "fix" it, just patch it up and make the system work like it used to, everything will be fine.
That mental model is highly unlikely to yield real solutions to the fundamental problems we face. Our health care system is not broken. It is outdated, outmoded, obsolete-pick your word. The point is that the system we've inherited, the one we're now struggling to make work, is a legacy system. It is the hand-me-down product of a bygone era when the overwhelming burden of disease fell into the category of acute, often self-limited illness and injury; when the technologies available to diagnose and treat disease were much more restricted in scope and complexity; and when the overall cost of health care was still in the single digits as a percentage of GDP. Given those realities, a system with the following features was capable of meeting most needs:
- Independent practitioners working solo or in small groups
- Self-contained hospitals competing with one another for patients
- A payment system structured to deal with isolated episodes of illness and discrete encounters with individual providers
- Diagnostic and therapeutic decisions often based on local practice patterns and convention rather than on evidence of effectiveness
- Physicians at the unchallenged apex of a hierarchical arrangement in which other health care professionals were subservient helpmates
- Paper-based medical records kept independently by each of a patient's providers in poorly accessible repositories
- A penchant for assigning blame to individual providers for adverse patient outcomes.
Our problem is this: We no longer live in that era, but we're still trying to make that legacy system work for us today. It simply cannot do so. A fragmented, uncoordinated, fee-for-service system tolerant of wide variations in practice by excessively autonomous providers cannot hope to address the health needs of an era characterized, among other things, by:
- An overwhelming burden of chronic, unremitting illness and disability
- Unprecedented complexity and specialization
- Well-documented concerns about the safety of patients
- Inexorable increases in health care costs
- Demands for greater accountability
- Unconscionable health care disparities.
Unfortunately, most policymakers persist in basing their recommendations on the inappropriate mental model of a "broken" system. And they think all they have to do to "fix" the system is to patch up the most gaping holes. Moreover, virtually all the talk here in Washington is about the high cost of health care and the need to reduce expenditures, as if that alone would take care of things. It's not that costs aren't a problem; it's that they aren't the problem.
The problem is that the system we've inherited is obsolete; no matter how much we try to moderate escalating costs, the system itself is simply not capable any longer of addressing contemporary health needs. Using the more appropriate "obsolete" mental model would force us to stop tinkering with something that has outlived its usefulness and start the fundamental restructuring of the system to meet contemporary realities. That means beginning with a clear consensus about what we want the system to do and only then turning attention to what kind of financing arrangements will best sustain it.
If we could get policymakers to shift their mental model from "broken, let's fix it" to "obsolete, let's redesign it," I don't think we'd find much disagreement about what features we would want the system to have. The key feature would be greater integration and collaboration among health care providers. Indeed, the unit of accountability would cease to be individual providers. Instead, local organizations of coordinated health care professionals, hospitals, and other community health care resources would be accountable in the aggregate for maintaining the health and managing the acute and increasingly chronic illnesses of a defined population over an indefinite time.
Moving from our dysfunctional, fragmented legacy system to an integrated, accountable system will not be easy. And it strikes me as wishful, if not entirely fanciful thinking, to depend on Congress, state governments, insurance companies, employers, or the invisible hand of the market to catalyze the needed transformation in a timely way.
Our best hope for generating movement in the right direction is for one or more academic medical centers (AMCs) to establish a prototypical model of the system of the future. Many AMCs already have the ingredients for a nascent system, given their organized faculty practice plans, their hospital networks, their community physician referral bases, their IT infrastructure (including a comprehensive electronic health record), and their loyal patients. Aggregating these ingredients, preferably in collaboration with other regional AMCs, into a robust demonstration project would illustrate in real time the multiple advantages of a system designed explicitly to deal with the realities of today.
I'm encouraged by the work of many AMCs to implement some of the wrenching changes needed. However, many more must join the redesign effort if academic medicine is to fulfill its vital role as the creative, innovative core of the health care system. That role, it seems to me, obliges us to lead our country away from an obsolete system left over from another era, to one that is advanced, high-performing, and better suited to current and emerging health care needs.
Our present system isn't broken, so let's not waste time trying to fix it. It's worn out, so let's get about replacing it.
Jordan J. Cohen, M.D.
AAMC President
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