A “Wicked Problem”: Health Care System Reform and Change

By Robert Nesse, MD, chief executive officer, Mayo Clinic Health System

In light of the Supreme Court review of the Affordable Care Act and the political brouhaha that surrounds it, I know that many providers of health care have mixed feelings about the future of our industry. Let me share with you my cautious optimism as we work to design and then implement the new system of health care in America.

First, we must remember that we are already well into change and every healthcare organization in America must adapt and deal with our current reality. We must accept these incontrovertible facts:

  • The number of people who require care and the percentage of our patients with chronic comorbid disease will increase, increasing the demands on our systems.
  • The government does not want to or even have the money to cover the costs of our current system, so we should expect that reimbursement for our services will decrease.
  • New payment systems will hold us accountable for the quality and safety of our care, and we will be at risk for our costs and outcomes.
  • By 2020, greater than 66% of the American public will get their health care coverage from a government-sponsored program. In 2025, the Advisory Board estimates the total will rise to 70%.

How do these facts make you feel? I suspect that for most, optimism (even cautious optimism) is not the feeling. Some of our colleagues are stuck in pessimism because they are in love with the problem. They painstakingly examine each facet of the problem and continue to bemoan our current state.

I believe that the health care industry is spending too much time trying to defend our past successes and preserving old systems. It is time to move on. We need to change. We need to understand the issues and accept the truth; discover and design our response; and move on.

And as we move on, we must address these three questions:

  • What can we do to solve the problems of health care in America?
  • What are fundamental attributes that medical groups must have to succeed in the future?
  • Why should we do it now?

I will address the first question in this column today:   What can we do to solve the problems of healthcare delivery in America?

The answer:  We won’t solve the problem.

Reform and change of the American healthcare system carry all of the attributes of a “wicked problem.” “Wicked problems” are a common occurrence in other industries. The term originated in the software industry, which faces a wicked problem almost every time they release a new product. No software product is perfect, so when is it good enough to release to the public? Success varies. Think Windows Vista vs. Windows XP or Windows 7.

Wicked problems have the following characteristics:

Different stakeholders describe the problem differently depending on what aspect of the problem they deal with. Consider the views of healthcare costs. Providers think of patient compliance, preventive services and cost shifting. Payers think of excess utilization, provider strongholds, and waste. The government apparently thinks we haven’t got enough regulations, and the patients think we are all at fault for the entire mess!

Changes that address one aspect of a wicked problem will influence other aspects of the problem. Here are a couple of examples. If we are able to change the sustainable growth formula and implement new payment models,  we may finally get an opportunity to reward high-value care. However, if we increase support for primary care, specialty-care reimbursement will likely decrease. If we increase eligibility for low income populations and they join Medicaid we will decrease the uninsured in America. This is laudable but the cost of the program will increase for both the federal and state government.

Wicked problems have no stopping rule. This basically says that you can’t “solve” a wicked problem. This is really hard for clinicians to grasp. In our  clinical practice all our patient problems have a stopping rule. They recover and go home. They transfer to another system, or they die. Healthcare system challenges are not going anywhere. We have discussed the many problems of health care for all of my 31 years in practice, and we will be doing it for the next 310 years.

To address the wicked problem of new health care models what we need to do is choose to work on one aspect of the entire problem that seems to have the best potential for improvement. Fix that. Review the result and see if other opportunities emerge based on your previous effort. Remember that changing one aspect of a wicked problem can impact other areas of the problem.

For the next few years, my choice for that one aspect to work on is to become competent in accountable care delivered through integrated physician group practice, and seek to be competitively relevant in a system that will reward outcomes and total cost of care. This, I believe, is our best first step forward.

This commentary was first presented as part of the opening remarks delivered by Dr. Nesse recently at the annual Amerian Medical Group Association conference held in San Diego, California. In the next “What the Experts Say” column, Dr. Nesse will address the second question: What are the fundamentals that physician groups must have to be ready for the future?

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  • heindoc

    Reblogged this on heindoc and commented:
    This reblog is to be paired up with my previous blog about wicked problems

  • Daniel Zappala

    “The government apparently thinks we haven’t got enough regulations”

    Nice throwaway line, but it would help if you would at least acknowledge the stakeholders here and the real problems they see with our healthcare system. “The government” is a nice placeholder for all we dislike about politics, but in reality, these are representatives, and they are generally trying to work on behalf of some constituents. There is a broad set of the American public that wanted fundamental reform in our healthcare system so replace ‘the government’ with those demographics who voted for President Obama and his ideas. The next step is to recognize the actual problems they see, and not to shrug them off as simply more regulations. These problems include a system where costs are unjustifiably high (compare to other developed nations) yet many people are left without health coverage of any kind. For the overall price we pay (including taxes and out-of-pocket costs) the outcomes are simply not that great compared to those countries with universal healthcare coverage. So this would better be phrased as:

    “A broad set of the American public wants universal healthcare coverage and lower costs.”

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