How Large Health Care Organizations Set the "Rules of the Game" to Dominate Health Care

The notion that health care is increasingly "dominated by large, bureaucratic organizations which do not honor ... [its] core values"(1) just made it into a main-stream, large circulation US medical journal.  A brand new commentary in the American Journal of Medicine(2) by Supri and Malone declared:

To explain why we have the most expensive health care system in the world and yet one of the lowest performing, we need to take a perspective that focuses on the US institution of medicine as a whole. We expose the hidden rules by which this institution operates and discuss how its powerful organizations shape, control and perpetuate this ailing system.

The article then described the main types of large, powerful health care organizations:

The US institution of medicine is not a single, comprehensive and cohesive system of health care. Instead, it is comprised of a myriad of large and powerful organizations, including insurance companies, Health Maintenance Organizations (HMOs), corporate for-profit hospital chains, and pharmaceutical companies. This institutional structure is large and vast, and has over the years become ever more labyrinthine.

Note that there are even more kinds of large and powerful health care organizations, including non-profit hospitals and hospital systems, employers acting as payers for health care, government agencies, device and biotechnology companies, health care information technology companies, public relations firms, medical education and communication companies, contract research organizations, professional societies, patient advocacy groups, accrediting bodies, health care charities, etc, etc, etc.  But the point is that the large organizations, not the patients, the physicians, nor the public dominate.

Supri and Malone suggested that each kind of organization sets the "rules of the game," that is, the priorities important to the organization, which are very different from the core values that many of us believe ought to guide health care:

Not only is the institutional structure large, it is dynamic, and actively creates, shapes, and maintains the institution of medicine. It does this through what we call setting the “rules of the game”; that is, by imposing the terms by which the system operates.

For example,

Insurance companies have set the rule 'restrict choice and coverage.' They enact this through their elaborate system of copayments and deductibles, exclusion clauses and loopholes, each designed to deter patients from claiming the health care they need, and to override physicians' medical judgment.

Similarly, it cited the rules for managed care, "manage care," that is, "restrict utilization of health care" regardless of patients' needs; the pharmaceutical industry, "charges as much as we want, because insurance will pay;" and "corporate hospital chains ... test as much as we want, because insurance will pay." Thus it made the point that US health care now is driven by the priorities of large organizations whose interests at best may disregard and at worst may conflict with providing the best possible care for individual patients.

Further, the resulting complexity is to the benefit of the large organizations:

As each organization has created its own 'rules of the game,' the institution of medicine has grown into a complex entity that few really understand. This very complexity actually works to the advantage of the organizations that comprise the system, creating an operating environment that allows them to siphon off billions of dollars. It is one of the main reasons why the cost of health care has spiraled out of control.

This is very important, and suggests that the system will just become more bureaucratic, complex and opaque until it finally collapses.

Finally, it raised the point that the organizations collude to promote their priorities at the expense of patients' and the public's health:

Although each organization sets their 'own rules of the game,' they are also strongly and deeply interlinked, and cooperate and collaborate to protect the system of health care that they have devised, so that it remains intact and continues to serve their own interests.

Although  Supri and Malone did not differentiate the leadership of large organizations from the organizations themselves, we have pointed out that the top leaders of various kinds of organizations seem to think alike, becoming a sort of de facto executives' guild, with a "superclass" of oligarchs at its pinnacle.  The guild may be enabled by these leaders' often huge compensation and other benefits and corporate arrangements that keep them shielded from the vicissitudes of daily life that patients, health care professionals, and lower level organizational employees must face.  Furthermore, the leadership of these organizations is often interlinked, for example, by leaders of one organization serving on boards of directors or trustees of others.

It is so nice for us at Health Care Renewal to have some company. It is a very important blow to the anechoic effect for these sorts of views to appear in a mainstream medical journal.

When I interviewed a motley group of physicians and health care professionals in the early part of the 21st century, many expressed concerns about how medicine had been taken over by large organizations which did not honor its values. The article published in 2003(1) in Europe which tried to summarize their concerns probably could not have been published at that time in the US, but its publication remote from its main topic only made it more anechoic. It may be that an article published in a respected American journal will generate some more echoes. Here is hoping that Health Care Renewal can help create some such echoes. 

Obviously, those who lead large organizations in health care will not be happy about that, so it is possible this article's appearance in a main-stream journal may incite some pushback, perhaps generated by the public relations machines of the large health care organizations (see this post about how Wendell Potter's excellent Deadly Spin documented how large organizations use propaganda and disinformation to undermine viewpoints that threaten their domination.)

In conclusion, I strongly support Supri and Malone's final sentiments:

The sum of the 'rules of the game' devised by these organizations has resulted in a fragmented, haphazard and broken system of health care. Reform is long overdue, and demands root and branch transformation of the 'rules of the game' governing the US institution of medicine. This requires us to understand these rules, who is setting them, and how these rules are being used to exploit the system of medicine. Only then can we begin to heal our ailing health care system.

Well said!

But now almost 8 years since the publication of "A Cautionary Tale," we still have a long way to go.

References


1.  Poses RM. A cautionary tale: the dysfunction of American health care.  Eur J Inte Med 2003; 14: 123-130.  Link here.
2.  Supri S, Malone K. On the critical list: the US institution of medicine. Am J Med 2011; 124: 192-193.  Link here. 

How Large Health Care Organizations Set the "Rules of the Game" to Dominate Health Care

The notion that health care is increasingly "dominated by large, bureaucratic organizations which do not honor ... [its] core values"(1) just made it into a main-stream, large circulation US medical journal.  A brand new commentary in the American Journal of Medicine(2) by Supri and Malone declared:

To explain why we have the most expensive health care system in the world and yet one of the lowest performing, we need to take a perspective that focuses on the US institution of medicine as a whole. We expose the hidden rules by which this institution operates and discuss how its powerful organizations shape, control and perpetuate this ailing system.

The article then described the main types of large, powerful health care organizations:

The US institution of medicine is not a single, comprehensive and cohesive system of health care. Instead, it is comprised of a myriad of large and powerful organizations, including insurance companies, Health Maintenance Organizations (HMOs), corporate for-profit hospital chains, and pharmaceutical companies. This institutional structure is large and vast, and has over the years become ever more labyrinthine.

Note that there are even more kinds of large and powerful health care organizations, including non-profit hospitals and hospital systems, employers acting as payers for health care, government agencies, device and biotechnology companies, health care information technology companies, public relations firms, medical education and communication companies, contract research organizations, professional societies, patient advocacy groups, accrediting bodies, health care charities, etc, etc, etc.  But the point is that the large organizations, not the patients, the physicians, nor the public dominate.

Supri and Malone suggested that each kind of organization sets the "rules of the game," that is, the priorities important to the organization, which are very different from the core values that many of us believe ought to guide health care:

Not only is the institutional structure large, it is dynamic, and actively creates, shapes, and maintains the institution of medicine. It does this through what we call setting the “rules of the game”; that is, by imposing the terms by which the system operates.

For example,

Insurance companies have set the rule 'restrict choice and coverage.' They enact this through their elaborate system of copayments and deductibles, exclusion clauses and loopholes, each designed to deter patients from claiming the health care they need, and to override physicians' medical judgment.

Similarly, it cited the rules for managed care, "manage care," that is, "restrict utilization of health care" regardless of patients' needs; the pharmaceutical industry, "charges as much as we want, because insurance will pay;" and "corporate hospital chains ... test as much as we want, because insurance will pay." Thus it made the point that US health care now is driven by the priorities of large organizations whose interests at best may disregard and at worst may conflict with providing the best possible care for individual patients.

Further, the resulting complexity is to the benefit of the large organizations:

As each organization has created its own 'rules of the game,' the institution of medicine has grown into a complex entity that few really understand. This very complexity actually works to the advantage of the organizations that comprise the system, creating an operating environment that allows them to siphon off billions of dollars. It is one of the main reasons why the cost of health care has spiraled out of control.

This is very important, and suggests that the system will just become more bureaucratic, complex and opaque until it finally collapses.

Finally, it raised the point that the organizations collude to promote their priorities at the expense of patients' and the public's health:

Although each organization sets their 'own rules of the game,' they are also strongly and deeply interlinked, and cooperate and collaborate to protect the system of health care that they have devised, so that it remains intact and continues to serve their own interests.

Although  Supri and Malone did not differentiate the leadership of large organizations from the organizations themselves, we have pointed out that the top leaders of various kinds of organizations seem to think alike, becoming a sort of de facto executives' guild, with a "superclass" of oligarchs at its pinnacle.  The guild may be enabled by these leaders' often huge compensation and other benefits and corporate arrangements that keep them shielded from the vicissitudes of daily life that patients, health care professionals, and lower level organizational employees must face.  Furthermore, the leadership of these organizations is often interlinked, for example, by leaders of one organization serving on boards of directors or trustees of others.

It is so nice for us at Health Care Renewal to have some company. It is a very important blow to the anechoic effect for these sorts of views to appear in a mainstream medical journal.

When I interviewed a motley group of physicians and health care professionals in the early part of the 21st century, many expressed concerns about how medicine had been taken over by large organizations which did not honor its values. The article published in 2003(1) in Europe which tried to summarize their concerns probably could not have been published at that time in the US, but its publication remote from its main topic only made it more anechoic. It may be that an article published in a respected American journal will generate some more echoes. Here is hoping that Health Care Renewal can help create some such echoes. 

Obviously, those who lead large organizations in health care will not be happy about that, so it is possible this article's appearance in a main-stream journal may incite some pushback, perhaps generated by the public relations machines of the large health care organizations (see this post about how Wendell Potter's excellent Deadly Spin documented how large organizations use propaganda and disinformation to undermine viewpoints that threaten their domination.)

In conclusion, I strongly support Supri and Malone's final sentiments:

The sum of the 'rules of the game' devised by these organizations has resulted in a fragmented, haphazard and broken system of health care. Reform is long overdue, and demands root and branch transformation of the 'rules of the game' governing the US institution of medicine. This requires us to understand these rules, who is setting them, and how these rules are being used to exploit the system of medicine. Only then can we begin to heal our ailing health care system.

Well said!

But now almost 8 years since the publication of "A Cautionary Tale," we still have a long way to go.

References


1.  Poses RM. A cautionary tale: the dysfunction of American health care.  Eur J Inte Med 2003; 14: 123-130.  Link here.
2.  Supri S, Malone K. On the critical list: the US institution of medicine. Am J Med 2011; 124: 192-193.  Link here. 

Why The Overambitious, Cavalier Approaches of the Healthcare IT Industry Are Harmful To Health: Guest Post by Dr. Jon Patrick, U. Sydney

Apparently Holland is now veering away from a national project for health information exchange. From a researcher at Erasmus University Rotterdam:

While failures of IT implementation in the UK and more recently the Cerner implementation in Australia has been dissected by [U. Sydney Professor] Jon Patrick, the Dutch initiative for a national health IT infrastructure for exchanging patient data that would start with a medication record and a summary record is about to be voted down in the upper house (Senate) of the Dutch parliament. It means that the trajectory to get this infrastructure and which lasted thirteen years will grind to a halt. Unfortunately this implementation has been poorly documented in scientific journals (to my knowledge only one paper describing the infrastructure was published in Methods of Information in Medicine).

I wrote about the exposé by Prof. Jon Patrick of U. Sydney of poor software engineering practices, poor usability, unreliability, and dangers posed by a commercial health IT product slated for the ED's of the Australian state of New South Wales (NSW) at my Mar. 5, 2011 post "On an EMR Forensic Evaluation by Professor Jon Patrick from Down Under: More Thoughts".

Prof. Patrick offers the following additional pithy and highly insightful commentary, reposted here with his permission (emphases mine):

Colleagues,

Since the publication of my long report on the discontent with and weaknesses of Cerner Firstnet/Millenium in Australia (see http://www.it.usyd.edu.au/~hitru/index.php?option=com_content&task=view&id=91&Itemid=146) I have been pondering the issue of how we can better define the "EMR" and its functions.

I certainly think that the notion of an EMR in terms of current popular discussions in AMIA-WGs [American Medical Informatics Association work groups - ed.] and blogs [such as this one - ed.], government policy and vendor publicity is defined at too high a level of generalisation for analysts to create an adequate specification of it and likewise for the engineers to understand the requirements so that they can build such a system.

This position is further justified by the failures to create such systems in the UK, NSW and Victoria (Australia) and the loss of political support in Holland. A counterpoint to this are the successes in New Zealand, Denmark and Scotland with systems of smaller ambition and scale targeted at particular problems.

I offer this thesis for deliberation: that large scale enterprise software implementations are an over generalisation of the EMR problem so that their lack of ability to capture local context and their intrinsically weak engineering base demonstrate that the advocates of large scale EMR don't know how to do it, have failed to do it in the past at great cost to various communities, and will continue to fail until they understand and define the task properly and in great detail of what has to be done and how to do it.

In other words, the healthcare IT industry itself - starting with its leadership - does not know what it's doing and may itself be ill-suited to purpose, the purpose of facilitating better healthcare. Its overall brute-force, mass-scale, ham-fisted ideologies and approaches cannot succeed except in wasting billions of healthcare dollars. Or, more precisely, transferring that wealth to the IT sector and leaving little to show for it in the health sector.

I agree with Prof. Patrick's "thesis."

At my own HIT website now at http://www.ischool.drexel.edu/faculty/ssilverstein/cases/ years ago I wrote similar words:

Healthcare information technology (HIT) holds great promise towards improving healthcare quality, safety and costs ... however, this potential has been largely unrealized. Significant factors impeding HIT achievement have been false assumptions concerning the challenges presented by this still-experimental technology, and underestimations of the expertise essential to achieve the potential benefits of HIT. This often results inclinician-unfriendly HIT design, and HIT leaders and stakeholders operating outside (often far outside) the boundaries of their professional competencies. Until these issues are acknowledged and corrected, HIT efforts will unnecessarily over-utilize precious healthcare resources, will be unlikely to achieve claimed benefits for many years to come, and may actually cause harm.

Once again, you heard it here first.

I also reiterate, our own "National Program for Health IT in the HHS" needs the same treatment that Prof. Patrick recommends for his own state of NSW, as at my Mar. 8, 2011 post "The Future Pathways for e-Health in NSW."

-- SS

Why The Overambitious, Cavalier Approaches of the Healthcare IT Industry Are Harmful To Health: Guest Post by Dr. Jon Patrick, U. Sydney

Apparently Holland is now veering away from a national project for health information exchange. From a researcher at Erasmus University Rotterdam:

While failures of IT implementation in the UK and more recently the Cerner implementation in Australia has been dissected by [U. Sydney Professor] Jon Patrick, the Dutch initiative for a national health IT infrastructure for exchanging patient data that would start with a medication record and a summary record is about to be voted down in the upper house (Senate) of the Dutch parliament. It means that the trajectory to get this infrastructure and which lasted thirteen years will grind to a halt. Unfortunately this implementation has been poorly documented in scientific journals (to my knowledge only one paper describing the infrastructure was published in Methods of Information in Medicine).

I wrote about the exposé by Prof. Jon Patrick of U. Sydney of poor software engineering practices, poor usability, unreliability, and dangers posed by a commercial health IT product slated for the ED's of the Australian state of New South Wales (NSW) at my Mar. 5, 2011 post "On an EMR Forensic Evaluation by Professor Jon Patrick from Down Under: More Thoughts".

Prof. Patrick offers the following additional pithy and highly insightful commentary, reposted here with his permission (emphases mine):

Colleagues,

Since the publication of my long report on the discontent with and weaknesses of Cerner Firstnet/Millenium in Australia (see http://www.it.usyd.edu.au/~hitru/index.php?option=com_content&task=view&id=91&Itemid=146) I have been pondering the issue of how we can better define the "EMR" and its functions.

I certainly think that the notion of an EMR in terms of current popular discussions in AMIA-WGs [American Medical Informatics Association work groups - ed.] and blogs [such as this one - ed.], government policy and vendor publicity is defined at too high a level of generalisation for analysts to create an adequate specification of it and likewise for the engineers to understand the requirements so that they can build such a system.

This position is further justified by the failures to create such systems in the UK, NSW and Victoria (Australia) and the loss of political support in Holland. A counterpoint to this are the successes in New Zealand, Denmark and Scotland with systems of smaller ambition and scale targeted at particular problems.

I offer this thesis for deliberation: that large scale enterprise software implementations are an over generalisation of the EMR problem so that their lack of ability to capture local context and their intrinsically weak engineering base demonstrate that the advocates of large scale EMR don't know how to do it, have failed to do it in the past at great cost to various communities, and will continue to fail until they understand and define the task properly and in great detail of what has to be done and how to do it.

In other words, the healthcare IT industry itself - starting with its leadership - does not know what it's doing and may itself be ill-suited to purpose, the purpose of facilitating better healthcare. Its overall brute-force, mass-scale, ham-fisted ideologies and approaches cannot succeed except in wasting billions of healthcare dollars. Or, more precisely, transferring that wealth to the IT sector and leaving little to show for it in the health sector.

I agree with Prof. Patrick's "thesis."

At my own HIT website now at http://www.ischool.drexel.edu/faculty/ssilverstein/cases/ years ago I wrote similar words:

Healthcare information technology (HIT) holds great promise towards improving healthcare quality, safety and costs ... however, this potential has been largely unrealized. Significant factors impeding HIT achievement have been false assumptions concerning the challenges presented by this still-experimental technology, and underestimations of the expertise essential to achieve the potential benefits of HIT. This often results inclinician-unfriendly HIT design, and HIT leaders and stakeholders operating outside (often far outside) the boundaries of their professional competencies. Until these issues are acknowledged and corrected, HIT efforts will unnecessarily over-utilize precious healthcare resources, will be unlikely to achieve claimed benefits for many years to come, and may actually cause harm.

Once again, you heard it here first.

I also reiterate, our own "National Program for Health IT in the HHS" needs the same treatment that Prof. Patrick recommends for his own state of NSW, as at my Mar. 8, 2011 post "The Future Pathways for e-Health in NSW."

-- SS

Is Microsoft slowly edging towards an "exit stage left" in health IT?

Interesting item seen here:

From Dabney: “Re: former Sentillion exec departures from Microsoft. Microsoft transferred their 800 Health Solutions Group people into the small-to-medium commercial sector group (Microsoft Business Solutions) last Monday. Peter Neupert and his whole organization have been pushed out of the incubation group in Microsoft Research with the guys who sell Microsoft Axapta ERP and CRM for small commercial customers. That will mark the end of acquisitions and spending of Microsoft on health because they haven’t had any significant sales of Amalga UIS in the past year after already withdrawing Amalga HIS and Amalga RIS/PACS from the market. Microsoft is slowly edging towards an exit stage left in health IT.

Why would this not surprise me if true?

Because I predicted it.

In July 2006, nearly 5 years ago, in my July 2006 post "Bill, Have You Lost Your Mind?"

Nobody was listening, just as nobody seems to be listening to my current dire predictions for the National Program for IT in the HHS™ .

Wait until 2016...

-- SS

Is Microsoft slowly edging towards an "exit stage left" in health IT?

Interesting item seen here:

From Dabney: “Re: former Sentillion exec departures from Microsoft. Microsoft transferred their 800 Health Solutions Group people into the small-to-medium commercial sector group (Microsoft Business Solutions) last Monday. Peter Neupert and his whole organization have been pushed out of the incubation group in Microsoft Research with the guys who sell Microsoft Axapta ERP and CRM for small commercial customers. That will mark the end of acquisitions and spending of Microsoft on health because they haven’t had any significant sales of Amalga UIS in the past year after already withdrawing Amalga HIS and Amalga RIS/PACS from the market. Microsoft is slowly edging towards an exit stage left in health IT.

Why would this not surprise me if true?

Because I predicted it.

In July 2006, nearly 5 years ago, in my July 2006 post "Bill, Have You Lost Your Mind?"

Nobody was listening, just as nobody seems to be listening to my current dire predictions for the National Program for IT in the HHS™ .

Wait until 2016...

-- SS