Improving the effectiveness of health care and public health: a multiscale complex systems analysis

Abstract

The US health care system is struggling with a mismatch between the large, simple (low-information) financial flow and the complex (high-information) treatment of individual patients. Efforts to implement cost controls and industrial efficiency that are appropriate for repetitive tasks but not high-complexity tasks lead to poor quality of care. Multiscale complex systems analysis suggests that an important step toward relieving this structural problem is a separation of responsibility for 2 distinct types of tasks: medical care of individual patients and prevention/population health. These distinct tasks require qualitatively different organizational structures. The current use of care providers and organizations for both purposes leads to compromises in organizational process that adversely affect the ability of health care organizations to provide either individual or prevention/population services. Thus, the overall system can be dramatically improved by establishing 2 separate but linked systems with distinct organizational forms: (a) a high-efficiency system performing large-scale repetitive tasks such as screening tests, inoculations, and generic health care, and (b) a high-complexity system treating complex medical problems of individual patients.

FIGURE 1—

The structure of the US health care system today. Note. Information (?) flows from patient to physician. Care and information (+) flow back to the patient. Financial flows ($) proceed from employers (employer) to insurers (insurer; private or public) and thence to care providers (doctors), who provide to insurers information (?) about the care being provided to individual patients (patients). Insurers receive lump sum payments, which are distributed in much smaller amounts to care providers for specific services.

FIGURE 2—

Complexity as a function of scale. Note. Schematic illustration of complexity C(k) (vertical axis) as a function of scale, k (horizontal axis). A system with the highest possible fine-scale complexity corresponds to a system with independent parts (curve a). When all parts act together, the system has the largest-scale behavior but the same low value of complexity at all scales (curve b). Complex systems have various possible scales of behavior, as illustrated by one example (curve c).

FIGURE 3—

A proposed structure for a new health care system. Note. The proposed new public health component (left box) provides efficient population-based care (+) to its customers, including employers (as shown by the upper left arrows), private insurers, government agencies, or individuals (similar to high-efficiency fast food and other mass market products or services); arrows are not shown for the latter cases. Moreover, it refers (gray arrows) those who need individualized care to the other part of the healthcare system (with interactions and symbols as in Figure 1 ▶) that is focused on individualized care.