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Sunday, April 19, 2015

Who coordinates the coordinators?

This is the first line of an article written by Paula Span and published this week in the New York Times (the-tangle-of-coordinated-health-care). It is good news that there is a recognition that coordination of care is an important and up to now under recognized element(s) of the delivery of care.  However, it should come as no surprise that the simple recognition and allocation of modest sums of funds should not solve the coordination problem.


Second to and perhaps equal to the development of technology, the ability of humans to work together to address problems and delivery of human wants and needs is one of the greatest achievement of humankind. I am reminded of the first chapter of the book, Microeconomics by Samuel Bowles where he describes traveling into a rural area of southern India to the village of Palanpur. He wrote:


Like the overnight train that left me in an empty field some distance from the settlement, the process of economic development has for the most part bypassed the two hundred or so families that make up the village of Palanpur. They have remained poor, even by Indian standards: less than a third of the adults are literate, and most have endured the loss of a child to malnutrition or to illnesses that are long forgotten in other parts of the world. But for the occasional wristwatch, bicycle, or irrigation pump, Palanpur appears to be a timeless backwater, untouched by India’s cutting edge software industry and booming agricultural regions. Seeking to understand why, I approached a sharecropper and his three daughters weeding a small plot. The conversation eventually turned to the fact that Palanpur farmers sow their winter crops several weeks after the date at which yields would be maximized. The farmers do not doubt that earlier planting would give them larger harvests, but no one the farmer explained, is willing to be the first to plant, as the seeds on any lone plot would be quickly eaten by birds. I asked if a large group of farmers, perhaps relatives, had ever agreed to sow earlier, all planting on the same day to minimize losses. “If we knew how to do that,” he said, looking up from his hoe at me, “we would not be poor.”
--Samuel Bowles, Microeconomics: Behavior, Institutions, and Evolution, pp. 24-25


The time, money and effort allocated to health care delivery has basically exploded within our economy over the past 70 years. The amount of money which has been invested in systems to coordinate care has been vastly outstripped by the investment to simply do more things, whether that be delivery of drugs, surgery, or other discrete interventions. The primary purpose of the payment mechanisms deployed to deliver these services has been to insulate the consumers from the cost of those services, not to assure that interventions are effective or wise.


Furthermore, this system underwent extraordinary expansion at the very time where a concurrent expansion in wealth and productivity was also experienced. Thus, this allocation and investment in health care services was not held to the same standards used to assess the wisdom of investment. By insulating the public of the cost, at least in the short term, they were not sensitive to whether this investment was a good investment in their needs and wants. They received a product(s) which appeared to be worth their investment, the size and scope of which they were blissfully unaware.


The lack of investment in coordination of services virtually guarantees that there are huge elements of waste. Because we experienced such dramatic economic growth, the magnitude of that waste could be masked, at least for a while. We are now reaching the point to where that waste cannot be hidden and business as usual cannot go on. However, how does one create effective coordination within a business which has undergone extraordinary growth in both size and scope when so little investment was made in coordination infrastructure?


The issue is not so unique, as noted by Dr. Bowles above. It is foundational to the effective development of any system which delivers basically any product or service to large numbers of people and is integral to any system with depends upon the specialization of labor. This is not a problem, the details of which will yield to proscriptive human efforts and planning, working off some master human plan. The track record of this approach has a perfect batting average, that being perfectly awful and uniform failure.


The title of the subheading immediately prior to the paragraph above in Dr. Bowles book is labeled simply "Getting the rules right". What are those rules which create the correct incentives which allow for complex systems which effectively coordinate human activities? Note that the rules to achieve this are not likely unique to health care environments and we just as likely to gain insights from circumstances divorced from health care delivery than from within.


Given  this historical context, the thought that Medicare or some other insurer could fix this problem by creation of a handful of billing codes to pay for "care coordination" is essentially laughable. The fact that a host of disconnected delivery entities has created new coordination issues in their attempts to fix care coordination problems should come not as a surprise.

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