I can’t believe I’ve gone this long without knowing about Gall’s Law (thanks to @niquola for tweeting it!). For those of you similarly unaware, John Gall was a pediatrician who, seemingly in his spare time, wrote Systemantics: How Systems Work and Especially How They Fail in 1975. His “law,” contained therein, is:
Have you ever heard of anything that applied so perfectly to our healthcare system?
As anyone who has been reading my prior articles may know, I’m a big believer in simple. I’ve advocated that healthcare’s billing and paperwork should be much simpler, that “less is more” when it comes to design, that healthcare should first do simple better but, above all, that healthcare should stop doing stupid things. I’ve equated the ever-increasing intricacies of our healthcare system to the epicycles that kept getting added to the Ptolemaic theory in a desperate attempt to justify it.
Few would disagree that the U.S. healthcare system is complex. Healthcare systems in general have evolved towards more complex, but the U.S. system takes complexity to extremes, with its thousands of payors, its powerful pharma/medical device industry, and its highly concentrated hospital markets (including ownership of physician practices), among other things.
Simple isn’t always better, of course. Life is complicated and so is our health, but, come on: how many people can explain why PBMs exist, what their heath insurance plan actually covers, how their health care bill was arrived at, or why we spend so much time in the healthcare system just waiting? Literally no one understands our healthcare system.
It shouldn’t be that way. It doesn’t have to be that way. But it is.
Some pundits argue we don’t even have “a system” but, rather, thousand or even millions of smaller health-related markets that co-exist but don’t really work together. For anyone who doubts that, try to explain the presence of workers compensation healthcare or why dental is at best a separate form of coverage (last I looked, the mouth was part of the body). Try to explain why child care is most definitely not part of healthcare but home care is — depending, of course, on whether it is “custodial” or not. Silos abound.
It could be argued that healthcare started with a simple system that “worked.” Some are nostalgic for the days when people saw their family doctor, paid their doctor, and that was it. It doesn’t get much simpler than that. Of course, those doctors couldn’t really do all that much for their patients and didn’t really get paid all that much, so to say that it “worked” for either party is debatable.
Many reform advocates propose what they see as a simple solution — Medicare For All! Having everyone with the same coverage could lessen some administrative burdens, but no one who has been covered by Medicare, nor treated patients with Medicare, would describe Medicare as either a simple system nor one that “works.” Medicare For All would have to be radically different from the Medicare program we know now, and that would seem to risk Gall’s “inverse proposition.”
We need, to use Dr. Gall’s words, a “working simple system.”
The trouble is, I’m not sure I can imagine what that is. Group practice HMOs were supposed to be one, but that experiment has not gone the way it was forecast to. More recently, new entrants like Oscar Health or Iora Health were going to reinvent health insurance, but, as it turns out, not so much.
Health system integration/consolidation was supposed to make care more effective and efficient, but it turns out that is a false promise. Companies like TelaDoc and AmWell have been preaching telehealth for a couple decades now, and the world has awoken to its potential, but it keeps tripping over the complexities of the non-digital parts of our healthcare system.
One of the barriers to developing a working simple system in healthcare is lack of agreement on which of healthcare’s many problems to focus on. Is it lack of universal coverage, or excessive costs? Is it our poor health behaviors? Is it how health prices are so radically different between payors? Is it how we continue to tolerate our intolerable health inequities? Is it our lack of data interoperability?
For me, though, the core problem that needs to be addressed is this: we don’t really know what “quality” is — not only whether care has been delivered “correctly” but whether the treatment was even likely to be effective (e.g., look at NNT or any number of studies on unnecessary procedures).
“Quality” in healthcare is like what Supreme Court Justice Potter Stewart said about pornography: he can’t define it “but I know it when I see it.” Unfortunately, in healthcare, we don’t even know it when we see it. Without actual evidence, we all think our doctors are the “best” and our faith in even fringe remedies is enduring (how many supplements do you take?).
Oh, we have lots of quality measures. We spend lots of money collecting them, and even make some of them available to the general public. But we’re kidding ourselves if we think that any of these various measures actually measure quality, or that consumers understand, much less really use, them.
As consumers/patients, we’re not demanding better measures, and, as healthcare professionals/institutions, we’re more worried about increasing our malpractice exposure than in figuring what we’re doing “right” and who is doing it better. Shame on all of us.
Job #1 of our healthcare system should be to find a simple working system for measuring quality for something important — a condition, a treatment, a procedure. Something accurate, easy to measure, and easy to understand. Get agreement on it, and use that to drive decisions about what to pay how much for that part of healthcare. Then iterate.
I’m not saying this is going to be easy — it’s not — but I am saying that if we don’t do this, then all the brainpower we’re using on other problems in healthcare is, essentially, wasted.
Our healthcare system is broken. It’s way too complex yet way too ineffective at every level. As Dr. Gall urged us, we have to start over, and starting with a simple working system for measuring quality seems like as good a place as any.