Design Matters - Healthcare Systems Edition

Design Matters – Healthcare Edition

In his book The Opioid Crisis Wake-Up Call, Dave Chase quotes Dan Munro by writing, “The [healthcare] system was never broken, it was designed this way.”

 

I’m a fan of Debbie Millman’s podcast, Design Matters. When we are making something that other people will use and engage with, it is important to think about all the various aspects of how the thing will be used and how it can meet the needs and expectations of others. Whether what we are producing is art, a branding campaign, or a national healthcare system, design matters.

 

Unfortunately, the Untied State’s healthcare system wasn’t built on a design matters philosophy. We see inefficiencies everywhere, with some people getting care they don’t need while others can’t get routine basic care that could save their lives. Dan Munro says that the system was built this way, meaning that the inefficiencies, the inequalities, and the high costs were part of the system from the beginning, intentionally built in. The dysfunction we see in the system, according to Munro, is not so much a bug but rather a feature, helping someone make a profit or get priority access to the healthcare they want.

 

I think Munro is a little wrong. I think the system is a hodgepodge of pieces smashed together over the years. It is an incoherent patchwork of tools and players that has been haphazardly assembled over the years, with some working to truly do good, and others taking advantage of design flaws for their own aims. The system, in my argument, was never designed at all.

 

Design matters and what needed to happen decades ago was a real conversation about how the country would design a healthcare system that could innovate, that could meet the needs of citizens, that could ensure basic access to medical services, that could help provide preventative care rather than just emergency interventions, and that could be sustainable. Instead, doctors went about providing medical services, insurance companies popped up to help pay for some pieces here and there, and eventually businesses got in the mix and offered health insurance to employees. Each new step in healthcare in the Untied States has happened almost randomly, without a lot of deliberate planning.

 

Now the system is so large and complex that planning feels impossible. Legislation to address the challenges of the system is thousands of pages long, and because the most comprehensive law to restructure the program adopted the namesake of the nation’s first black president, a Democrat that became a polarizing figure, half the country derided the attempt to design something better. We can try to reshape bits and pieces of the system now, but design matters, and I understand why so many want to hit a restart button and rebuild a system from scratch.
Medical Technologies

The Problem with Healthcare Technology

In my last post I wrote about hidden costs of the healthcare system in America. I wrote about tax breaks for employers who offer health benefits, and I wrote about third party insurance preventing the healthcare system from working like a pure market. This post introduces one consequence of the hidden costs of our system and the ways in which our system fails to act like a market: the high cost of medical technologies.

 

In The Opioid Crisis Wake-Up Call, Dave Chase writes, “We ended up focusing on a certain type of high-technology, acute medical care – which we financially reward far more than lower-level preventive and chronic care – without regard for the quality of the outcomes or value of the care.”

 

When I took a healthcare policy and administration class along with a healthcare economics class for my graduate studies, I was surprised to see a critique of advancing medical technologies as part of the problem of American healthcare costs. I live in Reno, under the sphere of influence of the Bay Area, where technological solutions to global problems are hailed as the cure-all, deus ex machina that we need for a peaceful and prosperous world. I always thought that better medical technology saved lives, made us healthier, and ultimately reduced cost by being more efficient and precise than older technologies.

 

As it turns out, new medical technologies are incredibly expensive, and often times the benefits that patients receive are only marginally better than what existing technology offers. In some instances those marginal improvements make the difference between life and death, but in many instances, the new technologies might only add a few months of life to a terminal diagnosis, a few additional months lived in pain and fear. In other instances, the new technologies might add a little more comfort or certainty in a patient’s procedure or diagnosis, but it is fair to question whether its really necessary and worth the additional cost.

 

The quote from Chase reveals that when we are shielded from the costs of care, and when we remove market aspects from the healthcare system, we adopte a mindset that healthcare equals expensive interventions with high cost technology. I had clearly bought into this narrative prior to my graduate studies. The alternative that Chase highlights in his book, which we have underdeveloped in the United States, is to move upstream, and take care of people at a preventative level before they are sick and before they need expensive technological interventions. Developing systems, structures, and norms for healthy lifestyles will do more to reduce costs than the development of new magical cures and technological fixes. Our priorities and the focus of our system is flawed, and a as a result we focus on high cost interventions within a system no one is happy with. Rather than develop a system that actually supports healthy living, we have fished around for quick, high-cost technological solutions to our health woes.
Opioids and Mental Health Disorders

Opioids and Mental Health Disorders

Opioids and mental health disorders probably do not seem like a good mix in anyone’s mind. I’m sure most of the general public would find it problematic to prescribe opioids to someone with a mental health disorder, but every day, physicians across the country prescribe large numbers of opioid prescriptions to these patients.

 

Dave Chase, in his book The Opioid Crisis Wake-Up Call, writes, “According to a recent study, more than half of all opioid prescriptions in the United States annually go to adults with a mental illness, who represent just 16 percent of the U.S. population.”

 

Why do we over-prescribe so many opioids to people with mental health illnesses? I can think of three potential causal models that lead to our over prescription of opioids for people with mental health disorders. 1: our system was never set up to treat health broadly speaking, 2: mental health has always been stigmatized and hidden in America, and 3: we have sabotaged ideas of community in the United States as we pursue our own self-interests and spend unreasonable amounts of time working and commuting.

 

1: The history of the American medical system was focused on interventions and solving health problems after the problem had popped up. Insurance companies were created to help people access different parts of the medical system, and over time private insurance has become more or less the only way to reasonably access affordable medical care in the United States. Our reliance on third party payers allowed prices to profligate, and it feels as though we are at a point where we can’t turn the ship around. If you have a mental health disorder, you are less likely to have stable employment, which means you are less likely to have quality health insurance provided through your job, and less likely to establish the mental health care that you need. As a result, you probably see your primary care provider and end up with an opioid prescription during your 10 minute appointment because your doctor doesn’t have time to really work with you on addressing your mental health challenges.

 

2: There are many examples throughout history of people hiding children with intellectual disabilities. Generations before us warehoused children in mental health institutions that did little to help improve health. We are mostly beyond that today, but nevertheless, we hide anxiety, depression, learning disabilities, and other mental health challenges from our friends, families, and coworkers. We still don’t do a good job of accepting that mental health disorders are not something that people should be ashamed of, and many people do not seek appropriate care but instead life lives that are less than healthy, where ending up with an opioid prescription, or self-medicating with something worse, is a less public alternative to dealing with mental health challenges.

 

3: Tying both points one and  two together, our lack of community makes mental health management almost impossible. We don’t have a lot of friends and family members that we can truly rely on for help with physical, mental, and emotional challenges. It may take a village to raise a kid, but we have run away from our villages to hide in our suburbs. We have dis-invested in the communities where we live and as a result, people with mental health disorders lack the social support systems necessary to truly address their needs. Even if people with mental health issues have some family and friends close by, those who they rely on probably lack the support they need to care for someone with mental health challenges. We spend too much time at work, spend too much time commuting to work, and don’t have time to help those who are more vulnerable. As a result, we simply shut people with mental health disorders out of our lives and out of society, and numb their lives with opioids.

 

Our country has not set up a system that truly takes care of our health, from before we are sick or have significant health challenges through to a successful recovery. We have overloaded the system that we built which was designed for people with the means to afford care after they were ill. We have ignored mental health and pretended we didn’t know it was an issue, until now, when it is too late and we don’t have the supports we need. Our communities are non-existent, and taking the steps to care for our community feels impossible.

 

The path forward involves a shift in how we provide, pay for, and think about healthcare. The systems we turn to for health need to move up-stream, where we focus on health before people are sick. To do that, we have to be honest about things like mental health, we have to be willing to provide spaces and community so that people can engage with healthy lifestyles and behaviors. We have to break out of our 40 hour work-weeks, and find ways to work closer to where we live, to end the soul sucking commutes that so many of us have. We have to give people time, and develop communities of support so that we can take care of our health and the health of those most vulnerable people in our communities. Without making these transformational changes, we will be stuck in our default of opioid prescriptions, unable to give people what they need to live healthy and meaningful lives.
Finding Success Through Structure

What Happens When Your Day Lacks Structure

In the past I have found it incredibly helpful to have fully planned out days. To know what I have going on, what the most important priorities are for my day, and when I am going to buckle down with focus work versus when I am going to sift through emails is a great feeling. When I have thought through what to work on and know I have blocked off sufficient time, I can really do some great work.

 

Without having such planning, each day is a bit of a challenge. Things come to mind as the day passes for what I should work on, but I often float from one task to the next without a great sense for why I am working on any specific thing at any specific moment. This strategy is easy and might work fine when I am not under tight deadlines, but I have run into a real crunch when suddenly remembering a project or task that needs to be done today. Or, when fortunes change and an emergencies pops up, I have been wholly unprepared to deal with the new reality that needs my attention immediately.

 

My last post was all about finding success and finding willpower in a routine that makes you effective. Creating spaces, planning ahead, and developing rituals for deep concentrated work is the best way to ensure that you can do hard things continuously. This structure is important, and Cal Newport describes it in more detail in his book Deep Work, “without this structure, you’ll have to mentally litigate again and again what you should and should not be doing during these sessions and keep trying to assess whether you’re working sufficiently hard.”

 

Whether you work as part of an organization, lead a campaign, or work as a solo entrepreneur, you need time for deep work. You also need to think about what each day is going to entail and have a plan to get the most important work done. Spending a few minutes thinking about what is most important and what you should be focusing on at what time can help free up the mental energy and space required to get into deep work. Having to think continuously about what you should be doing at any moment is exhausting and will lead you to flutter around at a shallow level with your work. If you haven’t yet developed an effective structure to approach your day, you are missing out on being effective and finding a sense of stillness in doing the important work that needs attention.
Being in a state of flow

Deep Flow

A book I need to read sometime soon is Flow by Mihaly Csikszentmihalyi (that’s sick-cent-mihalie – thanks to Daniel Kahneman for the pronunciation tip). Csikszentmihalyi looks at how time seems to behave differently when we are deeply engaged in what we are doing versus when every second of boredom drags by at the end of a workday. Flow is how he describes the state we are in when we are concentrated and focused, when an hour seems to blink by.

 

It’s the state where we are so engaged with our work that time seems to bend around us. Rather than looking at the clock every few minutes, and rather than experiencing time, we are absorbed by what we are doing, and when we finally pause, we can’t believe how much time has passed. It is a complete feeling of commitment and purpose with what  we are doing, and we all find different ways to be in a state of flow.

 

For me, my morning writing and editing work is a brief flow state. My running is usually a flow state, and sometimes other work that I have ranging from spreadsheets, to building training slides, to report writing can actually be flow work.

 

I know others who find flow from riding motorcycles, drawing, and even from being part of a band. The commonality between everything is a sense of presence and focus specifically on the task, work, or activity of the moment. Flow, in many ways, is the fulfillment we live for, even if it is found in report writing rather than singing in a garage band.

 

Cal Newport highlights this reality in his book Deep Work. He writes, “Most people assumed (and still do) that relaxation makes them happy. We want to work less and spend more time in the hammock. But the results from Csikszentmihalyi’s ESM studies reveal that most people have this wrong.” What we actually want, and what actually brings us the most happiness is being able to be in flow states. Free time and leisure can be meandering, purposeless, and even boring. Work that provides us with flow feels good, even if it is difficult and is still work. I believe this is part of why some people find it hard to retire or stay retired. Unstructured free time doesn’t always give us something that we can be absorbed and engaged in, and we don’t find the same level of happiness as we find when we can tackle a project and get into a state of flow.

 

This suggest that when we are considering our weekend plans, considering our career choices, and considering hobbies, we should be looking for things that provide flow states. We should find ways to set up a space and environment where we can focus deeply on a specific task, and find our flow. Rather than only chasing promotions and money, we should consider whether a new job or promotion will provide more or less flow time. Rather than seeking a beach retirement, we should seek a retirement that opens more flow opportunities. We will be focused, engaged, and find more fulfillment in both work and retirement if we can ensure we have an opportunity for focused flow.

A Glitch in Voting With Our Feet

In the United States, we hold on to terrific myths about the power of the individual. We celebrate (mostly) entrepreneurs like Elon Musk who bring us new technologies and cool cars, and we have magazines focused entirely on major business leaders whose insight and innovation power our most successful companies. We believe that individuals hold the power to change the world, and we believe that giving people freedom will lead to rational decisions on the part of individuals to find the best outcome for our country.

 

An idea that pops out of this myth is the idea of voting with our feet. The term refers to people making a decision to go someplace else, to chose something else, and to literally move ourselves with our feet to a different option. We might vote with our feet when we move from one city to another, or when we leave one store to shop at another, or quite literally in some state caucuses when we walk from one side of a room to another to support a different political candidate. We believe that our individual choices and where we chose to shop and how we chose to vote will really make a difference in the world.

 

This is only partially true, and only sometimes has the positive outcomes we hope for. In many instances, our individual choices are just not enough to overcome structural factors which entrench the status quo. Sometimes we vote with our feet, but really move from one option provided by a company to another, without really making a difference in the bottom line of the company we are voting for or against with our feet (think of moving from Facebook to Instagram, which is still owned by Facebook). Voting with our feet can also have very negative consequences, such as entrenching segregation without having anyone who is clearly to blame.

 

In The Complacent Class Tyler Cowen writes about the ways in which our society is becoming more segregated through the use of voting with our feet. Across the country we see people move into “nicer” neighborhoods which creates a level of economic, racial, and political segregation that should (I would argue) raise moral concerns. About the issue Cowen writes, “The self-selection process is running its course, and how people are voting with their feet often differs from which is coming out of their mouths.”

 

Many people who believe that schools and communities should be more diverse are moving to areas with less diversity. They are not consciously choosing to live in more or less segregated areas, but they are voting with their feet to leave areas of worse economic condition but greater diversity in favor of more economically sound and culturally homogeneous regions.

 

This works because we empower the individual in our society and don’t want to do anything to limit the power of the individual’s choice. Segregation is a result of the power to vote with our feet, but it is also the dismantlement of the myth of the individual. The rational individual is not making individual choices that make the world a better place. Instead, the individual is working on feelings that lead to a desire for greater similarity between themselves and their neighbors, ultimately creating a worsening system of segregation. They are following cultural and structural factors which push us to want ever larger houses in ever more expensive neighborhoods, recreating segregation that often created pockets of towns that are so different economically and culturally. We should learn from this example that our individual choices are both not sufficient to bring about the best outcomes for our society and planet, and that simultaneously our individual choices can have a serious power to shape the world for better or worse. We must think first about the systems that structure our decisions, and then think about how we can make the most of our choices for positive, rather than negative outcomes.

Resistance to Change

A short section in Michael Bungay Stanier’s book The Coaching Habit is titled “One of the laws of change: As soon as you try something new, you’ll get resistance”.

 

I think we have all experienced this at one time or another in our lives. We end up with the habits and patters of our lives because it is easy. We get used to doing the same thing each day and become accustomed to the same routine. Changes and adjustments to that routine become incredibly difficult and we often find ourselves doing the same things each day and then reflecting back and wondering why we didn’t make the change we wanted or why we couldn’t fit in something new.

 

Bungay Stanier doesn’t see these habits and the resistance to change as a necessarily bad thing. If you can develop a great routine that is helping you to be healthy, encouraging meaningful relationship with those around you, and allowing you to accomplish the most important things in your life, then you can use the power of habit to your advantage. The grooves and tracks in life that make change hard, can be an advantage when you don’t want to think about working out in the morning or after work and when you want exercise to be something you do out of habit. What is important with habits is to remember that habits can be tools to shape the structure of our lives so that we achieve the outcomes we desire. Bungay Stanier writes, “We live within our habits. So change the way you want to lead, and build the right coaching habits.”

 

The book is specifically about coaching and adopting the right mindset and habits to be a strong coach in areas of life, business, or sports. However, the awareness of our habits and actions is powerful and applies to every part of our life (not just the coaching side of our lives). Recognizing when we have let a habit set in is crucial for change and for living an intentional life. If dessert is a habit after dinner that you don’t consciously think about or if the doughnut on Friday is automatic without pause, then you will never be able to change the behavior. If you can become aware of times when you are on auto-pilot, you can begin to change yourself and your routine so that the same decisions do not exist and you break out of the habits you dislike. It is not easy and you will feel push back from your own habits and the structures in place, but you can adjust all of these things to build the new habit that you would prefer.

Design Matters

One of my favorite podcasts is Debbie Millman’s Design Matters. She interviews architects, artists, marketers, designers, and other creative people about their work and their place in the world. It is an excellent show to learn about people who see the world differently and to see what people did to reach success, often without following a traditional path. A common theme running throughout Millman’s show is that design matters. It matters a lot when we look at the built world around us and ask questions about why things operate the way they do, about why people behave the way they do, and about why society is designed the way it is. Design matters because the built environment and the societal structures we adopt or inherit shape who we are as people. Everything hinges on the design we give the world around us: our futures, our possibilities, our idea of what is possible, and our understanding of what is reality.

it is incredibly important that we think about design as a society because poor design leads to inequality and bad outcomes for individuals and for society as a whole. I thought about this when I returned to a sentence I highlighted in Michelle Alexander’s book, The New Jim Crow. Alexander writes, “The unfortunate reality we must face is that racism manifests itself not only in individual attitudes and stereotypes, but also in the basic structure of society.” When we think about design we can begin to connect the inequalities, the disparate impacts, and the problems with society today to the attitudes and behaviors of the past. In his podcast series, Seeing White, on his show Scene on Radio, host John Biewen reflects on the structural elements of racism in our society as opposed to the individual elements. Individual racism is easy to see, easy to condemn, and easy to change, but structural and institutional racism is hard to see, hard to understand, and very difficult to change. However, just because it is hard to see and understand does not mean that structural racism is any less of a threat to society or any less real for the people impacted.

We should be honest with ourselves and accept the idea that structures and systems designed by people who were openly racist can still impact the lives of people today. System and procedures were designed with the interests of white people and white culture in mind, and part of the decisions that were made involved the oppression, the limitation, and the containment of black people. We still must deal with many of these systems, even if their design has been slightly changed, because the original design was effective in allowing some to prosper while others were limited. These designs mattered, and they still matter today. A system that deplores individual racism while supporting hidden and structural racism can influence and shape the lives of individuals and the direction of society arguably more effectively than a system that encourages individual and open racism. To move forward, our nation needs leaders who can be honest about systems and structures and understand that design matters when thinking about government, society, services, communities, and neighborhoods. By becoming more aware, all of us can recognize the way that systems which are currently in place can shape our quality of life and the perceptions we all share, and we can push for new systems that compel us to interact more with our fellow citizens, and encourage us to see each other as people as opposed to enemies.

Organizational Structure

In his book Return on Character author Fred Kiel addresses ways in which a business leader’s strong moral character can boost the bottom  line for the company they work for, and how their strong moral character can have a meaningful and positive impact on the lives of the employees working for them.  Part of the way that strong character can translate into a more engaged and fulfilled workforce and a better bottom line is through an organizational structure which supports the employees of the company, and helps them do their best work with the ethos of their virtuoso CEO. A strong structure can help guide a company by allowing everyone involved to act in a morally defined manner, helping everyone do better work.  Kiel sets up the idea that a great business structure depends on a strong moral ethos developed by the leadership team and the CEO:

 

“Even an ideal structure offers no guarantee that the dynamics will be positive, harmonious, and energized.  As the ROC [Return on Character] data revealed, this is where the character habits of the executive team come into play.”

 

Kiel is explaining that an efficient organizational structure within the business is not enough for great business success.  His argument is that CEOs need to develop moral habits and characteristics that help build people up by treating them as more than just extra hands on deck.  When the CEO is able to truly live through this idea and create and shape a leadership team that can spread this idea, then everyone within the company will be taken care of, and they will feel as though they work in an environment where people truly care about them and want to help them do their best work.

 

The opposite end of this scale would be a self focused CEO who displays character habits of a dog-eat-dog, success hungry individual. This type of character will show that what is most important is personal growth, even at the expensive of others. They likely will not develop strong leadership teams that can put the interests and goals of employees at the same level of importance as their own. As a result, employees feel disconnected and have no reason to demonstrate strong moral habits within their own work.

 

By voicing, living up to, and building a leadership team that is focused on strong moral goals, a CEO can create a structure in which all actors of the company are able to make positive moral decisions and feel encouraged to do their best work.  The strong moral values of the company will be reflected beyond the work space and into the world in which the company provides value to those with whom they serve.  Reinforcing this structure and maintaining it requires more than just a keen eye for efficiency, and requires a true respect for human beings.