Correspondence

Homeostasis without Reserve — The Risk of Health System Collapse

N Engl J Med 2003; 348:1410April 3, 2003

Article

To the Editor:

I accept the premise, stated by Sandy in his Sounding Board article (Dec. 12 issue),1 that “a high-quality, cost-effective, and just health care system” can be developed, but I see no sign that the public is currently willing to pay for it — unless it costs less than the current system. We seek to educate the public and policymakers about what we believe is best; perhaps it is time to present totally new models that can actually do better for less. Our system of hospital-centric and office-centric care, with traditional rounds and visits, evolved several centuries ago, and our administrative methods could most neutrally be described as preindustrial. We constantly embrace new knowledge, new drugs, and new forms of technology, and yet we are trapped in a paradigm that produces only half a loaf: improved outcomes that are not available to all, high rates of errors, and rising costs. Industrial productivity did not initially improve with the transition from steam power to electric motors; it took decades to evolve factory designs that could take advantage of the new technology.2 By analogy, we keep bolting new equipment and methods onto the same model of care. The “deep forces” causing stress in the system are not being addressed; Dr. Sandy's suggestions are on the mark. We need a “request for proposals” for new models of health care delivery that recognize the political realities of limited resources. Such models would certainly differ dramatically from the current situation, and they will require some time to evolve.

Stephen Sandroni, M.D.
Allegheny General Hospital, Pittsburgh, PA 15212
sandroni@pol.net

2 References

1
Sandy LG. Homeostasis without reserve -- the risk of health system collapse. N Engl J Med 2002;347:1971-1975
Full Text | Web of Science | Medline

2
Twigg CA. Superficial thinking: the productivity paradox. Educom Rev 1995;30:(5)50-1

Author/Editor Response

Dr. Sandroni suggests that we need completely new models of care to address the systemic stress facing the system. I could not agree more. Fortunately, there are innovators seeking to develop and test such models. For some, the starting point is from the bottom up, for others, from the top down. Among the former is work by Nelson et al. on understanding high-performing, frontline clinical units, known as microsystems.1 The best of these microsystems combine patients, clinicians, and care processes to produce highly effective, efficient, and personalized care. Analyzing and understanding these local units of care will be critical in achieving overall system redesign. From the top down, the request by Health and Human Services Secretary Tommy Thompson to the Institute of Medicine led to Fostering Rapid Advances in Health Care: Learning from System Demonstrations, 2 a report recommending new demonstrations in the areas of information technology, expansion of coverage, malpractice reform, management of chronic diseases, and enhancement of primary care. Within academic medicine, some forward-thinking leaders recognize that advances in genomics, management of chronic illness, and risk assessment demand the creation of new models for service delivery.3 These and other calls for transformational change, although encouraging, need far greater support among the medical community, policymakers, and the public.

Lewis G. Sandy, M.D.
Robert Wood Johnson Foundation, Princeton, NJ 08543-2316
lsandy@rwjf.org

3 References

1
Nelson EC, Batalden PB, Huber TP, et al. Microsystems in health care. 1. Learning from high-performing front-line clinical units. Jt Comm J Qual Improv 2002;28:472-493
Medline

2
Corrigan JM, Greiner A, Erickson SM, eds. Fostering rapid advances in health care: learning from system demonstrations. Washington, D.C.: National Academies Press, 2002. (Accessed March 14, 2003, at http://books.nap.edu/books/0309087074/html/R1.html.)