As we know, the large problems we are facing as a nation, like what to do about health care, are complex and multi-faceted. The systems they involve are what Santa Fe Institute's complexity science gurus like John Holland would call "complex adaptive systems." Complex adaptive systems are made up of many interconnected pieces, have the capacity to change based on past experience and make adjustments to what they do to fit emerging needs and new realities. We need to evolve the thinking and solution planning associated with such critical challenges as coverage and access in health care to consider new approaches. We can't continue to try and "fix" our system by applying new variations of old solutions. If we impose new solutions on top of a broken paradigm and a broken health system, do we really make progress? Is anyone asking important questions like: What is the actual impact of having more access to a broken health care system? What is the value of an 8 minute office visit for someone with both mental and physical issues? What is the impact of mandatory coverage when physician practices will not accept new patients due to low reimbursement and issues with insurance carriers? Other options do exist.
Franklin Memorial Hospital's Contract for Care (Farmington, Maine) is one innovative program which "revives an age-old solution to a modern problem: allow people to volunteer and work off their bills when they cannot otherwise pay for them."
True North Health Center's indirect bartering system (Falmouth, ME) through the Hour Exchange Portland is "an innovative, alternative monetary system where members trade services with one another." Patients offer needed services through the exchange for access to high-quality providers.
In each of these cases, patients are engaged in "paying" for their care through offering their gifts and skills. Their self-esteem is not harmed (in fact many patients are better positioned to get well because they know that they have "earned" their care), there is no need for government funding, and providers receive reimbursement for their time and effort (in the form of services).
In True North's case there are pilot studies that show people who receive care in this way not only have access to great care but also get better.
Are our health care reformers assessing whether having access to our current broken system actually helps people to get well? The Patient Centered Medical Home (PCMH) is another wonderful concept with promise and potential. In 2006, the American College of Physicians (ACP) published a monograph detailing the concepts of the Advanced Medical Home (now called the Patient Centered Medical Home), a model of primary care that intends to modify our health care system to better address an aging and chronically ill population.
Many aspects of this model make great sense including having primary care physicians partner with their patients to assure health care provision is coordinated effectively, using innovative scheduling systems to minimize delays in getting appointments and giving access to non-urgent medical advice to patients through email and phone consultations. And yet, this new model is being built on top of the current broken system, which may be setting it up to fail. For example, within the PCMH, physicians will still be reimbursed based on productivity measures and in some practices that means a physician is required to see 30 patients per day; a reality that does not match well with the stated desire to have the patient's well-being as the focus. The PCMH also incorporates the repackaging of other old programs that did not produce their intended outcomes such as quality based incentive programs (later known as "Pay for Performance") and the use of the Primary Care Physicians as a gatekeeper. PCPs as gatekeepers was in vogue in the late 1980's and into the 1990's but did not significantly improve the health status of individuals and communities, in part because they could not spend enough time with patients to get to the root cause of their problems due to the way health care is financed.
The complexity of the challenge before us will not be solved unless we step outside of traditional thinking and stop recycling solutions that do not work. There are creative options available to us - we simply need to be open, be creative, be innovative and remain focused on the goal of both providing access and positioning people for true healing.