Diversity and Interdependence

Two important principles in modern organization change theory, conflict management and power development are diversity and interdependence. They interact in some curious ways to produce complexity in most social systems and enterprises. They are useful constructs to help explain some of the difficulties we face in changing health care organizations and perhaps, more importantly, can help direct the attention of health leaders to more effective remedies of our current situation.

Diversity is an essential element of modern existence. Five hundred years ago most people never traveled more than a mile from their place of birth, worked as their parents had and rarely saw people not exactly like themselves. The Renaissance and Enlightenment, scientific and technological advances and market economies changed all of that forever. Today the modern experience is one vast mosaic of experiences, beliefs, values and perspectives. The stress that characterizes our modern life is probably a byproduct of this once sedate species encountering such an array of stimuli.

Diversity in and of itself is not the sole generator of challenges in most organizations. Diverse populations that do not have to have significant contact with the outside world do not necessarily generate conflict. And even if they do encounter the other, if it is controllable, then the level of conflict is below the threshold of disruption. Most large, modern organizations do not have such luxuries. They value the diversity of highly specialized knowledge because it is a source of significant strategic advantage and has been for the past two hundred years. This is the essential nature of conflict in all modern organizations. Diverse perspectives are needed to produce a valued outcome but, because they differ, ideologies conflict at many, if not all, points of contact. Organizations and their leaders work hard to overcome this friction by developing powerful mediating structures to align the work of their complex organizations.

On the other hand, health care in the US does not fall within this dynamic of alignment. It is not that it is not diverse, because by any measure it is richly diverse. There are of course the vast differences in professional training, values, expectations, vocabulary and theory that exist between two large professional bodies responsible for health care: nurses and physicians. Multiply these differences by the more than 225 licensed health professionals and the Babel is understandable. But diversity only begins here. There is also the deep conflict of perspectives between clinic and hospital, public health and patient care, insurance and provider interests, and health plan and purchaser, just to name a few.

Why are other nations able to deliver services of comparable quality to every one of their citizens for a fraction of what we pay? The slippage in the US occurs in how we fail to manage the interdependent nature of diversity and align diverse interests to serve the needs of the patient and customer. To accomplish this some social mechanism more powerful than the collective interests of the various tribes that make up health care will have to come forward. Before we become too hopeful, remember that the health care natives stopped the realignments proposed by the Clinton administration’s Health Security Act and redefined managed care as something venal just because it wanted to alter the prerogatives of the health care incumbents.

Self-directed health plans and savings accounts argue that the consumer armed with flexible purchasing power and better information will create the discipline that is missing. Perhaps, but it is harder to imagine a more extreme David and Goliath match up. Federal override and delivery actually has worked out quite well recently in the Veteran’s Administration and many of the state Medicaid programs, but all those who oppose such moves will have to do is to liken such proposals to the US Postal Service taking over health care. Personally I admire the USPS, but I would not want to make the case in a political campaign.

Actually I increasingly believe that the change to more interdependent systems will come with less of a bang and a bit more of a whimper. Consumers finding the current health delivery system less and less to their liking in terms of satisfaction, outcomes or costs will simply exit it. As they do they will create a new secondary market for a great variety of services including complimentary and alternative care, doc in the box primary care, health promotion services, information brokers, self assessment tools and access to foreign pharmaceuticals to name a few. In fact these already exist outside of the traditional delivery and payment mechanism. But what about that expensive specialty care that some will need? Today it is increasingly just a short commercial flight away.

The system must become more aligned before it can function in a truly interdependent manner; until then diverse interests will continue to win out, sub-optimize the performance of the system and leave the American public with the bill.