Healthcare’s Blackjack Thinking is Broken

We have a competitive group here. We play tennis, racquetball and ping pong with a cutthroat congeniality. When we need a break from healthcare, we fill our lunches with board games, most frequently, the widely popular Settlers of Catan. We do it to change our head space, but playing games improves our work even while distracting from it. It’s also a helpful metaphor.

We’re successful problem-solvers because we recognize patterns. We learn from experience and catalog information for further use. We test our hypotheses, indulge our curiosity and iterate on our approach. We design when we work and when we play.

That’s how problems are solved today — except in healthcare.

Now, no one would confuse Settlers of Catan for chess. There’s luck involved, and we’re sure to remind one another of that when irritated after losing a close game. But chess is a little draining for lunchtime, and Settlers still requires a ton of strategy. In game parlance, Settlers of Catan is “well-balanced.” That means that there’s no obvious inefficiency that can be exploited by a singularly shrewd player. There are many different ways to win, each equally viable, though board-dependent.

Success in the game is a function of two distinct types of thought. First, you have to plan around the state of nature, which is different every time the board is assembled (There are somewhere in the neighborhood of 7.7 x 1027 different starting configurations possible). Then you have to decide to either stick with that plan or alter it, based on rapidly changing conditions and forces that are beyond your control. When it’s all over, you have to put the result in context to see how you you should change your approach next time.

Pardon the extended metaphor, but if you’re curious, pick up your phone and download the pocket version of Settlers of Catan. It comes loaded with pre-built computer opponents with distinct skills and personalities. Some of these “players” are far more challenging to wrangle than others, but most of them adhere pretty closely to a personality-dependent strategy. They have a way that they want to play, and they always try to find a way to do it.

A lot of decision makers and consultants in healthcare work the same way. They have a methodology and they’re damn well sticking to it. They come into an environment and ignore the fact that it’s different and unique than any other. They examine it, but they are ultimately only looking for an an on-ramp to play the way they want to play. Just like the players in the iPhone game, they’ll get it right when the conditions are perfect for their approach, but on the whole, they’re hopeless because they can’t adapt. They can’t contextualize the problem-spaces they work in — the entire approach is retrograde.

Healthcare executives have become accustomed to getting a horrid return on their consulting investment, and so these companies get hired again and again to be blunt instruments of more-of-the-same. The money in healthcare has always been so big that change efforts could afford to be monolithic. You embark on a project, form a committee, hire consultants, dump millions into a strategy without testing it or iterating on it. When it doesn’t work, wash, rinse repeat. More committee meetings. Mini danish for everyone!

A 2012 study from the Institute of Medicine found that 24.8 percent of healthcare waste is excessive administrative costs. 17 percent is inefficiency in care delivery. Those percentages are big slices of a $750 billion pie. And traditional consultants are tweaking the org chart and providing trademarked matrices for better communication.

These people are playing blackjack — there’s a right decision and a wrong decision and it’s always the same, no matter what table you’re sitting at or what dealer you’re across from. If fortune favors you, you walk away a winner. If it doesn’t, you lose, but you still employ the same strategy the next time you go to the casino. It couldn’t be more fitting that the HIMSS conference starts next week in Las Vegas.

Blackjack thinking won’t solve the kind of problems that are facing modern healthcare.

To change healthcare, we have change our entire approach to solving problems on the ground. The methods that have been employed for decades aren’t having an impact. We can wait for a halcyon policy solution to fix it all, or we can admit that the way we do things is broken, and start playing a more interesting game.

Originally published at