Rube Goldberg was an American cartoonist and inventor, perhaps best known for the extremely complicated contraptions he devised for performing the simplest tasks. Each year, a national Rube Goldberg Machine Contest is held, challenging competitors to devise bizarre contrivances that can shine a shoe or zip a zipper. One day while watching a group of children marvel at such a machine in a museum, a thought occurred to one of us: As healthcare becomes more complex, the interactions between patients, physicians, hospitals, payers, and communities increasingly resemble a Rube Goldberg machine.
Consider a recent case. Ms. Jones was a 50-something year old African American woman with type I diabetes, high blood pressure and end-stage kidney disease requiring peritoneal dialysis, a form of dialysis performed nightly at home. She was recently admitted to the hospital because of an apartment fire that destroyed everything she owned, including her home dialysis equipment and medications. Once she was hospitalized, the medical team restarted her dialysis, restored her blood chemistries to normal, corrected her blood sugar, and began to make plans for her discharge. There was just one problem. They had no place to send her.
Ms. Jones could not return to her apartment, which had essentially burnt to the ground. She did not qualify for admission to a nursing home. And she couldn’t afford to rent a new apartment, at a cost of about $1,500 per month. She had paid for insurance on the apartment for years, but had recently let the insurance lapse to help finance the purchase of an $8,000 living room suite. The medical team had heard that social service agencies would provide one month’s rent, but it turned out that she could get only one-time distributions of $100 from the Red Cross and $200 from the Salvation Army – not nearly enough.
As the days rolled by, the medical team caring for Ms. Jones began feeling escalating pressure from hospital administration to discharge her. Her medical problems had been taken care of, and there was no medical need for her to remain in a hospital bed at a cost of $1,500 per day. The team arranged to get her dialysis supplies delivered to her sister’s house, hoping that she could stay there until she found a place of her own. But it turned out that too many people were already living there. Attempts to find temporary housing through friends and her church dead-ended. Hotels she contacted were all too expensive. Going to a homeless shelter was not a viable option; it would give her a place to sleep, but she couldn’t perform her dialysis there. She volunteered that she could live out of her car, for which she reportedly used some of the $300 to buy gas, but it later turned out that she did not have one.
As pressure to discharge Ms. Jones mounted, team members became increasingly frustrated. Each new hope was thwarted by an opposing reality. The team had provided their patient with the best available medical care, marshaling the impressive resources of a major academic medical center to solve her acute medical problems as effectively and efficiently as possible. But now they had run up against a barrier for which they lacked the necessary training and resources – not a medical problem so much as a social one. Treating acute illness was doable, but looking out for their patient as a whole person with a real life outside the hospital was proving quite another matter.
Mrs. Jones frequently made decisions that, from the medical team’s point of view, simply didn’t make sense. How could someone with chronic medical conditions requiring expensive treatments fail to be more prudent with her finances and ensure access to life-sustaining medications? How could she let her insurance lapse to buy an $8,000 living room suite? No one on the medical team would even think of letting their insurance lapse, and not one of them had anything in their home of similar value. Such problems were all too frequent. Patients whose drug habits had landed them in the hospital would complain that they did not have the money to buy their prescription medications. It was difficult for team members to understand the life circumstances behind such choices.
The situation was no less difficult for the hospital administrators, who were running a high-tech, acute-care medical center that had been designed to rescue patients from serious illnesses. Could such a huge, high-budget organization afford the few thousand dollars needed to keep Ms. Jones in her hospital bed a few more days? Of course it could, but the hospital needed to develop and abide by policies that supported its mission and ensured that it remained on a sound financial footing. This meant avoiding expenditures that did not promote these goals.
From the point of view of Mrs. Jones, the whole situation seemed unfair and unjust. She knew that the medical center was a multi-billion dollar organization, boasting facilities, equipment, and personnel as fine as those available anywhere. Its billboards and television ads proudly trumpeted its advanced, compassionate care. How in the world, she wondered, could such a formidable organization lack the modest resources needed to find her a place to live? Couldn’t they let her stay in the hospital just a few more days while she worked it out? Couldn’t “the system” offer more? The medical team asked many of the same questions, wondering how they could promote their patient’s health when the social safety net seemed so moth eaten.
So what happened to Ms. Jones? Essentially, she was discharged from the hospital against her will and sent away in a taxi cab. Everyone at the hospital had fulfilled their job descriptions, providing expert care at a financial loss. The patient’s acute medical issues were all addressed. Dialysis supplies had been delivered to a relative’s house, and the team had arranged financial assistance and provided prescriptions for the least expensive medications.
Yet everyone, and most of all Ms. Jones, was deeply frustrated by the whole experience. How can each part of a system do its part, yet the overall outcome still feel to everyone like a failure? It was as though, no matter how hard everyone tried, it was somehow rigged to fail. It wasn’t just Catch-22. It was catch 2,222.
And here lies one of the core frustrations of healthcare today. The interfaces between healthcare and the people, organizations, and communities it touches aren’t just a Rube Goldberg machine. They are a Rube Goldberg machine on steroids. They are so complicated that virtually no one is capable of stepping back far enough even to see – let alone understand or control – the big picture. Who is ultimately responsible? The doctors? The hospital administrators? The patient? The payers? The politicians? And who are they ultimately responsible to? The patient? The profession? The system? Who has the authority – economic, administrative, and professional – to ensure that patients’ needs are met?
Far from solving the problem, most current proposals, which tend to bolt on more layers of complexity, merely compound it. The Rube Goldberg machine has become so byzantine that no one, including even the most knowledgeable and intelligent people in the system, can get their heads around it. Simply lubricating it with compassion does not solve the problem.
What can be done? It is hard to say, but one thing is certain: to turn things around, we need to stop attempting to solve the problems of complexity by adding more complexity. Our current approach means that no one is responsible, enabling everyone to shift the blame to someone else. The big question of our day is this: where should ultimate responsibility lie: with the federal government, the health system, the health professionals involved in the case, or with patients themselves? In our view, the actors on the local scene have the best grasp of the situation, and as much authority and responsibility for resolving it should be entrusted to them. As it is, the unwieldy contraption we call healthcare frequently adds up to much less than the sum of its parts.