OP-ED

Health Care’s Rube Goldberg Machine. Who Is Responsible?

flying cadeuciiRube 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.

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esteban cruzBob HertzlawyerdoctorsteveSaurabh Jha Recent comment authors
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John Ballard
Guest

Thanks to three or four decades of condescending remarks by sanctimonious political types and ordinary people eaten up with righteous indignation, the word welfare implies as much social disrespect as whore or bastard — even worse than “charity.” I wish there was a way to change that. By the same dynamic many of us who once self-identified as Liberal were shamed into saying “Progressive” instead. Liberal has become something like the N-word in many otherwise polite conversations. Talk radio and some columnists signal many arguments against anything they don’t like by dropping that word early and often in their diatribes.… Read more »

Bob Hertz
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Bob Hertz

Just to continue, there are two ways to pay for emergency medical services: either everyone pays a little tax, or the few unlucky users pay thousands of dollars (and-or carry good insurance). But then, by the time we subsidize and regulate the insurance markets so that nearly everyone has coverage, this too costs tax dollars. We might be better off just having public hospitals and federally funded emergency rooms. Cuts out the insurance middle man. It also sounds like welfare. Well it is welfare in a way. Meanwhile thousands of highly Republican communities have public funding for fire and police.… Read more »

Bob Hertz
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Bob Hertz

John the problem you see is the result of funding hospitals through user fees. when we do that, every claim for $30,000 shows up like a sore thumb. However suppose we funded hospitals like we fund fire departments, with lump sums each year from the taxpayers. Fire departments go just as fast to the homes of those who smoke in bed, as to the homes of prudent homeowners who are struck by lightning. It is not perfect but no one complains. The same is true for the ambulances that go rapidly to traffic accidents. We tolerate a little sloppiness in… Read more »

John Ballard
Guest

My point exactly. Biblical, too. He causes his sun to rise on the evil and the good, and sends rain on the righteous and the unrighteous. US healthcare still has gaping holes, including more pro-active mental health, basic dental care and aftercare coaching and assistance for family members and other non-medical caregivers. Hopefully some of these experimental ACOs will discover the long-term benefits of some of this low-hanging fruit. We know dental care, for example, has preventive value but only rarely does that healthcare angle get mentioned. And dare I mention substance abuse treatment and counseling for problems like those… Read more »

esteban cruz
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esteban cruz

Oh did I mention, the majority of the Pts (80% +) who don’t care are on medicaid (usually by age 30 and above); IVDA 30yo; anemia 40yo, Morbidly obesity- they eat themselves into a disability so they can get more food thru – you guess it – medicaid/disability. Fibromylagia- this is the new Dx to get disability money and Medicaid money at a young age 20yo and up- to cont a crack habit/ oxycodone addiction – which started before the fibromylagia disorder. (Pts have figured out that there is no labs to check if you really have fibromyalgia, diagnosis by… Read more »

John Ballard
Guest

You have described the poster child for someone who seems undeserving of medical care. People such as you have described are not limited to the poor. I have seen well-off suburbanites (and you have, too) who are functioning substance abusers as well as others who can afford high-end preventable medical care because they can afford it. I take a very dim view of people with bad habits they can afford bitching about others with the same bad habits they cannot afford. Are you suggesting that those who can afford morbid obesity, excessive substance abuse and/or chronic self-destruction deserve a pass… Read more »

esteban cruz
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esteban cruz

So ..let me get this straight, a patient’s irresponsibility in life finances becomes everyone else’s responsibiltiy. I get this a lot (80%) of the time. A patient’s non-compliance with meds; bad choices in life (IVDA) endocarditis at 30 years of age with an emergent aortic valve replacement (due to IVDA); a lung cancer Pt- due to smoking which led to mets to bone and breast tissue- comes in for anemia – every month or so for blood transfusions (due to bone marrow failure) becomes the society/hospital’s problem to fix. Many times its the responsibilty of many pts too avoid bad… Read more »

John Ballard
Guest

Margalit Gur-Ari has a post at Kevin, MD obliquely related to this subject — whatever the subject is. The basic question is at what point does medical care reach a practical threshold and when has the magic of modern science cross the line from practical care to the upper reaches of anything possible. The sub-text, of course, is more about how much it costs, who will pay and what are the limits, if any, to what is done. Sooner or later that hateful British acronym QALY will creep into the discussion. Check this paragraph. Why wouldn’t hospitals auction off original… Read more »

Perry
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Perry
Bob Hertz
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Bob Hertz

There was a fascinating book several years ago on this very subject called “Momma might be better off dead.” I do not know how to say this politely, but by and large America would rather like its poorest black citizens to die off, and more cheaply, please. This was true when the great singer Bessie Smith died in the 1930’s, after being denied admittance to a white emergency room. I have visited dialysis centers where many of the patients were poor blacks – who were given no decent education, no jobs, and awful housing, but now found their lives being… Read more »

John Ballard
Guest

Good point, but it’s worth noting that it is either tax money or a tax deductible charitable contribution. And it applies to poor people of all colors. ESRD is covered for Medicare/Medicaid beneficiaries.

Arguments against “redistribution” fall to a whisper when the revenue stream flows from taxpayers to the corporate private sector. But mention single-payer or community health provokes cries about socialism and “handouts.”

MD as HELL
Guest
MD as HELL

The other part is they all vote Democrat

John Ballard
Guest

It’s hard to know how children vote, but where I live most Medicare beneficiaries are Republicans — and say so in no uncertain terms. It may be different elsewhere but I’m skeptical. As for Medicaid beneficiaries: Children account for nearly half of all Medicaid enrollees but just one-fifth of Medicaid spending. Only one-quarter of Medicaid enrollees are seniors or persons with disabilities, but because these beneficiaries need more (and more costly) health care services, they account for nearly two-thirds of all Medicaid spending. http://pllqt.it/qaIBUN Seniors in long-term care are a big part of Medicaid spending. That is the “third rail”… Read more »

lawyerdoctor
Guest

Agree with those who promptly and correctly identified this issue as a SOCIAL support problem, and NOT a hospital or medical care problem. The writer suggests somehow that the hospital facility could let this unfortunate woman “stay for a few more days at a cost of just a few thousand dollars”?? This is in fact what they did. I’m certain she stayed well beyond her point of “maximal hospital benefit” or past the point of where inpatients services were warranted by Milliman or Interqual. BTW, since she is on Medicare (she has hemodialysis!) – the taxpayers are paying the bill… Read more »

John Ballard
Guest

Careful there, Mr. lawyerdoctor. You’re getting perilously close tot he third rail of health care — seniors on the way out. No one likes to speak openly about it, but one of the most costly features of Medicare/Medicaid is the rarely-mentioned expense of what is politely called “custodial care.” Anybody in the know can tell you that an important part of the protocol of getting a family member into a nursing home is first getting him or her into a hospital for three days, after which a doctor orders them to “rehab.” Forget the fact that there ain’t no meaningful… Read more »

lawyerdoctor
Guest

I think many of you are missing the point. NO one is advocating this lady be denied “medical care.” In fact, she is getting more “medical care” than she would appear to need. What she needs (and doesn’t have much access to) is HOUSING. This is not a function of the health care system. It is a social need and a social issue, and we will frequently admit a patient overnight for a “social admit” who is homeless, or missed the queue at the shelter, etc. But hospitals are not taxpayer funded hotels. And to Mr. Ballard’s point, this lady… Read more »

John Ballard
Guest
lawyerdoctor
Guest

Good one!! Isn’t that the guy who played the evil Dr. Lizardo from “Buckaroo Banzai”?? He sure is doing a good imitation of John Lithgow. Maybe he could take his own message, skip the creepy eye shadow for a while and pay for some poor guy’s crack habit? Again, you guys are missing the point. We can debate the utility of social infrastructure, “safety nets” for people, ad nauseum. The point is that when seniors pay into Medicare, they are not paying to subsidize other people’s housing. They are paying for healthcare. You may not think that is fair, or… Read more »

John Ballard
Guest

The notion of social safety nets is not debatable. You and I should agree to disagree about that. I find the laissez-faire Libertarian philosophy repugnant and mean-spirited. I’m sorry I pushed your political button. Big mistake on my part.

Saurabh Jha
Guest
Saurabh Jha

“we need to stop attempting to solve the problems of complexity by adding more complexity.”

Indeed.

The solution may lie in a temporary moratorium to solving.

Hans Duvefelt, MD
Guest

Health care in this country is not designed to solve social problems. That’s just the way it is. In Sweden, this woman’s plight would have been the subject of volleying between the health department and the social services department of the (same) local government. Here, there is not enough dialogue between the totally separate systems of health care and welfare. That seems to be what we need.

“Sometimes the questions are complicated and the answers are simple.”
Dr. Seuss

John Ballard
Guest

I don’t like the notion of healthcare as an ivory tower benefit, an amenity only for those who merit access. And that appears to be the drift of this comments thread. A standard is needed below which no one — even non-citizens, criminals or bums — is allowed to sink. We expect safe drinking water, properly engineered highways and bridges, public and private buildings meeting minimal codes, toys that don’t kill or injure kids, foods and medicines that don’t make us sick or kill us and a whole list of benefits of living in a modern civilized society. It is… Read more »

William Palmer MD
Guest
William Palmer MD

Sometimes emergence takes over in the management of complex self-organizing systems. I wouldn’t worry too much here. Remember all the file formats for image transimission on the Net? First we had ascii graphics, then GIG, PNG, TIFF, JPEG, VRML, XBM, XPM, BMP, PICT, IFF, and a few more.
Usage and evolution and survival of the fitest will gradually simplify. But I agree that it is a disgrace today, and unless something changes…..

Perry
Guest
Perry

I agree Jeff, the healthcare provided to this lady was apparently excellent. The underlying issues are social. This is also why our “healthcare” is not in the top positions as some other industrialized countries, because we are not a socialized society and our freedoms allow for people to live lives that may have bad consequences for their health. I also agree with Richard, however that these underlying social issues have significant impact on how well we can provide health care for certain segments of the population, namely the poor and homeless. Unfortunately the Rube Goldberg part of our current system… Read more »

Jeff Goldsmith
Guest
Jeff Goldsmith

OK, guys, this isn’t the health system’s problem, is it? We don’t have the type of society where someone is sitting in the control tower saying,”Mrs. Jones got burned out of her apartment. Go requisition her a new one and we’ll pay for her to move into it!”. I’m not arguing that our health system isn’t absurdly complicated, but why is it the health system’s problem that she got burned out of her apartment and doesn’t have a place to live? Maybe I’m missing something. The health system did its job. This is about our society, not Rube Goldberg.

Richard Gunderman
Guest
Richard Gunderman

One of our greatest pitfalls is to focus all our attention on healthcare, as though it is an island separate from the rest of our lives, when in fact many of the most difficult problems healthcare professionals deal with on a daily basis involve the interaction between what we call healthcare and the rest of our patients’ lives. If we treat healthcare as an isolated machine that needs to be fixed, we will be overlooking important challenges and opportunities that any effective healthcare professional needs to be mindful of, and on which they may even need to engage in community… Read more »