The Affordable Care Act: a case study for understanding and applying complexity concepts to health care reform.

RATIONALE, AIMS AND OBJECTIVES: The current health system in the United States is the result of a history of patchwork policy decisions and cultural assumptions that have led to persistent contradictions in practice, gaps in coverage, unsustainable costs, and inconsistent outcomes. In working toward a more efficient health system, understanding and applying complexity science concepts will allow for policy that better promotes desired outcomes and minimizes the effects of unintended consequences. METHODS: This paper will consider three applied complexity science concepts in the context of the Patient Protection and Affordable Care Act (PPACA): developing a shared vision around reimbursement for value, creating an environment for emergence through simple rules, and embracing transformational leadership at all levels. RESULTS AND CONCLUSIONS: Transforming the US health system, or any other health system, will be neither easy nor quick. Applying complexity concepts to health reform efforts, however, will facilitate long-term change in all levels, leading to health systems that are more effective, efficient, and equitable.

Teamwork in health care.

It is becoming increasingly clear that maintaining and improving the health of the population, and doing so in a financially sustainable manner, requires the coordination of acute medical care with long-term care, and social support services, that is, team-based care. Despite a growing body of evidence on the benefits of team-based care, the health care ecosystem remains "resistant" to a broader implementation of such care models. This resistance is a function of both system-wide and organizational barriers, which result primarily from fragmentation in reimbursement for health care services, regulatory restrictions, and the siloed nature of health professional education. To promote the broader adoption of team-based care models, the health care system must transition to pay for value reimbursement, as well as break down the educational silos and move toward team-based and value-based education of health professionals.

Regulatory and reimbursement innovation.

Coverage with evidence development and parallel review for molecular diagnostics aid regulation and reimbursement.

Prospects for change.

This chapter addresses the prospects for change in health care delivery. The focus is on value - high quality, affordable care for everyone. We consider three domains that participate in the flow of value and the nature of the interfaces among these domains. We also discuss strategic priorities that should align in various ways with these domains. Finally, we address the business transformations needed to enable the provision of value by enterprises that are viable and successful.

Putting the needs of the patient first: Mayo Clinic's core value, institutional culture, and professionalism covenant.

From its inception more than a century ago, Mayo Clinic's founders instilled the core value, the needs of the patient come first, into the institution's culture. Today, this core value of professionalism continues to guide the clinic's leadership practices, management strategies, and daily activities. Members of the Mayo Clinic staff embrace and reinforce this core value and regard it as a professionalism covenant: a collective, tacit agreement that everyone will earnestly collaborate to put the needs and welfare of patients first. This covenant is articulated for patients and learners in two key documents, both crafted in 2001--the Mayo Clinic Model of Care, and the Mayo Clinic Model of Education--and is reaffirmed through Mayo Clinic's mission to provide the best outcomes, service, and value in health care to every patient, every day. Mayo's value-based culture serves as a powerful, positive hidden curriculum that facilitates the accomplishment of desired practice and educational outcomes and fosters the development of health care professionals with the highest standards of professionalism. The profound allegiance of Mayo Clinic staff and students to its patient-centered culture connects all to the purpose and meaning of their work, elicits collaboration and voluntary efforts, and fosters an environment that is committed to excellence and continuous improvement. In the context of contemporary challenges and competing commitments facing academic health centers, the authors discuss key initiatives that Mayo Clinic has implemented to preserve the institution's culture, honor the professionalism covenant, and enable faculty, staff, and learners to align their behaviors, work activities, and resources to accomplish the institution's mission.

Managing conflict of interest in clinical practice.

Conflict of interest, even the appearance of potential conflict, has long been a concern for physicians and scientists. Conflict of interest arises when an activity is accompanied by a divergence between personal or institutional benefit when compared to the responsibilities to patients and to society; it arises in the context of research, purchasing, leadership, and investments. Conflict of interest is of concern because it compromises the trust of the patient and of society in the individual physician or the medical center.

The emerging context for advances in comparative effectiveness assessment.

The call for an entity for independent assessment and guidance on alternative medical interventions is timely. The emergence of four developments underscores the importance and sets the stage for progress: an improving evidence base; growing recognition of the importance of variation in the effectiveness of treatments across patients; recent emphasis on transparency; and growing adoption of pay-for-performance initiatives. To advance progress on these issues, the Institute of Medicine (IOM) has convened a Roundtable on Evidence-based Medicine. The roundtable is exploring ways to improve the development of evidence, the thoroughness with which it is applied, and the mechanisms for increasing national capacity for the work.