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Searching for a new paradigm in health care delivery.

The cartoon character Pogo, uttering his now famous line, "We have met the enemy and it is us," might well have been referring to the dilemmas that we face today in American health care. A major source of our current difficulties in solving these admittedly complex problems lies in our way of thinking about, or conceptualizing, health care and health care delivery. We are caught in an old paradigm that is simply not adequate for dealing with the health care delivery problems of the '90s, not to mention those of the 21st Century.

Paradigms are models or frameworks that determine the basis of how we see a given problem. They are a starting point or "given" set of values and concepts that influences our perception and interpretation of what we observe.(1) Paradigms are analogous to filters on a camera. As long as there is, for example, a red filter covering the lens, the picture will look red, regardless of how vivid other colors might be or how the camera is manipulated. That filter exerts tremendous influence over what is perceived and how it influences the individual. Its presence prevents a more objective perception of what is there. Only when the filter is changed--similar to changing to a different paradigm--can the real picture be seen.

For instance, nonscientific factors play a major role in shaping the paradigm through which scientific issues are viewed. They affect what scientific work is done and how it is approached and may introduce biases into the results. Most important, they affect how results are interpreted, whether or not new scientific data are generally accepted, and what, if any, behavior changes result from the new data. The less consistent new scientific data are with the prevailing model, the more difficulty there is in maintaining objectivity about the data and in accepting their validity, no matter how convincing the level of scientific proof.

The history of science is replete with examples of discoveries that were not accepted until decades, or even centuries, later. Kuhn explained the phenomena of paradigms and paradigm shifts in connection with Copernicus' finding that the planets revolved around the sun. Copernican theory, despite its accuracy, became the focus of tremendous controversies in religion, philosophy, and social theory for 150 years.(2) It took that long for a shift in paradigms to take place.

Contemporary Health Care

Despite the fact that we live in a world unrecognizable to those in Copernicus' time, the process of human thinking and the importance of paradigms have changed little. The interpretation, acceptance, and implementation of new scientific data are greatly affected by nonscientific conditions dictated by the framework in which we think. Thus, the old paradigm, by preventing or retarding understanding, acceptance, and implementation of new ideas, represents an obstacle to progress.

The same principles operate today in the health care arena. The old paradigm has become outdated and simply will not work as a model for the future. Furthermore, the constraints on our thinking brought about by the persistence of the old paradigm represent the single greatest obstacle to meaningful progress in solving the cost and access problems facing the American health care system. These constraints are a major factor in the resistance to change found in this tradition-bound industry.

Continuing to ignore the paradigm in which we operate and its constraints will only lead to further frustration and continued failure in our attempts to bring order from the current disarray in the system. It is time to identify our current paradigm and to devise a new, more relevant, and useful one. To use Kuhn's concepts, the window of opportunity for a paradigm shift(3) is open, and it is up to us to seize the opportunity. We can think of no more fruitful way of addressing the current problems in health care delivery than by understanding the filters, constraints, and limitations of our historical paradigm for health care.

The Current Paradigm

The current health care delivery paradigm is deeply rooted in our cultural history. To trace all parts of it to their origins would be a daunting task. Fortunately, if we can simply identify some of the major factors in the paradigm, we can begin to assess their importance and understand how they are a help or a hindrance in implementing innovative and meaningful changes in the health care delivery system.

It is important to keep in mind that the majority of health care professionals in the United States are operating in the same, or nearly the same, paradigm. This should not be surprising; we trained in many of the same medical, nursing, or health care administration schools and are affected profoundly by many of the same dominant cultural norms. Culture changes slowly and often remains the same while being disguised in new terms or garb. Seemingly quite different systems, e.g., an HMO and a feefor-service system, may actually be quite similar in terms of most aspects of the paradigms under which they operate.(4) In this example, it is the reimbursement systems that distinguish the two, but the prevailing models for how health care is actually delivered for the systems are essentially the same.

To illustrate the point, we have chosen the following two components of the "traditional" health care paradigm for discussion:

* The supremacy of technology.

* The focus on treating acute illness and acute manifestations of chronic illness.

The Supremacy of Technology

Our current model of health care delivery grew from the technological revolution of the past half century, when rapid technological advances produced cures for many acute, infectious illnesses that formerly plagued mankind. Elegant diagnostic techniques and surgical successes bordering on the miraculous became the norm. We came to rely upon the maxim that "technology conquers all" and came to believe that problems could be solved simply by developing better technology. Unfortunately, the initial extraordinary successes of medical technology camouflaged the fact that technology cannot solve many of our health and health care problems. This is borne out by studies of health that show that, compared to many less technologically oriented countries, we are improving in fewer categories of measured health status.

Despite this, the belief in the preeminence of technology remains an important part of our current thinking. The prevailing paradigm continues to give the greatest emphasis to "high-tech" diagnostic and treatment interventions, while relatively little attention is paid to other, much less technological measures. If one set of high-tech solutions fails to achieve a desired result, we try another high-tech measure.

Our continued reliance on high technology has prevented us from investigating the role of other "low-tech" solutions to many of our current problems. Operational solutions that would involve much better and more efficient management of patients have only rarely been explored. Pervasive illnesses such as heart disease are left to flourish at the levels where education and behavioral change, both "low-tech" interventions not supported by the traditional paradigm, would make a difference. In the meantime, we expend vast amounts of resources on developing expensive high-tech attempts at cure.

Focus on Acuity

Not only is the current paradigm focused on illness, it is focused on acute illness rather than the chronic illnesses that account for the overwhelming majority of morbidity and mortality in America today. This orientation promotes excellent care for those with acute illnesses or acute exacerbations of chronic illnesses. It does not facilitate adequate care for many of the underlying causes of these acute exacerbations or for measures that would help prevent chronic illnesses in the first place.

Patients often get excellent, intensive, expensive care during an acute episode, only to go home with little or no appropriate follow-up care. They "fall through the cracks" until they become acutely ill again. Much is done to diagnose and treat people who become ill; too little is done to prevent them from becoming ill.

The short-term focus of our society and a reimbursement system that is highly short-term in its thrust combine to make our health care delivery system equally short-sighted. This focus allows us to spend almost 13 percent of our GNP--$671 billion(5)-- on health care without significantly improving the health status of the population. Until the acute-care-oriented paradigm is changed to include a major long-term emphasis, we can expect to see little, if any, improvement in the health status of American people. The current paradigm does not recognize the critical role played by chronic illness in developed countries and the need to approach these chronic illnesses from a long-term perspective. Any emphasis upon health--however it is defined--must await such a concept's being incorporated into the prevailing paradigm.

Recent Innovations

We acknowledge that in recent years there have been individuals and health care organizations that have made appropriate modifications in the paradigms in which they operate. Managed care organizations represent perhaps the most common and most significant such innovations. High technology interventions are routinely screened for their appropriateness in this cost-containment environment. Some managed care firms have begun to use patient incentives aimed at improving health status. The very nature of the managed care process, i.e., having someone other than the provider oversee the delivery of medical care, is in itself an element of a new paradigm.

The chronic nature of many serious illnesses has been recognized by Southern California Edison in its preventive health program. This company has plowed new ground in corporate ambulatory health care management.(6) The Oregon Health Plan, with its proposed use of a priority list of health services to determine access to publicly funded health care, is another example. Many other new and exciting concepts could be cited. Those involved in these new approaches to health care delivery have begun the process of change that will accelerate in the future.

What we are advocating is a comprehensive rethinking of the principles that govern our health care delivery system models. We need to recognize that the old frameworks and ways of thinking are primary problems in their own right--problems that must be addressed in conjunction with the development of new methods if we are to be successful in revamping the health care delivery system.

The Relevance of Paradigms

It took one and a half centuries for a scientifically based concept of the universe to be accepted. While our paradigms continue to change slowly, we do have several advantages over our ancestors in the 17th Century. We have the ability to understand paradigm issues, to identify the specific elements of these critical frameworks that influence our attitudes and behavior, and to do something about changing them--before it is too late. We must address our paradigms directly. If we do not, we will implement a series of solutions for problems that we have not yet defined. We will cling even more tightly to the old---"tried and true"--paradigm by default and increase the dissonance well beyond what it is today.

Where from here?

It is time we stop and take stock--not of all the complex forces stressing health care but at ourselves and our thinking. It is our thinking--its rigidity and our lack of understanding of its importance in the scheme of things--that prevents us from developing and implementing more innovative and effective solutions to the health care crisis. We would propose the following process:

* Health planners, administrators, physicians, and legislators--to name a few--need to begin to examine the paradigms that shape their thinking and behavior. This could be done within organizations, across organizations, within states, etc.

* Once there is improved understanding of our current attitudes and expectations, we can assess whether or not these firmly held ideas continue to deserve emphasis. Are they relevant or workable for the '90s and beyond?

* Then we could ask ourselves what should constitute a workable paradigm for now and the future in American health care? What should be our model? Our standards? Our goals? What are we after? What are we trying to do?

* We would then have laid the basis for developing a mission statement for the health care system--for health care organizations and systems, for the various states, and for the country as a whole. One might argue that we do not have time to do this; we would argue that we cannot afford not to address these issues.

* Having clearly defined our mission, we could then--and only then--be able to determine a way to achieve our goals with some degree of likelihood of success.

Much of what has happened in health care in recent years has been aimed at trying to determine trends and then position oneself or one's organization to take full advantage of this knowledge. As long as we do not confront our paradigm, that is perhaps all we can do. But if we can get a solid grasp on the framework that so profoundly affects our thinking and behavior--the paradigm under which we operate--we can begin to be truly proactive. Pogo was fight. It is us. But because it is us, we have a great deal of control over what we do about it and how we resolve the current crisis.


1. Covey, S. The 7 Habits of Highly Effective People. New York, N,Y,: Simon and Schuster, 1989, p. 23.

2. Kuhn, T. The Copernican Revolution. Cambridge, Mass.: Harvard University Press, 1957,

3. Kuhn, T. The Structure of Scientific Revolutions, 2nd Edition. Chicago, Ill.: University of Chicago Press, 1970.

4. Callahan, D. What Kind of Life (The Limits of Medical Progress). New York, N.Y.: Simon and Schuster, 1990, p. 77.

5. Wagner, L. "Cost Containment: Carrot or the Stick?" Modern Healthcare 21(49):37, Dec. 9, 1991.

6. Walker, J., and Brown, J. "Managing Quality in Corporate Ambulatory Health Centers: The Southern California Edison Story. Journal of Ambulatory Care Management 14(3):68-74, July 1991.

7. Kuhn, T. Op. cit., pp. viii-ix.
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Author:Moser, Dennis R.
Publication:Physician Executive
Date:Mar 1, 1993
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