Characteristics of Systems
A system is a group of interacting people and processes that are organized for the purpose of producing goods and services and delivering them to the people who need or want them. A system openly interacts with its environment to procure raw materials and identify consumers of its goods and services and to respond to changes in need and demand, technology and innovation, demographic and economic trends, political realities, and natural and man-made disasters. Organizational and systems theories indicate that the effectiveness and survival of systems require continuous adaptation to internal and external factors. Systems must self-adjust to remain relevant and viable. If systems become too complex to function efficiently and effectively, adaptations falter, resulting in poor outcomes for the system and the population it serves.
Health care in the U.S. is an example of a very complex system. Its basic elements are patients, providers, and payers. However, the patients are diverse in age, education, social and economic status, and cultural/ethnic roots and include people who are: well but need routine examinations, screenings, health education/promotion, and guidance; experiencing critical illnesses or injuries and need extensive diagnostics and technology intensive care; experiencing common illnesses or life events that respond to routine interventions; experiencing chronic diseases or disabilities that vary in intensity and number and require monitoring and care over time; or experiencing terminal illnesses that require symptom management and supportive care. The health care providers are also diverse and include: institutions with a wide range of mission and capacity from high-technology diagnostics and interventions to homemaker services; clinicians drawn from multiple professional disciplines with different training and competencies; support services that range from the simple (e.g., greeters who welcome patients) to the sophisticated (e.g., diagnostic testing or information systems); and suppliers that provide goods and services that range from tissue paper to genetic material, from spiritual support to computer support, from paper clips to titanium replacement parts. Finally, health care payers vary widely and include: insurance companies that are regulated differently by each of the 50 states; various federal and state programs for special populations and the uninsured; individuals who pay out of pocket for premiums, services not covered by insurance, and philanthropy. Even these basic building blocks of the health care system are complicated.
Patients, providers, and payers interact at different times and with different motivations. Insurance companies seek to make money by designing benefit packages to market to individuals and employers and by managing benefits to enrollees to maximize patient outcomes and patient satisfaction. Employers purchase insurance packages for their employees to attract and retain workers. Individuals with insufficient knowledge of their future health care needs choose health insurance plans based on cost of premiums, co-payments, and deductibles. Individuals then use their health insurance to pay to visit an array of providers depending on the specific need for health care, the availability of providers, the nature and urgency of the problem, and even the time of day. Each provider has patients covered by many insurance plans, all with different benefits and administrative process for approving and paying for services. In the ideal world, there is synergy among patient, provider, and payer. In the real world, the variety and complexity of patient needs and health providers can lead to very disjointed service. Another real world fact is that up to one third of people under age 65 do not have health insurance and another 25 million are underinsured (Whelan & Feder, 2009). Uninsured people often delay treatment, become more seriously ill, and need more extensive and expensive treatments in more complex settings when they do present for care. And their care is financed by shifting the cost to insured patients, the insurance plans, and the taxpayer in a way that makes tracking the true cost of this care almost impossible.