Education and Health Care: Complex Systems Dreams, Volume Operations Budgets
While different in many ways, education and health care share a common predicament. The receivers of these services—parents and students on the one hand, patients and advocates on the other—are cultured to expect superior, personalized attention, the sort of thing that a complex systems business model excels at. The immediate providers of these services, teachers and doctors, share these same aspirations as well.
Unfortunately, the complex systems model is not scalable to the needs of a large society. The only model that scales is the volume operations model. (For a discussion of the contrasts between these two models, see Harvard Business Review, December, 2005, “Strategy and the Stronger Hand”). It does so by transforming unique relationships into standardized transactions. It is not driven to achieve excellence but rather to meet minimum quality standards as economically as possible. This is the model that legislatures and health plans fund, that administrators seek to administer, leaving teachers, aides, doctors, and nurses with the task of mediating between complex systems expectations and volume operations budgets.
It does not take a great deal of reflection to realize that the volume operations path is the only feasible one to take from a social safety net point of view. More affluent citizens may avail themselves of the complex systems model, but only at a considerable price. The key point is that such service is not, and should not be represented as, a social entitlement.
And this is where things get hairy, specifically in a society dedicated to egalitarian principles. The economics of education and health care do not support entitlements beyond a basic safety net. Yet the public dialog implies those entitlements exist, or would exist if only the economically privileged would be more generous. At this juncture in the dialog a liberal/conservative split ensues, something which has played out over my entire adult lifetime, with no end in sight, and no insight in sight either.
I think the constructive path forward begins with abandoning any expectation of providing broader access to the complex systems model and instead focusing our creative energies on raising the standards of the volume operations capability as much as possible. This means focusing public investment on the mean, not the extremes, of the health care continuum, investing in more efficient, effective, and pervasive basic health services. Private funding can pursue the esoteric edges—that’s its privilege—but public funds should not. We need to focus those dollars more on process, on access, on communication, on methodology, and on resetting societal expectations about the nature and value of primary care.