摘要：The US health care system is struggling with a mismatch between the large, simple (low-information) financial flow and the complex (high-information) treatment of individual patients. Efforts to implement cost controls and industrial efficiency that are appropriate for repetitive tasks but not high-complexity tasks lead to poor quality of care. Multiscale complex systems analysis suggests that an important step toward relieving this structural problem is a separation of responsibility for 2 distinct types of tasks: medical care of individual patients and prevention/population health. These distinct tasks require qualitatively different organizational structures. The current use of care providers and organizations for both purposes leads to compromises in organizational process that adversely affect the ability of health care organizations to provide either individual or prevention/population services. Thus, the overall system can be dramatically improved by establishing 2 separate but linked systems with distinct organizational forms: (a) a high-efficiency system performing large-scale repetitive tasks such as screening tests, inoculations, and generic health care, and (b) a high-complexity system treating complex medical problems of individual patients. THE STRUCTURE AND processes of the existing US health care system have been designed around the need to respond to the medical needs of a self-presenting individual. Widespread recognition of the importance of prevention and of population health 1 – 3 has led to efforts to charge the health care system to respond to these needs. There is, however, limited recognition that imposing on the same organization the need to respond to such radically different tasks leads to ineffectiveness and inefficiency. Instead, it should be understood that a distinct system (or subsystem) that is well adapted to the task of prevention and population health services can be much more effective and efficient at those tasks and, by serving these needs, help to solve many of the existing difficulties of the health care system. Thus, the imperatives of public health, which are concerned with prevention and population health, may be better served by developing organizations that serve these needs directly. This is an organizational approach to the separation of tasks rather than an approach based on questions of public or private financing or delivery. A precise analysis distinguishes tasks that are numerous and repetitive (and thus “large scale”) from those that are numerous and variable (and thus “fine scale” or “highly complex”). Distinct organizational structures are effective at these distinct types of tasks. Separating medical care for individual patients from preventive and population health services provides a first and important line of distinction between highly complex and large-scale health care services. The concepts of scale and complexity can be used to analyze various aspects of organizational structure. A formal multi-scale analysis implies that for an organization to be effective, there must be a match between the scale and complexity of the functional capabilities of the organization and the scale and complexity of the tasks to be performed. My analysis implies that (1) the serial coupling of large-scale financial flows and complex medical decisionmaking is largely responsible for organizational turbulence and ineffectiveness in the health care system, and (2) Development of separate organizational forms for tasks at different scales is an essential step toward resolving the structural problems of the health care system and will both relieve the financial and organizational turbulence of the health care system and lead to greater effectiveness of complex medical care and large-scale prevention and population health services.
