I talk to a lot of people who treat addiction. I talk to counselors, psychologists, and physicians. I talk to nurses and administrators. It doesn’t matter who it is, I’ll talk to them, and I love to ask about their experiences and how they’re doing. So I get a lot of input from people who treat addiction from all over the country. They aren’t, for the most part, a happy lot.
Generally, they don’t understand what’s happening to them. They work hard, have good hearts, and only want to help. Seemingly, at every turn, they are thwarted and hindered.
I talk to a lot of insurers too. They aren’t happy either, and, generally, they don’t understand what’s happening to them. They work hard, have good hearts, and only want to help. Seemingly, at every turn, they are thwarted and hindered.
And each group points to the other as the main source of hindrance. What a mess.
The good news is that neither group is the problem. Both groups are filled with enough people of good intention and honest work ethic that everything can work out. The problem is that the groups are caught in a cultural bind that is beyond their ability to effect; in fact, it’s beyond their knowledge. They don’t even know it exists. To explain it I have to tell some stories.
The first story is that of Termites, Turtles, and Traffic Jams by Mitchel Resnick. The story he tells is a grand one. Resnick explains how small actors like termites, without big brains or complex rules, can work in massively parallel systems to create things seemingly far beyond their individual ability. He tells us why birds fly in formation and why traffic jams even when there’s no reason. The rules of Resnick’s actors are few. In any given system 2 to 3 rules are enough to generate complex results without the actors understanding the system or the result. If you were a termite building a mound, and could then look at it from a distance, you’d be amazed at what you were part of creating.
That’s the experience of the traditional addiction treatment world. The actors of this world follow only a few simple rules like: don’t use a lot of medicines, keep the patient in treatment a long time, keep saying the same thing over and over. It’s just their job and they do it. Like the termite who’s job is to put a daub of mud on a wall, they do that job over and over again no matter how many times the daub falls off. Eventually, after a while, they can back up and look at the termite mound of an alumni group and be amazed that their puny individual efforts were part of something so amazing. It’s an experiential process; it’s a parallel process; it’s a simple process, but with enough effort it can produce, over time, amazing results at high cost.
The second story is that of Eliyahu Goldratt and The Theory of Constraints. The story he tells is also a grand one, but profoundly simple at the same time. Goldratt explains how specialized actors like welders, machinists, engineers, following sophisticated plans and algorithms can work in serial systems to create amazing things far beyond their individual ability. He tells us how factories work, how people can create new medicines for new illnesses from limited knowledge, and why everybody has one goal. The rules that Goldratt’s actors follow can be different from actor to actor and from situation to situation, but the overarching set of logical rules they follow to produce the serial algorithms are simple and infinitely scalable.
That’s the experience of medical insurance companies. The actors of this world need to follow a more complex set of rules to get their job done. To do things like build washing machines or create algorithms for chest pain in an emergency room, you definitely need more than 3 rules. Instead of all the birds in a flock following the same three rules to produce a formation, in the sequential world of Goldratt, each person may have a specialized role that is not at all interchangeable with anyone else’s. The jobs may be simple but they are sequenced in specific ways to produce much more complex feats of engineering than a termite mound. It’s a data based process; it’s a serial process; it’s a complicated process, and it’s designed to produce, all the time, amazing results at low cost.
Is it any wonder that these two groups, traditional addiction treaters, and insurers, have trouble getting along? So is it a lost cause? A hopeless case? Is there no resolution? I didn’t say that. I think there is a resolution, and the resolution starts with the groups realizing that they have not only been speaking different languages, they’ve been living in different worlds. It’s like one group was living in Dr Zhivago, and the other group was living in All’s Quiet on the Western Front. Both books are about the same war, but the characters in one wouldn’t recognize the war in the other.
So what do we do now? Both sides have recognized the other is living in the “wrong book.” That doesn’t get us too far, does it? No, but oddly both Resnick and Goldratt give us solutions. Resnick would say that we, as an industry, are treating thousands of people in a massively parallel way and creating huge amounts of data, or we would if we had a standard set of questions and outcomes to apply. We could use that to create better data driven treatments and be able to speak to the insurance world with their language. Goldratt would tell us that we all have the same goal, and that any apparent conflict is due to mistaken assumptions; he’d sit us down and have us examine those assumptions to find that we were all on the same side to begin with.
I’ve recently been interviewing people working at insurance companies to see what they have trouble with when it comes to the addiction treatment field. Perhaps I’ll have more detailed answers soon.