5. The rules of the system.

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Such as incentives, punishment, constraints. Pay attention to rules, and to who makes them.

For example, a strengthening of the law related to chemicals release limits, or an increase of the tax amount for any water containing a given pollutant, will have a very strong effect on the lake water quality.

Rules that change a  negative feedback loop can slow down a process, tending to promote stability. The loop will keep the stock near the goal, thanks to parameters, accuracy and speed of information feedback, and size of correcting flows. For example, one way to avoid the lake getting more and more polluted might be through setting up an additional levy on the industrial plant based on measured concentrations of its effluent. Say the plant management has to pay into a water management fund, on a weekly or monthly basis, depending on the actual amount of waste found in the lake; they will, in this case, receive a direct benefit not just from reducing their waste output, but actually reducing it enough to achieve the desired effect of reducing concentrations in the lake. They cannot benefit from “doing damage more slowly” — only from actually helping. If cutting emissions, even to zero, is insufficient to allow the lake to naturally purge the waste, then they will still be on the hook for cleanup. This is similar to the US “Superfund” system, and follows the widely accepted “polluter pays principle”

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Who makes the rules of healthcare delivery system?

  1. Congress and State Legislatures, influenced by lobbyists for AMA, AHA, Nurses, Pharma, Device Manufacturers, Insurance companies, Paramedics.
  2. Local and regional service delivery organizations: hospitals and physicians.

Who has the strongest voice in making the rules for the system is a huge problem, perhaps the biggest obstacle to real change. It is also worth considering that when we limit our attention to the fifth leverage point (#5 Rules) and above, we risk ignoring of intrinsic human motivations. The beliefs, the motivations, and the human goals are often disassociated from the daily decision making which become rule-based rather than intrinsically motivated. The game becomes much less engaging to humans. To significantly change the incentives, the people need to be able to influence the legislative process or at least remove some of these constraints–locally. Elinor Ostrom has much to contribute to the design principles for sustainable community resources.

And what are the rules that drive the system?

  1. Pay for acute care, visits, tests, procedures (not outcomes or satisfaction)
  2. Little to no focus on prevention (screening and life-style choices), continuous support, palliation, mental health, or well-being.

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If we assume that the system must be an illness care system rather than a health system, then we can assume that the rule makers are pretty entrenched and will be slow to change based upon the first four leverage points.

However, if we are willing to design a different system based upon health and human flourishing, the rules can be developed at the individual and community level. Then much of the cost and discomfort of the current system will melt away.  At any given age the population will have a lower burden of illness. Many of those who do become ill will be much more able to cope and heal. Many will be more at peace with themselves and their loved ones when death does inevitably come.There is no reason the limit access to care. However to avoid rationing we must get ahead of illness with training and support for human flourishing in schools, at work, and in neighborhoods along with emphasis on the non-acute services listed above.

Rules are a key part of successful, engaging “games”. Rules make the play fair and interesting. Rules constrain action and make the play challenging. However meaning is very important to successful, engaging games, especially multilayer games, and meaningfulness comes from values, ideas, and goals–in that order.

What difference would it make if we followed Elinor Ostrum’s eight rules that govern the management of common pool resources?