The Prussian military strategist Carl von Clausewitz once famously observed that pursuit is the second act of victory and is often more important than the first. In considering the future of health care, the question of pursuit is sometimes overlooked.
To deliver high-value health care, meaningful integration ought to be the object of focused pursuit. That integration should concentrate on coordination, consistency and reliability of care. And that will require robust connections.
The health systems of the future must expand and strengthen the networks that connect their caregivers. Networks have accelerated human progress for thousands of years. For example, the Romans wove a thickening network of roads across much of Europe and the Middle East. This web enabled a surge in trade. It also enabled the spread of Roman law and culture as well as rapid deployment of legionnaires. In the process, it catalyzed and solidified Western civilization.
In North America, railroads created another high-value network that moved people and goods. The railroads were the internet of their day. Eventually railroad rights‑of‑way made it easy to add telegraph lines, telephone lines and power lines, all of which set off explosive network effects. And although business historians routinely point to Henry Ford’s assembly line as the key to his success, a more appropriate explanation can probably be found in the automobile roadways that started to weave their way across the nation, then thickened into a high-value connective transportation web.
Sustainable networks, networks that last, are systems. Systems describe assemblies of things that interact and in so doing become more valuable than when they are apart. The father of “systems thinking,” Russell Ackoff, has suggested that you can tell something is a system if, when you take something out of it, that something is worth less than it was when it was in the system. The system is also worth less. A true system can rewrite the rules of math. There’s synergy in a true system — something that makes 1 + 1 worth much more than 2.
The synergy in a true system comes from network effects. The economies of scale pursued in the industrial era were linear phenomena and subject to diminishing returns, meaning there was invariably a point at which the return on an additional unit of production would begin to decline. Networks can generate increasing returns, value that starts to go up with every unit added. There’s a law that applies here. It’s called Metcalfe’s law, and it holds that the value of a network is the square of its participants. In other words, a network holds the potential for exponential impacts. Technology often serves as a powerful multiplier for such effects.
Economies of connection
Rather than economies of scale, it is economies of connection that give networks their power. Economies of connection are not proximity based, nor do they rely on concentration of volume to generate efficiencies. Instead, their volume is widely spread across many distributed nodes. While the volume per node may be relatively small, the volume from all the nodes can be substantial. Much more volume is generated across a distributed network than can be effectively concentrated in a single node.
Think of telephones. Every telephone connected adds value to the network of telephones. And every telephone is immensely more valuable because it is part of the network. Value and volume trigger rapid adoption. There are now about 7 billion people on the planet and about 7 billion cellphone subscriptions. Today 64 percent of American adults own a smartphone. In 1998 there were 120 million people on the internet. In 2014 it was 2.2 billion. And one year later, in 2015, it was 3.5 billion. That’s what increasing returns look like. It’s hockey stick growth. Slow at first, then — bang — straight up.
The network is the shape of things that last. Multiple connections per node reduce the risk of a breakdown because they diversify inputs and outputs. Multiple organizations bring a network the potential for a healthy mix of capabilities, experience and talent. The principle of diversification suggests that an organization connected, no matter how tightly, to just a few other organizations is at greater risk than one connected to many organizations on some meaningful basis. Isolated organisms eventually become genetically vulnerable over time. The same is true for isolated organizations.
When confronted with dramatic environmental changes, networks persist because they incorporate speed, flexibility, redundancy and dispersion. Those characteristics make networks extremely hard to kill. Knocking out one connection doesn’t imperil a node with many other connections. Information and value flow can simply shift. These characteristics of a network are not designed; they are emergent and inevitable.
The assembler-marketer model
As legend goes, Michael Dell started Dell Computers in his dorm room. He demonstrated that you don’t need to own factories to manufacture a competitive product. Dell was an example of what became one of the more transformative business models of the past few decades — the assembler‑marketer.
An assembler‑marketer, armed with a strong understanding of customer needs as well as deep knowledge of available technologies and components, assembles those things into a completed product and then markets it. Dell not only skipped factory ownership, he skipped the retail stores by selling computers directly to customers through mail order. And his business model allowed him to assemble computers customized to individual needs at the point an order was received. To make all this work, he relied on a tight network of suppliers.
Dell isn’t the only assembler‑marketer to have enjoyed success. Toyota has operated for a couple decades under a similar model. Its plants are more assembly centers than factories. Parts precisely specified by Toyota and manufactured by others are gathered together and assembled into automobiles well targeted to its worldwide market. To make this work, Toyota also relies on a network of just‑in‑time suppliers.
The assembler‑marketer model has greater flexibility than the old factory model. Because Dell wasn’t locked into manufacturing facilities and holding inventory, it could buy the most advanced components for its computers. Toyota was able to do the same but, unlike other auto manufacturers, it was careful not to outsource what it regarded as core capabilities, including engine manufacturing. Volvo, owned by Ford at the time, outsourced its engine production to Mitsubishi and ended up with a lemon that seriously undercut its reputation.
Today, assembler-marketers have proliferated beyond tangible products and into services. The reliance on ownership and control of hard assets has vaporized in the process. For example, Uber owns no fleet of taxis. Airbnb owns no hotels. Yet both organizations have quickly grown into enterprises with capitalizations exceeding those of their hard-asset competitors. Uber has expanded into 300 countries and is valued at more than $50 billion. Airbnb is valued at more than $25 billion.
If Uber and Airbnb own few tangible assets, what is it exactly that the market is placing such a high valuation on? Clearly it’s the unique network of connections that these organizations have created. These technology-enabled networks are often described today as “platforms.”
Ackoff suggested that the challenge of leadership in a system is the management of interactions rather than the management of actions. The job of a leader in a network is one of purposeful facilitation. Facilitation is the best way to manage interactions. Still, facilitation has to be intentional if it’s going to generate value. There is a constant question: “Facilitating toward what end?” This question circles back to other questions, such as “What is our mission and vision as an organization?”
Uber’s mission is to “provide transportation as reliable as running water everywhere for everyone.” It does that by relying on a network of assets it doesn’t own — privately owned automobiles and smartphones. All Uber owns is its app. Its vision is embodied in its app. Uber’s vision is “smarter transportation with fewer cars and greater access.” Visions should evolve. Perhaps someday Uber will move people across a network of privately owned aircraft or privately owned recreational vehicles.
Networks are an emergent phenomenon, meaning they are neither designed nor managed in any conventional sense. But they can be influenced, nurtured and preserved. Indeed, the history of Uber and Airbnb suggests there was a point at which these network‑based organizations crossed the line from accidental to intentional — from the first stirrings of an idea with potential to a promising business model.
In considering health care systems in the future, the focus should expand beyond value represented by tangible assets to the potential value that can be imbedded in networks. Big opportunities will soon be embodied in assembling and marketing high-value networks.
The most promising network platforms in health care will be composed of caregivers connected by patient data, delivered in real time at the point of care. The number of health care institutions in a network isn’t as important as the number of connected people who comprise those institutions. If each hospital in a seven-hospital network employs on average 2,500 people, then applying Metcalfe’s law suggests the number of potential connections is 2,5002 — well, you do the math.
Networks in health care
Today, some organizations that have moved far down the path in developing clinically integrated networks are achieving network effects. Advocate Health Care is an example of such a network. It connects employed and independent physicians in collaborations designed to enhance the value of care delivered and produces the data to validate that value.
Notable, too, are health systems like Geisinger that have blended an insurance network with a provider network. Also promising are networks that connect deep reservoirs of patient data. Mayo Clinic, IBM and UnitedHealthcare are busy networking their data reservoirs. All of these organizations own traditional hard assets such as hospitals and surgery centers as well as intangible assets like powerful brand identities. All of those assets have the potential to become exponentially more valuable when they are imbedded as part of a high-value network. For hospitals and health systems, technology-enabled networks will represent a new opportunity for growth.
Dan Beckham is the president of The Beckham Co., a strategic consulting firm based in Bluffton, S.C. He is also a regular contributor to H&HN’s website.
The opinions expressed by the author do not necessarily reflect the policy of the American Hospital Association.