What Actually Fixes Health Care: From Activity to Outcomes 

...By Lawrence Rosenberg, MD, CM, MSc, PhD, MEng, FRCPSC, FACS, FCAHSPresident & CEO, Integrated Health & Social Services University Network for West-Central MontrealShareNewsweek is a Trust Project memberSee more of our trusted coverage when you search.Prefer Newsweek on Googleto see more of our trusted coverage when you search.Over the first two articles in this series, we have reframed how health care systems behave. They are not machines to be optimized, but complex adaptive systems that evolve through countless interactions. When they are tightly controlled and overly standardized, they do not become more stable; they become fragile – drifting toward the kind of critical state where small disruptions can trigger system-wide crises. If that is true, and the evidence increasingly suggests that it is, then a more uncomfortable question follows: Why, after decades of reform, do the same problems persist? Why do costs continue to rise, outcomes remain uneven and systems operate under constant strain, even as they are reorganized, digitized and consolidated? The answer lies in something both simple and often overlooked: how the system is rewarded for behaving. In health care, every decision is shaped by signals that tell clinicians and organizations what matters, like what to do, when to do it and how often. These signals are often described as “incentives,” but at their core, they are simply the rules of the game and the way the system defines success in practice. And right now, in many systems, those rules quietly reward activity over outcomes, volume over value and short-term intervention over long-term health. What those rules reward today is not difficult to see. In many health care systems, activity is still the primary currency. The more tests are ordered, the more procedures performed and the more visits scheduled, the more the system pays. This model – often referred to as fee-for-service – was designed to expand access and ensure that care was delivered. Over time, however, it has created a powerful and largely invisible distortion that rewards doing more, not necessarily achieving better outcomes. The consequences are not abstract. Consider a patient with a chronic condition such as diabetes. Under an activity-based model, care becomes a series of disconnected encounters – appointments, tests, prescriptions – each compensated individually. Yet no single part of that process is directly accountable for whether the patient’s health actually improves over time. The system can be highly active, even technically excellent at each step, and still fails to deliver better outcomes. In fact, fragmentation, duplication and even unnecessary interventions can quietly increase because they are not penalized, and, in many cases, rewarded. This is the central paradox of building a successful health care system: A system organized around activity can appear productive while becoming increasingly inefficient and misaligned with its ultimate purpose. It is not that clinicians are making the wrong decisions; it is that the environment in which they operate is continuously nudging those decisions in a particular direction. When the rules of the game reward volume, volume is what the system produces – even when the real goal is better health over time. If the problem lies in the rules of the game, then the path forward becomes clearer. Change the rules and the system begins to behave differently; This is the main idea behind value-based care.…

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