Stonehenge and Health System Mergers: The Role of Inertia

by Tom Robertson

Executive Director, Vizient Research Institute

Last summer, I checked an item from my bucket list and walked a well-worn footpath around Stonehenge, one of the most famous landmarks in the world. A fair amount of science and more than a little conjecture surround the efforts to understand both the ‘why’ and the ‘how’ behind the iconic circle of stones. What is indisputable is the magnitude of effort that went into moving those stones and positioning them into a ring formation. The average weight of a Stonehenge boulder is 25 tons; conventional wisdom suggests that the stones were moved approximately 18 miles from Marlborough Downs and then placed in their current configuration, all without tools or machinery.

Almost as interesting as how the stones got to where they are is the question of why they haven’t fallen in the two thousand years since being raised into place. Both riddles revolve around the concept of inertia. Inertia is a property in physics which causes matter to remain unchanged in its existing state of rest unless that state is changed by an external force. The force required to lift the stones before the invention of bulldozers is difficult to imagine. Similarly, nothing has come along since with sufficient force to dislodge them. Inertia — the tendency of things to stay where they are — has played a role in health system architecture, particularly following mergers and acquisitions.

As health systems begin to restart clinical programs that were suspended during the COVID-19 crisis, a prevalent theme has emerged: not everything that was shut down will be returning, and what does return may resurface in settings different than where it was before the pandemic. Leadership teams are taking a very deliberate approach to restarting clinical programs; in the process, they are taking a close look at where they do what.

Too often in the past, in the wake of mergers and acquisitions, opportunities to rationalize the number and location of clinical programs — to realize economies of scale and to achieve the benefits of consolidation — were missed, largely due to organizational inertia. Reducing the number of programs within a health system or relocating them to more efficient settings was difficult; not unlike a 25-ton boulder, entrenched clinical programs are hard to move. In the course of leaning into the pandemic, however, health systems by necessity shut virtually everything else down. It has occurred to leadership teams emerging from the shutdown that it’s easier not to restart a program — or relocate it to a more efficient platform – than it was to close one down in the absence of the crisis.

Health systems are making purposeful choices with respect to which programs restart, how large they become and where they are situated. Previously independent and often internally competitive clinical programs are being combined. Surgical procedures with fewer complications, safely performed at lower-acuity facilities within the same system, are being relocated. Ambulatory care is being reimagined. Virtual encounters are replacing traditional face-to-face visits. Huge, complex facilities designed to bring large numbers of people within close proximity are being reexamined. Even administrative real estate is likely to shrink as staff discovers how much of their work can effectively be done remotely.

It’s interesting to contemplate what we would do if the boulders of Stonehenge toppled over. There would be immediate sentiment to bring in cranes to replace the stones as close to their original orientation as possible. Doing so, however, would have consequences. The intrinsic value arising from a seemingly impossible feat of prehistoric engineering would no longer exist. Future tourists could come and take selfies with the boulders in the background, but they would be photographing something built by heavy equipment, not by bare hands. Had Stonehenge not been created long ago in a totally different time, there would be no reason to build it today. The urge to reassemble it in its original location would be strong, but the logic behind doing so would be anything but certain.

Sometimes putting something back where it’s always been is the right thing to do, but before firing up the heavy equipment, it’s always a good idea to question the rationale.