Can Design Make Health Policy Truly Patient-Centered?

Karen Matsuoka is poised to change the way the government designs and implements healthcare policy. Let’s hope she does.

Karen Matsuoka, Chief Quality Officer & Director, Centers for Medicare & Medicaid Services.

Karen Matsuoka, Chief Quality Officer & Director, Centers for Medicare & Medicaid Services.

Karen Matsuoka knows what bad health policy feels like.  At 8 years old, she was diagnosed with Type 1 Diabetes – a rare form of the disease. Matsuoka’s regimen required her to get insulin shots every day at noon. But the public school she attended had a rule that no injections were allowed on campus unless they were administered by a nurse, and the district could afford a nurse only two days a week until 10:30 a.m.

“I was put into a situation where I had to choose between my health and my education,” Matsuoka said. Instead, Matsuoka’s mom drove to school every day at noon and pulled her out of class for her injection. Eventually, she enrolled in private school.

“Think about the child who can’t afford that option,” Matsuoka says. “When the school district instituted that policy, they didn’t mean to cause problems but it just didn’t work. So I learned from a young age that policy is often not designed in a patient-centered way, despite best intentions. I knew we really needed to do things differently.”

Matsuoka is working hard to do just that. As Chief Quality Officer for Medicaid and CHIP (the Children’s Health Insurance Program) & Director of the Division of Quality and Health Outcomes at the Centers for Medicare & Medicaid Services (CMS), she’s positioned to have a powerful impact on the lives and wellbeing of patients across the country.

And she’s convinced that human-centered design is the way to get there.

How did Karen Matsuoka arrive at this point?

Her background is heavyweight. With a B.A. and M.A. from Stanford and a Ph.D. in Social Policy from Oxford, she’s got the intellectual chops to take on just about anything. She’s served as a health economist and policy analyst at the White House and in Congress as a Presidential Management Fellow for the Ways & Means Committee’s health subcommittee. And she served as the Director of Health Systems and Infrastructure for the state of Maryland, where she was in charge of key health reform initiatives including the Maryland State Innovation Model – a project tasked with redesigning the state’s healthcare system to be just as effective at keeping people healthy as getting them well once they’re sick.

But what’s striking about Matsuoka goes deeper than her professional credentials. It’s the heart, insight and sensitivity with which she approaches healthcare challenges. She knows that people’s entire lives and families are at stake – and that government policies, while well-intentioned, can create more burden and hardship if they’re poorly designed.

So when she heard from a White House colleague about a fellowship program at Stanford’s Hasso Plattner Institute of Design (the that immerses professionals in design thinking, she leapt. “From the get-go, I intuitively understood why human-centered design was important. It didn’t require any convincing at all.

“It dovetailed with my feeling that we needed new approaches to address the failings of the healthcare system.”

The potential of design in healthcare is endless.

Design thinking is a process that immerses interdisciplinary design teams in the lives of their users to identify unmet needs and problems. The process as conceived at the includes 5 stages – empathy, define, ideate, prototype, and test. It’s part of the standard vernacular in Silicon Valley and other forward-thinking pockets of the world, and has been adopted by many innovative companies including SAP, Google, IBM, Fidelity, Intuit, GE and more. But – surprise – change is slow to take place in big bureaucracies, and the U.S. government is no different.

“I feel like government is the last bastion,” Matsuoka says. “Design thinking has permeated every other sector. We’re the last ones. There are pockets of design thinking happening across government but it’s still regarded as a novelty rather than the norm.”

In fact, Matsuoka had to quit her job with the Maryland Department of Health to come to the because her former boss was unsupportive. “The word ‘design’ or ‘redesign’ was in the title of almost every project I was working on. I was being asked to think and act like a designer but without any training in design, so I was stunned by the failure to see the value in this fellowship.” But Matsuoka saw the Stanford opportunity for the win-win it clearly was: “a chance to get coaching from the world’s greatest designers in applying proven approaches to health care redesign for our most vulnerable residents.”

So she jumped ship and moved to Palo Alto to spend a year at the to hone her skills in the process of design thinking developed by David Kelley – among the world’s leading design innovators. She was intent on finding ways to bring a human-centered approach to systems change and policy.

“Design unlocks the kind of ideas and approaches that truly get us to the patient-centered care that we policymakers talk about all the time yet struggle to realize. Imagine if we could do for health care what the iPhone did for cell phones or the Mac did for personal computing. Design thinking was behind those innovations, and arming policy makers with these tools would be huge for health care.”

Matsuoka thinks that if government can do any of the 5 stages of design well – even just a couple stages – the impact on the health care system and its outcomes could be profound. If the government could do all of them, “the potential is immense. It would unleash innovation potential in government.”

But for innovation to truly happen, Matsuoka thinks the typical federal policy-making model will need to be flipped on its head.

“Federal policy making tends to be a top-down process and assumes that simply changing how we pay for things will lead to patient-centered care. In my experience, payment reform is necessary but not sufficient. You also need people on the ground to figure out what patients actually need and want, and that’s where design thinking comes in.

“Before the, I thought I was patient-centered, yet I’d never actually interacted directly or intensively with patients as part of the policy making process,” Matsuoka says. “But to create effective policy, you need to understand who you’re designing for. I’ve learned from my time at the why it’s not enough to field surveys and hold focus groups, which is the way we traditionally do things in health services research and policy circles. Human needs and values can be incredibly complex and run really deep, making them hard for patients to articulate.”

For that depth of understanding, Matsuoka believes you need the ethnographic empathy tools of design to fuel small pockets of innovation all across the nation to test solutions in a hyper-local way. “Unleash designers across the country to test many possible micro-solutions on a small and low-cost scale in order to find the ones that patients truly need and want,” Matsuoka says, “and then use the tools of policy to scale and financially sustain them."

“How do we keep people out of hospitals? How can government work upstream to keep people healthy? This is the next critical stage for healthcare, and it requires all of us to work with people we haven’t worked with before.”

And that’s another reason why Matsuoka is so passionate about bringing design thinking to health care reform. “There’s something about the process that builds trust,” says Matsuoka. "When you’re working closely with people and collaborating to solve the problems of very vulnerable users, emotions and experiences are often shared in a way that’s intense. Design teams come out of the process feeling like they’ve known each other their entire lives even if they’ve only been working together for a few weeks. That’s incredibly important now that we’ve come to recognize the role of social determinants of health and how critical it is for health care providers to collaborate with community partners they haven't traditionally had to work with, like schools, prisons, social services, and public health departments.”

Matsuoka likes to imagine a situation like the TV show “Undercover Boss,” where the people who design policy could immerse themselves in the lives of the people for whom they design. To have people live the policy they’ve created to see what works well and what doesn’t work well. 

“I don’t know if policymakers fully appreciate the reality of the people they’re trying to serve, which is why it is so risky to assume you know what patients need and want” Matsuoka says. “My team has begun doing empathy interviews with Medicaid beneficiaries, and their stories are heart-wrenching.

“How cool would it be if we could co-design together?”

Design Thinking vs. Lean vs. Agile

Many hospitals have adopted Lean as a management tool, and have found it effective. When do you use design thinking and when is Lean more appropriate? Here’s Karen’s response:

“A good friend of mine heads up CMS’s Lean activities but also intuitively understands and appreciates design. We discuss the differences. What we’ve settled on is that it depends on the level of uncertainty. If you have a solution that is already working – for example, you’ve tested it and have confirmed that it’s desirable and feasible, and it’s demonstrating good results – and you’re just trying to make it more efficient by getting the waste out of a process, you use Lean. If you want to design something new or completely redesign something that isn’t working, you use human-centered design – you need to start with a blank slate and with the user to make sure that the solution you’re designing is desirable and usable. Agile is somewhere in between. The emphasis with Agile is on prototyping and testing, but Agile doesn’t really do the first 3 stages of empathy, define and ideate. If you really don’t know the problem or the solution, you need to start with design.”