Computer monitors positioned head-high every few feet flashed the orders for a given station.... The recipe has the ingredients on the left part of the screen and the steps on the right. A timer counts down to a target time for completion. The background turns from green to yellow as the order nears the target time and to red when it has exceeded it.Cheesecake Factory is Cooking Mama cosplay?
Checking on one patient, he found a few problems. Mr. Karlage, as I’ll call him, was in his mid-fifties, an alcoholic smoker with cirrhosis of the liver, severe emphysema, terrible nutrition, and now a pneumonia that had put him into respiratory failure.I feel a bit hurt they added a decade to my age. Also, I quit smoking years ago, when our nanny-state outlawed clove cigarettes, for tasting too yummy. Keep up New Yorker!
The doctors ordered a series of tests and scans, and kept her overnight. They never figured out what the problem was. Luz understood that sometimes explanations prove elusive. But the clinicians didn’t seem to be following any coördinated plan of action. The emergency doctor told the family one plan, the admitting internist described another, and the consulting specialist a third. Thousands of dollars had been spent on tests, but nobody ever told Luz the results. A nurse came at ten the next morning and said that his mother was being discharged. But his mother’s nurse was on break, and the discharge paperwork with her instructions and prescriptions hadn’t been done. So they waited. Then the next person they needed was at lunch. It was as if the clinicians were the customers, and the patients’ job was to serve them. “We didn’t get to go until 6 P.M., with a tired, disabled lady and a long drive home.”I wish this scenario weren't so goddamn familiar. What this patient needs -- what we all need when we encounter a serious medical problem -- is not so much a bunch of individual doctors, all of whom have maximum "freedom from arbitrary rules," but rather a well-managed medical institution that coordinates reliable, efficient, and effective cooperation between the many experts involved in our care. If that means subordinating doctors' whims to an actual standard of care, that's a good thing.
In medicine, too, we are trying to deliver a range of services to millions of people at a reasonable cost and with a consistent level of quality. Unlike the Cheesecake Factory, we haven’t figured out how....Big chains thrive because they provide goods and services of greater variety, better quality, and lower cost than would otherwise be available. Size is the key. It gives them buying power, lets them centralize common functions, and allows them to adopt and diffuse innovations faster than they could if they were a bunch of small, independent operations...Medicine, though, had held out against the trend. Physicians were always predominantly self-employed, working alone or in small private-practice groups. American hospitals tended to be community-based. But that’s changing...Health-care reforms—public and private—have sought to reshape that system...This is a radical shift. Until now, hospitals and medical groups have mainly had a landlord-tenant relationship with doctors. They offered us space and facilities, but what we tenants did behind closed doors was our business. Now it’s their business, too.He explicitly says that medicine is not like the Cheesecake Factory, but that as medicine is becoming more factory-like, it perhaps has something to learn from the mass standardization of food. He is drawing an analogy, and he is interested in learning how something as persnickety as a 400-item menu is standardized because medicine is even more complex. Nowhere does he state that innovations in mass food production explain or inspire innovations in mass medicine production; instead he says, explicitly and repeatedly, that the changes in medicine are being forced upon it through public policy and insurance company pressure to contain costs, a very different motivation than Cheesecake Factory's simply fear that you'll walk down to the other end of the food court. He does not say that they are functionally the same.
Cerberus—the multibillion-dollar private-investment firm—bought a group of six failing Catholic hospitals in the Boston area for nine hundred million dollars. Many people were shocked that the Catholic Church would allow a corporate takeover of its charity hospitals. But the hospitals, some of which were more than a century old, had been losing money and patients, and Cerberus is one of those firms which specialize in turning around distressed businesses.What could possibly fucking go wrong? How much you want to bet that for all this, when Dr. Gawande's heart starts giving out, he doesn't go to Steward for treatment?
Cerberus has owned controlling stakes in Chrysler and GMAC Financing and currently has stakes in Albertsons grocery stories, one of Austria’s largest retail bank chains, and the Freedom Group, which it built into one of the biggest gun-and-ammunition manufacturers in the world. When it looked at the Catholic hospitals, it saw another opportunity to create profit through size and efficiency. In the past year, Steward bought four more Massachusetts hospitals and made an offer to buy six financially troubled hospitals in south Florida. It’s trying to create what some have called the Southwest Airlines of health care—a network of high-quality hospitals that would appeal to a more cost-conscious public.
[Steward is] trying to create what some have called the Southwest Airlines of health care—a network of high-quality hospitals that would appeal to a more cost-conscious public...many health systems, for-profit and not-for-profit, share its goal: large-scale, production-line medicine. The way medical care is organized is changing—because the way we pay for it is changing.That exactly what he is saying has changed: From a system where doctors are by and large independent contractors who charge what they like and hospitals who don't care what the doctors charge because the negotiate independently with each insurance company to one in which doctors are employees of a huge chain of hospitals which will have the power to set prices for the doctor's services and take advantage of substantial economies of scale in order to negotiate prices with insures and suppliers. Further, their biggest customers have tied their pay to performance. The most efficient, best-performing hospital chains will be in a position to seize market share from competitors.
Historically, doctors have been paid for services, not results...Since [Hammurabi], we’ve generally been paid for what we do, whatever happens. The consequence is the system we have, with plenty of individual transactions—procedures, tests, specialist consultations—and uncertain attention to how the patient ultimately fares.
Health-care reforms—public and private—have sought to reshape that system. This year, my employer’s new contracts with Medicare, BlueCross BlueShield, and others link financial reward to clinical performance. The more the hospital exceeds its cost-reduction and quality-improvement targets, the more money it can keep. If it misses the targets, it will lose tens of millions of dollars. This is a radical shift. Until now, hospitals and medical groups have mainly had a landlord-tenant relationship with doctors. They offered us space and facilities, but what we tenants did behind closed doors was our business. Now it’s their business, too.
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posted by wilful at 7:34 PM on August 6, 2012 [26 favorites]