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The Cheesecake Factory as a model for the American health care system
August 6, 2012 7:24 PM   Subscribe

A new model for the American health care system: The Cheesecake Factory
posted by Egg Shen (96 comments total) 30 users marked this as a favorite

 
Of course if I had a dysfunctional healthcare system I would look to the restaurant trade for what works rather than to healthcare systems in other countries! So wise, so insightful!
posted by wilful at 7:34 PM on August 6, 2012 [25 favorites]


I bet MeFi can pound this article's premise into 'fuck no you can't' in.... 5 posts.
posted by jscott at 7:36 PM on August 6, 2012 [1 favorite]


I would like a six-pack of mental health please. No need to bag it I will be consuming it here. Thanks.
posted by Sebmojo at 7:37 PM on August 6, 2012 [8 favorites]


Gotta say that hospitals are pretty good at take out.
posted by weapons-grade pandemonium at 7:38 PM on August 6, 2012


The irony, it burns...
posted by Huck500 at 7:38 PM on August 6, 2012 [1 favorite]


Walking past the impossibly huge heart-lung and MRI machines in the display case, the cacophonous sound of hundreds of families getting care in the same room is broken up by our nurse leading me down long ambience-free bed farms to a somewhat sticky booth of my own, where I am given a tome of hundreds of options, many with minor variances.
posted by jscott at 7:40 PM on August 6, 2012 [7 favorites]


Reading that made me hungry.
posted by antiquated at 7:40 PM on August 6, 2012 [1 favorite]


So, treat patients like groceries, and make them pretty and edible in ten minutes?
posted by zippy at 7:42 PM on August 6, 2012 [2 favorites]


I'll resist any further snark - the article was interesting, and it did have a point. Not sure I ever want to eat at the cheesecake factory however.
posted by wilful at 7:45 PM on August 6, 2012 [2 favorites]


And if you break your arm the Doctor will paste ads on your cast.
posted by pwally at 7:46 PM on August 6, 2012 [4 favorites]


This is some aggressive and interesting brand promotion and I'm not sure it's going to work.
posted by RobotVoodooPower at 7:53 PM on August 6, 2012 [1 favorite]


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?
posted by zamboni at 7:54 PM on August 6, 2012 [6 favorites]


For those preparing the snark on a writer's idea of looking at the Cheesecake Factory for ideas on improving healthcare, the writer is Atul Gawande, an expert on practices for improving health care outcomes, professor of surgery at Harvard Medical, and a director at the World Health Organization.
posted by justkevin at 8:00 PM on August 6, 2012 [60 favorites]


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!

And the obvious joke for using Cheesecake Factory as a model is that health care is already too expensive! Dear Cheesecake Factory (self-link)

Read more http://www.newyorker.com/reporting/2012/08/13/theseurlinclusionscriptsarefuckingdumb
posted by cjorgensen at 8:01 PM on August 6, 2012


For those preparing the snark on a writer's idea of looking at the Cheesecake Factory for ideas on improving healthcare, the writer is Atul Gawande, an expert on practices for improving health care outcomes, professor of surgery at Harvard Medical, and a director at the World Health Organization.

Yeah? But what does he know about cheesecake?
posted by cjorgensen at 8:01 PM on August 6, 2012 [6 favorites]


I'm hard-pressed to decide whether I'd rather eat at a Cheesecake Factory or spend time in a hospital. I guess I'd take the restaurant: you never know what you might pick up at a hospital, or how much it'll cost.
posted by spacewrench at 8:02 PM on August 6, 2012 [1 favorite]


(But if I had better health insurance, I'd totally rather be sick!)
posted by spacewrench at 8:03 PM on August 6, 2012


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.

As the Deliverator is pulling out of the chute, building up speed, checking the address that is flashed across his windshield, deciding whether to turn right of left, it happens. His stereo cuts out again--on command of the onboard system. The cockpit lights go red. Red. A repetitive buzzer begins to sound. The LED readout on his windshield, which echos the one on the pizza box, flashes up: 20:00.

The have just given the Deliverator a twenty-minute-old pizza. He checks the address; it is twelve miles away.
posted by mollymayhem at 8:04 PM on August 6, 2012 [29 favorites]


I work at a university and am not a MD, but received a grant from Partners Healthcare. The project I'm working on is related to a system that Partners has implemented, which alerts doctors if they've made a prescription that may harm the patient, perhaps due to an excessive dose (a typo maybe) or a drug-drug interaction.

I'm not sure if a Cheesecake Factory solution is the best for solving the extensive problems of the American healthcare system. But I think it's true that this alert system is a good thing, protecting the health of patients while not imposing arbitrary rules on doctors. And I really don't think individual doctors offices would implement it themselves.
posted by bessel functions seem unnecessarily complicated at 8:05 PM on August 6, 2012 [2 favorites]


I can't wait for my vastly oversized serving of xanax.
posted by feloniousmonk at 8:10 PM on August 6, 2012 [5 favorites]


I thought the article was interesting for talking about outcomes-based medicine, and for showing how having someone who is assessing the quality of care can have a positive impact.

I don't know if the framing of the article was the best, but there's real content in there.
posted by hippybear at 8:12 PM on August 6, 2012 [5 favorites]


I'm pretty sure Atul Gawande knows all about the healthcare systems of other countries. And most of what other countries do well is in terms of doing the economics, not in terms of quality control or innovation.

Dear Cheesecake Factory (self-link)

You've self-linked here more than 50 times. Please give it a rest.
posted by grouse at 8:12 PM on August 6, 2012 [11 favorites]


If The Cheesecake Factory was modeled on hospitals: There is no menu, you have no idea what anything costs, you have to share your table with a random person who might have severe dementia, after your meal someone from the restaurant calls you in the middle of the night to check the status of your cheesecake digestion, and you get a bill five months later with charges for carrying the cheesecake to the table ($2000) and the plate on which the cheesecake came on ($500)...also the cheesecake contains an antibiotic-resistant staph infection.
posted by melissam at 8:13 PM on August 6, 2012 [63 favorites]


I'm not sure that the Cheesecake Factory is really as good an example as the author thinks it is, mostly because it just derails the conversation with obvious snarkbait (but then again, it got him into the New Yorker), but what he's basically asking for is the logical progression of current trends in evidence and data-based medicine, and in particular, for the the decisions on how to proceed for a large number of relatively uncomplicated scenarios (i.e. the "menu" items) be figured out in advance, perfected with scientific precision until someone with minimal training (the line cook) can perform them, in quantity, and then repeated over, and over, and over. All the while while measuring the outcomes and feeding that output back into the process in order to continually improve it.

That doesn't sound unreasonable to me and it's where a lot of medicine is heading, even if it's not all the way there yet. It's stuff that other industries have been doing for decades, but healthcare has been really slow to pick up on. Probably because when we're sick, we all want to think that we're special snowflakes ... but looked at in aggregate, we're just like, well, snow: a big pile of basically-identical, infinitesimal units largely interchangeable from the next. We need to start thinking about that large scale if we want to solve the big problems.
posted by Kadin2048 at 8:14 PM on August 6, 2012 [8 favorites]


Of course if I had a dysfunctional healthcare system I would look to the restaurant trade for what works rather than to healthcare systems in other countries! So wise, so insightful!

You did not read the fucking article. You did not. Your willful display of ignorance is vile.
posted by Diablevert at 8:19 PM on August 6, 2012 [25 favorites]


from the article:

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.

yes, which is exactly why we need single-payer health care. thank you, and good night.
posted by cupcake1337 at 8:19 PM on August 6, 2012 [30 favorites]


Atul Gawande has written quite a number of articles for the New Yorker, all of them excellent and thought-provoking, and this is no different. The choice of Cheesecake Factory as a comparison seems to have derailed the response, but the comparison is still a compelling one, even if he has overstated the camaraderie, efficiency, and customer care of the restaurant chain - because hospitals these days are so freaking far from good places to be, even Red Lobster would far outshine them. I have too much experience with hospitals to feel safe in them. My mother, who had Parkinson's and was in nursing care, would end up in the ER when she fell out of bed. She got left on a gurney for many hours without food or care one time, and when I was finally able to get there she desperately had to go to the bathroom. She and I sat there afterwards while she ate a sandwich I went and bought, and I felt as if I were in what we used to call a third-world country and should be sitting on a mat on the floor, not in a major metropolitan area of what is supposed to be a successful country.
posted by Peach at 8:20 PM on August 6, 2012 [9 favorites]


French fries with butterscoth, Bugs stop in Albuquerque.
posted by Mblue at 8:21 PM on August 6, 2012


ok, more technically, what he's getting at are economies of scale, listing the particular ways that a restaurant can benefit from them. with healthcare the economies of scale are: shared risk, bargaining power, and reduced administrative costs.
posted by cupcake1337 at 8:24 PM on August 6, 2012 [1 favorite]


until someone with minimal training (the line cook) can perform them, in quantity, and then repeated over, and over, and over.

I was thinking about this a while back when I went to my doctor to get a wart frozen. Here was someone with a BS, an MD, plus however many years of post-medical school specialist training, spraying liquid nitrogen from a little bottle. I could have done it myself if they would have just loaned me the bottle; any person with a CNA or any other training could have done it, while my highly trained and skilled doctor dealt with an actual, you know, medical issue. But no -- I got nitrogen sprayed by someone with an actual MD.

There are a lot of medical procedures that should be turned into assembly line repetition with high quality control. I think picking the Cheesecake Factory with its 3000 calorie dishes is a mistake, but the general idea is good.
posted by Forktine at 8:27 PM on August 6, 2012 [8 favorites]


with healthcare the economies of scale are: shared risk, bargaining power, and reduced administrative costs.

No, that's the economies of scale for insurance companies. Remember -- there are two sides to health care: the payment providing side (insurance) and the service providing side (hospitals, doctors, and such).

He's specifically addressing the second of these, the service providing side.
posted by hippybear at 8:27 PM on August 6, 2012 [1 favorite]


I'm not sure that the Cheesecake Factory is really as good an example as the author thinks it is, mostly because it just derails the conversation with obvious snarkbait (but then again, it got him into the New Yorker)

Dr. Gawande doesn't need a clever hook to get into the New Yorker. He's written many articles for them (and books as well) on the topic of how to improve healthcare.
posted by pasici at 8:28 PM on August 6, 2012 [1 favorite]


What I learned from this: Cheesecake factory may not be the best example, but I think they could be a useful analogy for health care in a lot of ways.

Like their menu, which has things like chicken in a biscuit and sweet corn tamale cakes. Really varied and tons of options. Plus they're family owned, right?

and their sweet corn tamale cakes are always made fresh, which is how we want our medicine; cutting edge and available as soon as possible.

Look, if I don't get some sweet corn tamale cakes I may literally die.
posted by boo_radley at 8:31 PM on August 6, 2012 [1 favorite]


I'm curious about the hate for the Cheesecake Factory. I've never eaten there, but the article makes it sound like it's actually a pretty good place to eat in a middle-of-the-road sort of way: prices are reasonable, there's plenty to choose from, the ambiance is OK if rather bland, and the food is fresh and delicious. Is there some reason why we hate it other than the fact that its customers are stereotyped as Fat, Dumb Americans with poor taste who might *gasp* be lower-middle-class?

Note that I'm not calling anyone out here for using ugly classist stereotypes, but that's the vibe I've always gotten from Cheesecake Factory hate in the past. I really know nothing about the chain first-hand other than that it's a pretty big chain and the portions are large. (Which is no big deal, that's what to-go boxes are for, right?)
posted by Scientist at 8:41 PM on August 6, 2012 [13 favorites]


I think the point is, both the restaurant and the hospital have to tailor their service to each individual customer, on demand, using an incredible array of options. and the final product is served with guidelines but is ultimately left up to the discretion of the person at the final stage. only one entity is doing this efficiently and with minimal amounts of waste. but it is being controlled centrally, ultimately.

it would be impossible for every hospital to be part of one chain.. so.. yeah single-payer seems to be the direction this points to.
posted by ninjew at 8:45 PM on August 6, 2012 [4 favorites]


I'm curious about the hate for the Cheesecake Factory.

I am sure a lot of the snark is what you note, classism. But it's also because the CF is famous for its excesses. For example, Cheesecake Factory tops "Xtreme Eating Awards" List:

The Cheesecake Factory’s Pasta Carbonara with Chicken, which, in addition to the 2,500 calories, has 85 grams of saturated fat. That’s more saturated fat than a person should consume in four days, Liebman says. The dish has four cups of white-flour pasta, smoked bacon, chicken, and Parmesan cream and butter sauce.

So there's a level of irony in pointing to them as a model for healthcare in the US.
posted by Forktine at 8:46 PM on August 6, 2012 [4 favorites]


yes, which is exactly why we need single-payer health care. thank you, and good night.

I dunno that that follows from Gawunde's article. There's two ends to the equation, yes? Size enables the producer to take advantage of economies of scale and the efficiencies of mass production. But the incentive for the producer to do so is the ability of the consumer to switch to a competitor. If a given producer achieves monopoly, the incentive is gone and the quality suffers, almost immediately and universally. This is simply the way monopolies behave.

Single-payer seems to me to inherently bear some of the same risks. Only one payer, only one price --- it's like an inverted monopoly. There's an inherent danger that things settle at whatever shitty equilibrium meets the budget of the single payer, there's no ability to push or threaten directly from the consumption end.

That said, I don't know that its advantages don't outweigh the disadvantages, in the end --- maybe it's necessary to combat the clout of the forecasted Big Medicine --- but it seems to me that one of the biggest problems with the US health care system now is that it's very difficult for anyone to tell what providers are best and worst and how much anything costs. As a patient, I'm always freaked out that if I go anywhere for anything it's going to cost me hundreds of dollars and even if I suspected that a certain hospital is likely better than another I wouldn't necessarily be free to go to it because all that's up to my insurance agency, not me.

with healthcare the economies of scale are: shared risk, bargaining power, and reduced administrative costs.

Gawunde's article seems to posit that there's plenty of fat on the labor a materials side, as well. (63 staff including 19 doctors who do some work on a single routine knee operation; nine different kinds of replacement knee, each of which has an attached sales rep making an estimated $500 commission per unit sold).
posted by Diablevert at 8:48 PM on August 6, 2012 [1 favorite]


I don't know if the framing of the article was the best, but there's real content in there

Yeah, this was my problem with it. He started with a classic style of anecdotal lede - doing something unrelated to my topic made me think about my topic in a new and unexpected way - but then he went all Gladwellian counterintuitive THIS EXPLAINS THAT COMPLETELY on it. Instead of treating upscale chain food and medical care as analogous, he got caught up in trying to explain how they were functionally the same. Which - like say Google and the education system - they are simply not.
posted by gompa at 8:50 PM on August 6, 2012 [3 favorites]


So there's a level of irony in pointing to them as a model for healthcare in the US.

No, there actually isn't.

Because this article isn't about the portion sizes or even really the food at the Cheesecake Factory. It's about the processes the Cheesecake Factory uses in order to provide an experience for their customers which is satisfying and leaves them feeling like they got their money's worth and like the experience was pleasant and isn't to be eschewed the next time the customer is looking to have their needs satisfied.

If you're going to include portion size and calorie count and such in the comparison, you'd have to admit that most medical care doesn't give you 4x what you actually need in portions which are satisfying enough to potentially supply several people with care and do it at a price which is only nominally higher than (in the case of food) buying a high-end non-value-meal selection of menu items at a much lower quality restaurant.

Again, he's not talking about the food at Cheesecake Factory. He's talking about the process which creates and supplies the food. And comparing that to the process which creates and supplies health care in the US. It's an apt comparison, and (again) while the framing of the article might be unfortunate (because of the snarkbait it contains that will keep people from truly understanding what he's saying), the actual points he makes in the article are well worth serious consideration.
posted by hippybear at 8:58 PM on August 6, 2012 [25 favorites]


OK, but I'm not sure that I get what the big deal is with places like the Cheesecake Factory having some excessive meals on their menu. I mean, people are free to take some home, right? And it's not like a mountain of pasta, cream, and meat is masquerading as a diet dish. Furthermore, this is not McDonald's -- very few people are going to make The Cheesecake Factory a staple of their diet, just as almost nobody is going to eat every meal at some of the higher-end restaurants that serve equally decadent food.

Heck, have you heard about some of the breakfasts that I cook in this house, on special occasions? A half-dozen strips of bacon, scrambled eggs with cheese, and potatoes fried in bacon fat is not something I should be eating on a regular basis, but I don't eat it on a regular basis -- just every once in a blue moon when I get a wild hair for something delicious and fatty.

It's the things that we eat every day that end up killing us, the constant slight surplus of cholesterol and fat and carbohydrates that we never quite use up. Nobody was ever killed by Thanksgiving Dinner, and the candy bars in the checkout aisle of the grocery store have probably killed more people than The Cheescake Factory or its ilk.
posted by Scientist at 8:58 PM on August 6, 2012 [4 favorites]


Only one payer, only one price --- it's like an inverted monopoly.

The difference is that, for the Cheesecake Factory, what you had for breakfast yesterday is pretty much irrelevant to your visit, while for healthcare, the care you have been given in the past is an incredibly relevant factor into the care you will need in the future.

And multi-payer systems actively discourage paying for preventative care -- because it does you no good to make a given patient healthier if they're just going to end up on somebody else's plan. You paid for it, and the other company reaps the rewards of a healthier patient.

In single payer, that doesn't happen. Preventative care becomes a huge factor in holding costs down -- far better to pay $1000 a year for five years if it avoids a $200,000 CCU stay.

Pretty much every nonsensical pricing decision you see in multi-payer systems comes from this -- the economic incentive does not match the social incentive.
posted by eriko at 8:59 PM on August 6, 2012 [18 favorites]


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.

I don't think this article is primarily about the economic questions. Rather, the point is good management -- this is what the Cheesecake Factory has that most hospitals don't. Training, accountability, reliability -- these are the things that good management could provide. I think our health care system needs these things, and badly.
posted by ourobouros at 9:05 PM on August 6, 2012 [21 favorites]


He started with a classic style of anecdotal lede - doing something unrelated to my topic made me think about my topic in a new and unexpected way - but then he went all Gladwellian counterintuitive THIS EXPLAINS THAT COMPLETELY on it. Instead of treating upscale chain food and medical care as analogous, he got caught up in trying to explain how they were functionally the same. Which - like say Google and the education system - they are simply not.

No, he did not, and you read it wrong. He simply did not do this. Here's an excerpt from his nut:
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.
posted by Diablevert at 9:11 PM on August 6, 2012 [3 favorites]


A very high percentage of therapeutic care would fit in a 400-item "menu". A 5-item menu would handle 99% of preventive care (don't smoke, limit booze, limit salt, limit carbs, exercise.)
posted by MattD at 9:24 PM on August 6, 2012


You did not read the fucking article. You did not. Your willful display of ignorance is vile.

Applauding your righteous fury there, but you could have out-snarked him with a burn of a lifetime. Just take out one letter. You even said willful. You were so close. So bloody close.
posted by Apocryphon at 9:29 PM on August 6, 2012 [1 favorite]


Everything will be better when the US healthcare system is run by private equity?
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.
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.
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?
posted by ennui.bz at 9:34 PM on August 6, 2012 [4 favorites]


I read the article. I agree with some of it, and I enjoyed the history lesson where doctors once had their hands removed for failing at miracles. I also get the fact that insurance exists because doctors will be paid whether you survive or not, and there is no simple way to offer a potentially unlimited demand for health care. I would start there.

I worry that pissing off all those health care workers by treating them like restaurant workers (who mostly work for tips as service goes), will have poor results. As costs are concerned, restaurants compete bitterly for that margin in order to realize their profits, and just because they can pull it off doesn't mean the food is better as a result. Going this supply-side route may be dropping the "care" from health care, and, perhaps, paving the way to turn out robot replacement parts for every body part imaginable in the future. I don't want to see it personally, but I think the widespread fear of death is driving us there. We seriously need to examine our ethics about health care and look at better options for those whose recoveries are losing propositions, and who simply need a dignified way out, at home. We need to ration care rationally.
posted by Brian B. at 9:36 PM on August 6, 2012 [3 favorites]


I got violently ill after eating at a Cheesecake Factory in Phoenix. Vomiting. Stinky diarrhea. Worst of all, I was too sick to fly home and was stuck in Phoenix, the butthole of the USA, for two extra days.

I know it doesn't have anything to do with healthcare, but I won't be reading the article because I can't even think about The Cheesecake Factory without reliving stinky diarrhea and Phoenix. *shudder*

Remember: Cheesecake Factory = diarrhea = Phoenix.
posted by Slarty Bartfast at 9:54 PM on August 6, 2012 [1 favorite]


The food at Cheesecake Factory is horribly bland. I spent a good summer eating there more than I care to admit, and the food just doesn't taste like anything. And I'm not being classist, I like other chain restaurants reasonably well. Cheesecake Factory is like the Chili's of well... every genre of food, actually. (I hope it's not classist to hate on Chili's, because their food is even more bland than Cheesecake Factory.)
posted by !Jim at 10:02 PM on August 6, 2012 [1 favorite]


Totally off-topic and not in any way relevant:

CF Pasta Carbonara with Chicken - 2291 cal, 81 g sat fat, 1628 mg sod, 144 g carb
Lay's Potato Chips (10 oz bag) - 1600 cal, 15 g sat fat, 1700 mg sod, 150 g carb

Yeah, that's for the entire bag.
posted by Ardiril at 10:12 PM on August 6, 2012


The main point is - to make our health system efficient - instead of focusing on bankrupting citizens.

They could have compared this to any number of companies that are successful in eliminating waste and focusing on efficiency.

Our health care system is broken on so many levels - that even a competently run corporation will never have the pull to overcome a system that is based on greed. The entire system is gamed for profit. You have lawyers, scammers, drug companies - and a hundred other forms of scum that have managed to create the absolute clusterfuck that we call heath care in America.

I like the idea of trying to create an efficient system - but you're going up against too many profiteers who have the politicians in their pockets - to ever make it a reality.
posted by Bighappyfunhouse at 10:20 PM on August 6, 2012 [1 favorite]


I enjoyed the article, but I've read of this approach before...perhaps a Discover magazine article a few years ago? It was tried in a big inner-city hospital. Cleveland? Detroit? And te results were gratifying, and then they dismantled the experiment. My brain clearly needs some care. Anyone?
posted by maxwelton at 11:01 PM on August 6, 2012


Sorry, the article I'm recalling specifically, if I remember correctly, concentrated on preventing post-surgical infections, maybe, with simple and specific rules everyone had to follow.
posted by maxwelton at 11:02 PM on August 6, 2012


I enjoyed the article, but I've read of this approach before...perhaps a Discover magazine article a few years ago? It was tried in a big inner-city hospital. Cleveland? Detroit? And te results were gratifying, and then they dismantled the experiment. My brain clearly needs some care. Anyone?


It was another article by Atul Gawande. He's been writing on this area for several years now; his last book, Better, was mostly concerned with how to improve medicine, and I think he retold the hand-washing story in a chapter in there.

What was different to me about this piece is that things are moving now, because of Obamacare and other forces. As he mentioned, his own hospital will have its compensation tied to outcomes for the first time this year, with millions at stake. The private equity group he cites which has built this new Big Medicine outpost, Steward, was only able to do so because it scooped up a network of Catholic charity hospitals for cheap. It got them cheap because they were losing money, and the orders could see the writing on the wall, as more and more government funding is tied to performance. As he said, within the past several years doctors have done from majority independent contractors to majority employees. They're losing power.

If economies of scale can be brought to bear on health care, then it's inevitable that weaker institutions will get picked off and absorbed into these larger conglomorates. The assembly line is being brought to the last truly artisanal industry....
posted by Diablevert at 11:21 PM on August 6, 2012 [2 favorites]


Dr. Gawande has been featured on Metafilter several times before. My personal favourite is Letting Go, about hospice care. He also has a home page.
posted by Harald74 at 1:02 AM on August 7, 2012


I'm not saying America has an obesity problem, but the answer to improving its healthcare system is a cheesecake restaurant...

With apologies to Ben Kuchera
posted by MuffinMan at 1:03 AM on August 7, 2012


I consider it to be a pretty thoughtful piece and an interesting look at processes rather than consideration of the companies used as examples themselves.

How often have you looked at your own job and realized that certain processes would make it a lot less tedious and easier?
posted by gomichild at 3:08 AM on August 7, 2012


It's surely an inevitable consequence of the rise of Evidence Based Medicine that the treatment plans for common conditions should tend towards a Best Known Method. Few of us are in hospital often enough to establish a relationship with a practitioner that would provide them with a detailed knowledge of our medical history. In the absence of a reason to suspect a complication, there should be a standard treatment plan. As I understand the article, this is likely the case on an individual practitioner level, but is unusual on a practice or organisational level. Experienced medical professionals don't like to be told how to do their jobs.
Large scale industry in other fields has clearly demonstrated the efficiency savings that can be achieved by standardising processes, and, correctly implemented, it will also result in an increased quality of care for the individual patient. If everyone is following the same treatment plan, any change in the care team (say, a different shift or a move to a different hospital) would be much less error-prone than is currently the case. Deviations in patient response will be easier to identify, exceptions will be more clearly visible and more closely tracked. Valuable medical attention could be used where it can be more effective.
The problem in achieving this is that medical professionals tend to see themselves as artisans rather than engineers, with each case seen as a special commission. There appears to be little justification for this in reality for many common conditions, but there is incredible professional inertia to be overcome in effecting a change to this perception. I suspect it may take a while to come around, and will probably be the result of external financial or legal pressure. I hope it can be achieved in a medically-led manner, such as with the Kiwi surgeon described in the article.
posted by Jakey at 4:11 AM on August 7, 2012 [1 favorite]


I've always thought the air travel industry is a better example to follow. Millions of transactions per day involving professionals performing complex tasks, an excellent safety record and a competitive marketplace despite strict government regulation.

Sure, people grouse about the prices, the lines, the extra charges -- but the reality is all of the North American airlines *combined* take in less profit in a year than the TSA spends, and you get to fly around in a chair in the sky, treated more or less like a customer.
posted by RobotVoodooPower at 4:20 AM on August 7, 2012 [2 favorites]


I thought I would hate this, but it is incredibly insightful. Only two things unaddressed:

1. Corporate takeover of medicine or not, doctors are incredibly difficult to manage in large numbers. Herding-cats difficult. The platonic ideal of medicine is still the single town doctor hanging out a shingle and running everything himself, and even though no one actually does that anymore, it still has a great deal of cultural cachet. Even getting uptake in things like evidence-based-medicine (which literally everyone agrees is easy to do and drastically improves outcomes, at the cost of a small amount of autonomy) is an uphill battle that has to be undertaken with finesse by administrators who understand how doctors work. If it became apparent that, say, Partners Group was taking their cues from a casual dining place and were subtly trying to turn them into line cooks, it would not end well for anyone in Partners management, as doctors wield a phenomenal amount of power.
2. If the customer at Cheesecake Factory wants his cheeseburger without pickles, there is zero chance that his choice will have serious adverse impacts on his health. If he orders, say, shards of broken glass on his cheeseburger, it would at least be easily apparent to the rest of his table mates that he had made a poor decision, and the waiter could explain why he cannot do this without being accused of elitism and poor customer service. Things in a hospital are different. There are exigent circumstances that require snap decisions by professionals operating off of reflex, and the amount of time it would take to explain those snap decisions can sometimes be prohibitive. A lot of patients won't take no for an answer, and bristle when you tell them "This drug isn't 100% effective, and can have some nasty side effects, but on net it is what the literature suggests is the optimal course of treatment, so if I don't give it to you and you die, my hospital is liable for my incompetence, so you are going to have to take it." Nonetheless, it is exactly those situations that create the largest sense of patient dissatisfaction, because everyone knows that doctors are arrogant narcissists who are just trying to spite you.

Still, Gawande has put forward more ideas about making medicine work at scale here than I've seen collectively in the last two years. This is a fantastic article.
posted by Mayor West at 4:48 AM on August 7, 2012 [4 favorites]


It was a little sad not to have even a mention of how other countries do this. The NHS in England and Wales has NICE, which has been a real boon in equalizing best practice for a health service which covers 55+ million people. I understand that he had to take a specific tack, and that explaining things in business terms might work best for a US readership, but his CV shows he must obviously knows about it and many many more. Maybe he thought mentioning the NHS, or any other healthcare system outside the US, would be offputting and stifle the message. If so, that's a damning indictment on the political debate surrounding healthcare in the US: business ideas are welcome, but foreign ones? oh no no no.
posted by Jehan at 4:54 AM on August 7, 2012 [2 favorites]


I bristled through this article for the same reason I only made it halfway through Complications, and it's a reason I can only half-articulate. Gawande views medicine as a technologist--"How do we do this better?" But medicine organizes itself not so much around technology, as personalities and the same management strategies that corrupt all other business. Hospitals might voice their goal as helping patients, but when it comes to the decisions they make, you can see it's about placating the money-makers (usually cardiologists or high-volume wound care docs) with pretty presents and as little interference as possible, while most of their idea of cost savings is in firing people (not doctors or upper-level administrators, obviously).

Even the push for more use of computerized record-keeping has been all about getting big money for following meaningful use policies with as little change to the overall structure as possible. Keeping paper records, but then scanning them (not OCR, just scanning) into unsearchable documents, for the sake of having some 'data' in the system, is my favorite example of this.

And this is within the big chains that Gawande posits as the technocratic saviors of medicine. If it seems like his favorite means for improving medicine are spreading at a glacial pace, it's probably useful to ask, mightn't that be because the chains have something else in mind, other than patient outcomes?

(um, like I said, half-articulate.)
posted by mittens at 4:55 AM on August 7, 2012 [2 favorites]


>>So there's a level of irony in pointing to them as a model for healthcare in the US.

>No, there actually isn't.

>Because this article isn't about the portion sizes or even really the food at the Cheesecake Factory. It's about the processes the Cheesecake Factory uses in order to provide an experience for their customers which is satisfying and leaves them feeling like they got their money's worth and like the experience was pleasant and isn't to be eschewed the next time the customer is looking to have their needs satisfied.


No, it is actually relevant. The CF is doing a superb job of providing people with the dining experience they are demanding -- but there are externalities to that, as indicated by their portion sizes. There would clearly be medical benefits to using CF-style processes (including, in my example above, not tying up a fully-trained doctor for the most minor procedure in the world), but there's also value in considering what might be some of the unintended consequences, and acknowledging both the pluses and minuses of the CF example recognizes this. Unlike increasing handwashing in hospitals, this isn't going to be a free lunch deal with only benefits.
posted by Forktine at 5:17 AM on August 7, 2012


Maybe he thought mentioning the NHS, or any other healthcare system outside the US, would be offputting and stifle the message.

Uh, yeah, and that's putting it mildly. You do not want to mention the NHS, or any other socialized medical system, in the current US political climate. We just had a knock-down-drag-out fight over a mandate to purchase health insurance, which is about as far from single-payer as you can get while still pushing for more health coverage rather than less. There is no appetite in the US, at least at the national political level, for that discussion.

There were some editorials in major US newspapers, back a year or so ago, talking about the Swiss healthcare system (which isn't single-payer but does have an individual mandate) and that didn't trigger quite the same about of rabid hatred. There is a very specific dislike on the part of a large swath of the US public of the idea of government-run hospitals or government-employed doctors (unless they are military hospitals or military docs, of course, in which case they're okay because it's un-American not to like the military).

So anyway, about the worst thing you can do in the US is to bring up an idea as an invention of a socialized healthcare system, and the NHS in particular. That is, in fact, how you denigrate an idea you don't like.

If so, that's a damning indictment on the political debate surrounding healthcare in the US: business ideas are welcome, but foreign ones?

On the list of damning indictments of the political debate surrounding healthcare in the US, that's at the top of a long list.
posted by Kadin2048 at 5:35 AM on August 7, 2012 [3 favorites]


I haven't finished the article yet or read the comments, but this line:

I asked one of the Cheesecake Factory line cooks how much of the food was premade. He told me that everything’s pretty much made from scratch

Made me "pretty much" raise an eyebrow.
posted by Miko at 5:43 AM on August 7, 2012 [2 favorites]


Any time a future state for health care is described in terms of some successful current operation, it's usually just met with a lot of snark. Instead, we could describe the current state of health care as a parochial society of 17th century craft villages with tradesmen controlled by closed trade guilds. But that wouldn't really improve the dialog either.
posted by klarck at 5:54 AM on August 7, 2012 [1 favorite]


My main objection to these articles isn't the hook but simply the way everyone talking about healthcare in the US acts as if we're bold pioneers tackling the impossible – forget industry, why not look at any one of *every other first-world country* and see why they're getting better care for so much less?

Gawande is very smart and no doubt understands all of this quite well, making it sad that the dialog in this country necessitates discussing cool new ideas rather than simply acknowledging that we're so far behind that catching up should be our first priority.
posted by adamsc at 6:01 AM on August 7, 2012 [1 favorite]


Jehan - It was a little sad not to have even a mention of how other countries do this. The NHS in England and Wales has NICE, which has been a real boon in equalizing best practice for a health service which covers 55+ million people.

Yes. NICE has its limitations, but it does great work to address several of the big problems mentioned in the article such as standardisation of practices, cost/benefit analyses, etc. I assume that other organisations around the world must do similar work.

In the specific case of standardisation, a couple of my doctor friends have commented in the past that flowcharts have probably done more to improve patient care in the NHS than any other recent innovation, drug or technology. The best practices for diagnosis and management of a huge range of common conditions are distilled into easily-understandable frameworks that any doctor can just pull out of their drawer. The flowchart allows the practitioner to follow the current best-possible procedures, without having spent years in apprenticeship-like positions in that specialty to learn or devise their own methods. They're not a replacement for highly trained, intelligent specialists, who can manage cases that are far too complex to neatly fit into a flowchart. But they make the front line a hell of a lot better, and can even nudge the specialists into more modern practices.
posted by metaBugs at 6:05 AM on August 7, 2012 [1 favorite]


doctors are incredibly difficult to manage in large numbers. Herding-cats difficult.

This is very true. A few years ago I sat in on a steering committee meeting for a large surgical service where the topic was a proposal to show the surgeons how they compared to their colleagues in supply cost per case, in hopes of shaming them into streamlining their procedures. There aren't many other jobs where your boss would take that approach to bring you in line.
posted by ghharr at 6:20 AM on August 7, 2012


There are three problems; health care systems, the pharmaceutical industry and health insurance systems. The Cheesecake Factory doesn't have independent servers/waiters giving you different limited menu items for your $15 or multiple food wholesalers who stop by the restaurant every day trying to sell their goods to the cooks who should be cooking.

My opinion is that the Cheesecake Factory is a bad model for restaurants.
posted by JJ86 at 6:43 AM on August 7, 2012 [1 favorite]


For those preparing the snark on a writer's idea of looking at the Cheesecake Factory for ideas on improving healthcare, the writer is Atul Gawande, an expert on practices for improving health care outcomes, professor of surgery at Harvard Medical, and a director at the World Health Organization.

And Tom Friedman is a bestselling writer and economic expert writing for the New York Times, so?
posted by MartinWisse at 6:47 AM on August 7, 2012


There are three problems; health care systems, the pharmaceutical industry and health insurance systems. The Cheesecake Factory doesn't have independent servers/waiters giving you different limited menu items for your $15 or multiple food wholesalers who stop by the restaurant every day trying to sell their goods to the cooks who should be cooking.

Well, I'm sure the Cheesecake Factory would --- if every line cook had the power to select his own preferred ingredient supplier. I'm sure you'd have Mac at station one who likes Yukon Golds and John at station two who prefers russets and Jose at station three who gets his from a farm his buddy owns, and customers would get slightly different mashed potatoes depending on who did the order. Doctors have this power, viz the knee components. Line cooks don't and the thought of them having it is absurd, because however much craft and skill goes into what they do, line cooks have bosses, and the bosses are the ones who make the call about supplies and material. So the solution is to strip doctors of power, and if Gawande's right -- and he is a practicing surgeon, so I assume he has some insight on this ---it's already happening, both for doctor-spurred reasons and for industry-spurred ones.
posted by Diablevert at 6:57 AM on August 7, 2012 [1 favorite]


I'm pretty sick and tired of people writing amazing well thought out articles touting their "solutions" to Health care, peak oil, global warming, education, childhood obesity etc. as if the real problem isn't figuring out how to circumvent the corporate stranglehold on the status quo. If you truly want to change the heath care system - or any other failing system - to work to benefit the individual, make the current health care system unprofitable for the corporate entities that annually suck billions in profits away from the people giving and getting care. I haven't heard a single solution on how we even begin to attempt that task outside of a bloody revolution.
posted by any major dude at 7:07 AM on August 7, 2012 [4 favorites]


And Tom Friedman is a bestselling writer and economic expert writing for the New York Times, so?

No, he's not and doesn't claim to be. Friedman is a former foreign correspondent who won a Pulitzer for coverage of the Lebanon war and is now a hacky op-ed writer. He has opinions about economics, but no expertise. You may be confusing him with Paul Krugman.

Gawande, in contrast, is a practicing surgeon who began a sideline in writing articles about the practice and ethics of medicine. He has an especial interest in healthcare reform and what can be done to improve the American health care system. You are free to disagree with his opinion, but I wouldn't accuse a guy who spends his weekdays elbows deep in people's abdomens of not speaking from knowledge on how the healthcare system really works. He treats patients, he teaches residents. He's not a tourist.
posted by Diablevert at 7:07 AM on August 7, 2012 [2 favorites]


I'm pretty sick and tired of people writing amazing well thought out articles touting their "solutions" to Health care, peak oil, global warming, education, childhood obesity etc....

You didn't read the article, either. Thank you for nevertheless taking the time to favour us with your opinion of it; I can see the value of that.
posted by Diablevert at 7:11 AM on August 7, 2012 [1 favorite]


I did read the article, I thought there were some well reasoned solutions, as I've read in half a dozen articles on healthcare over the last month or two. Please point out to me why a corporation with record profits in 2012 would summon the will to change to a more common sense approach that benefits patients but adversely affects their bottom line?

My mother's orthopedic doctor has probably put his daughter through a year of college trying to diagnose a problem with her hip for the last year, that another doctor figured out last week was a problem with her knee - in a single consultation. There are about 6 or 7 corporations that depend on that doctor and thousands like him to string along an 80 year old woman through test after MRI after pharmaceutical drug to keep the profit wheels greased. How do you exactly break that will and please point our the solution he outlined in the article if I missed it.
posted by any major dude at 7:27 AM on August 7, 2012 [1 favorite]



I'm not sure that the Cheesecake Factory is really as good an example as the author thinks it is, mostly because it just derails the conversation with obvious snarkbait


It does if there are too many mouthy jackasses involved in the conversation or if it's read and discussed by people other than his intended audience: adults.
posted by ambient2 at 7:30 AM on August 7, 2012 [4 favorites]


Diablevert - So the solution is to strip doctors of power, and if Gawande's right ... it's already happening, both for doctor-spurred reasons and for industry-spurred ones.

Here in the UK, one of the big selling points for the Conservatives' Health and Social Care Act was that it would give more power to doctors to manage their own purchasing decisions, care standards, and so on. This is widely agreed (on the centre/right, at least) to be self-evidently a Good Thing, allowing front-line doctors to make all the decisions whil,e saving millions by casting out useless middle-managers.

Several unions, together representing almost all of the medical practicioners in the country, called for the Act to be scrapped. It was a complex piece of legislation and people had all sorts of reasons for opposing it, but one of the major and prevalent reasons was that doctors don't want that extra power. The cost/benefit analyses, negotiation with suppliers, and business management are all very time consuming and require specialised skills in which, for the most part, doctors have little training and less interest.
posted by metaBugs at 7:35 AM on August 7, 2012


Still waiting for your answer Diablevert. You'd think someone who makes such a strong accusation would stick around to defend it...

Well, I found the part of the article I was referencing that our fine author took actually the time to acknowledge - in paragraph 107 and 108, yet almost dismissed as if it were some trivial hindrance on the path to healthcare nirvana:

The vast savings of Big Medicine could be widely shared—or reserved for a few. The clinicians who are trying to reinvent medicine aren’t doing it to make hedge-fund managers and bondholders richer; they want to see that everyone benefits from the savings their work generates—and that won’t be automatic.

Our new models come from industries that have learned to increase the capabilities and efficiency of the human beings who work for them. Yet the same industries have also tended to devalue those employees. The frontline worker, whether he is making cars, solar panels, or wasabi-crusted ahi tuna, now generates unprecedented value but receives little of the wealth he is creating. Can we avoid this as we revolutionize health care?


yet another brilliant article full of common sense solutions that begs the reader to solve his problem. Our country has plenty of Thomas Paines we are bereft of George Washingtons.
posted by any major dude at 7:57 AM on August 7, 2012 [2 favorites]


maxwelton: The story of the Detroit pilot program was in Checklist Manifesto.
posted by dr_dank at 8:01 AM on August 7, 2012


My mother's orthopedic doctor has probably put his daughter through a year of college trying to diagnose a problem with her hip for the last year, that another doctor figured out last week was a problem with her knee - in a single consultation. There are about 6 or 7 corporations that depend on that doctor and thousands like him to string along an 80 year old woman through test after MRI after pharmaceutical drug to keep the profit wheels greased. How do you exactly break that will and please point our the solution he outlined in the article if I missed it.

Well, if you can assume that your mother's first doctor was acting in good faith (and I think you should) but was just wrong or incompetent then the article does discuss solutions for that: standardized care based on established and current best practices.
posted by ghharr at 8:25 AM on August 7, 2012 [1 favorite]


ghharr,

my point is that subtle incompetence of a doctor be it intentional, indifferent or innocent benefits not only him but many others in the supply chain. For these corporate entities the supposed "solution" he advocates will actually hurt their bottom line. How do you implement change when the solution for the individual and society is at odds to that of the corporation? That is the one question that is often alluded to but never addressed.
posted by any major dude at 8:45 AM on August 7, 2012 [1 favorite]


RobotVoodooPower: I've always thought the air travel industry is a better example to follow.

Then you might be interested in Gawande's book The Checklist Manifesto.
posted by stebulus at 9:34 AM on August 7, 2012 [1 favorite]


It does seem like any improvement would result in less money coming in, yet I challenge you to find any largish hospital corporation, for or non-profit, that is not working in some way to reduce costs and provide better outcomes.

The reason is that the healthcare industry isn't a monolith, it's a whole league of teams fighting each other for part of the large but limited pool of money. Hospitals, doctors, pharma, suppliers, insurance, and all the rest are all in competition with each other. HCA would love to hurt Pfizer's bottom line by reducing wasted drugs because it probably means more money staying with them. I guarantee they're working on it right now in some way or another.
posted by ghharr at 9:41 AM on August 7, 2012 [1 favorite]


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?

Well, when his own mother needed a knee replacement, he took her to the guy who's leading the charge for standardizing knee surgery. Seems like a guy who's willing to put his money where his mouth is, so to speak.

Gawunde's article seems to posit that there's plenty of fat on the labor a materials side, as well. (63 staff including 19 doctors who do some work on a single routine knee operation; nine different kinds of replacement knee, each of which has an attached sales rep making an estimated $500 commission per unit sold)

I read this less as a condemnation of the number of people involved, and more as a description of why there needs to be SOMEBODY running the show, even if that somebody is just making sure that everybody follows the standardized procedure that was agreed upon by all these educated folks together. Somebody upthread was talking about how ridiculous it is to have an MD freezing off a wart; the U.S. healthcare system is gradually realizing this. We are starting to use more physician assistants (PAs) and nurse practitioners (NPs) to handle the routine stuff at lower cost. Even in the hospital, we have nursing assistants to take vital signs and help people to the bathroom, while the more educated and higher-paid registered nurses (RNs) assess changes in a patient's condition and look for things the MDs might have missed. I think this is a positive trend, but it does lead to more people being involved in a patient's care. If everyone understands the plan (hell, if somebody actually made a comprehensive plan in the first place), it makes it more likely that the patient will get consistent, high-quality care.
posted by vytae at 11:27 AM on August 7, 2012 [1 favorite]




"If Obamacare is in fact not repealed, we will find tactics to shallow out any Obamacare costs and core strategies to pass that cost onto consumers in order to protect our shareholders best interests," Schnatter vowed.

You rarely see it spelled out so clearly who a company exists to serve.
posted by Miko at 12:34 PM on August 7, 2012 [1 favorite]


Mr. Papa, that is a sweet deal but I have a counteroffer. Make it an even $1 more per pizza and let's do single-payer.
posted by ghharr at 12:44 PM on August 7, 2012 [4 favorites]



Still waiting for your answer Diablevert. You'd think someone who makes such a strong accusation would stick around to defend it...


I'm sorry. It was quite late and I was losing my temper and borderline-hogging the thread, so I went to bed. I haven't been able to check in again until now.


I did read the article, I thought there were some well reasoned solutions....

I apologise if I accused you incorrectly, I was getting pretty snappy and would have been better off walking away earlier. I'm sorry.

That said, since you've read the article, I think we disagree quite strongly about the author's point and/or theme. I do not believe it is a polemic. I don't read it as saying, "and here is the perfect model for modern medicine." I think what Gawande realised is that at a certain level of abstraction the problem medicine is trying to solve right now is a problem chain restaurants have already solved --- taking something like cooking, something which is idiosyncratic and creative and requires skill and extremely good time management and distraction management and split-second decision making --- and coming out the other end with a product that achieves a certain level of bland quality tens of thousands of times a day in hundreds of locations. A restaurant is not a hospital; you have to step back quite a ways to get to a point where what a doctor does and what a chef does are the same. And therefore the specifics of "what is to be done" in either situation are quite different. Just like there's a level of abstraction where a pitcher and a quarterback have the same job --- there might be some lessons they could learn from each other but that doesn't mean they'd could share the same coach.

I think Gawande acknowledges this. A lot, and quite prominently --- he lingers on the differences between the way the fancy schmancy command center interacts with the doctors its supervising and the way the back of the house manager interacts with the line cooks. What I think Gawande is interested in is looking at how these abstract forces have shaped chain restaurants and trying to think about what would happen to medicine if they act the same way in that realm. I think there's several spots where he acknowledges the potential limitations and problems of the Big Medicine approach --- he points out that standardising knee operations may make it more difficult for truly innovative new artificial joints to break in to the market, for example. It seems to me over all that he spends quite a bit of the article fretting over what the logic of the factory coming to the hospital will mean.

So overall, I don't read him as saying "the cheesecake factory has it right, guys, everybody go copy them." I read him as saying, "once, long ago in an industry far far away, there existed a business model that faced the same existential problems that we currently face, and this is what happened to it. We should examine its story carefully, for what happened to it may happen to us." More like a shoemaker saying to his guild, psst, hey guys, this is what happened to the weavers when they invented the automatic loom; now they've created an automatic tanning machine, it could happen to us too.

That's the whole point of the section immediately after the lede --- talking about how Big Medicine is already gearing up, how doctors are already losing autonomy, how Obamacare and other mandates are already tying pay to performance in a way that simply hadn't existed before.

There are about 6 or 7 corporations that depend on that doctor and thousands like him to string along an 80 year old woman through test after MRI after pharmaceutical drug to keep the profit wheels greased. How do you exactly break that will and please point our the solution he outlined in the article if I missed it.

Self-interst, of course. Pay doctors and hospitals who fuck up diagnoses and waste money less. You imagine there is a perfect alignment of interests all along the chain, but there isn't. Gawande is quite explicit about this:
[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.

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.
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.
posted by Diablevert at 7:45 PM on August 7, 2012


The Colbert Report: Obamacare's Effect on Pizza Costs
posted by homunculus at 11:29 AM on August 9, 2012


I walked into an emergency room the other day and asked how much my visit was going to cost and nobody knew! A waiter at the cheesecake factory knows how much the meals are. Things are definitely backwards.
posted by rjones44319 at 2:35 PM on August 14, 2012


Mmm, well, at the Cheesecake Factory you choose what you want from a list based on your idiosyncratic and changeable appetite. At the ER they follow protocols to treat you, and because things are unpredictable, it's not always clear what you're going to need ahead of time.

I mean, I don't know if you're asking things like "How much is this sterile dressing? How much would the stitches be? How much is this saline IV drip?" or asking something like "How much will this [entire visit] cost?" but it's reasonable that the staff doesn't know. First, the entire visit cost isn't clear when you walk in, because no one can confidently predict your complications or other conditions that might be discovered while you're there. Second, it's because they aren't salespeople. They're medical technicians following protocol and they really shouldn't have to worry about pricing.

I mean, there are a lot of things wrong with the system, but taking up a nurse's or doctor's brain with the latest pricing for every Tylenol and cotton ball is not something I think promises to be a helpful fix.
posted by Miko at 10:09 PM on August 14, 2012


I mean, there are a lot of things wrong with the system, but taking up a nurse's or doctor's brain with the latest pricing for every Tylenol and cotton ball is not something I think promises to be a helpful fix.

I agree. But it's also interesting to see how parts of medicine most exposed to the market have taken a different path, more like a restaurant menu. Elective surgeries (which generally get paid for in cash or with loans), like refractive eye surgery or breast augmentations, have been packaged into standardized packages with upfront pricing. You can walk in (or even just glance at a website) and find out immediately that Clinic A has a standard, all-inclusive price of $X for procedure Y, pretty much regardless of which of their doctors does the procedure, and with a fair bit of room in there to cover themselves if your case turns out to be completely simple or with a few complications.

ERs could charge that way, with a long "menu" of services and prices. "Let's see: it sounds like you have a broken femur and possible internal bleeding, so that will be..." Obviously that's unrealistic, but Gawande is talking about some steps on that path, so that your care (and presumably your billing) would be consistent regardless of which doctor was on duty that night in the ER.
posted by Forktine at 3:42 AM on August 15, 2012


Sure, but the second anything goes wrong with your elective surgery you are back in the world where consumers don't make choices, let alone select services based on price.
posted by Miko at 5:30 AM on August 15, 2012


Sure, but the second anything goes wrong with your elective surgery you are back in the world where consumers don't make choices, let alone select services based on price.

Of course! I was just pointing out one tiny area of medicine that is providing some of the price transparency that sometimes people want from the ER. But, and importantly for Gawande's point, they are providing price transparency but not standardization of techniques and care, which is what he is urging.
posted by Forktine at 5:36 AM on August 15, 2012


Oh sure, and I am a Gawande fan and totally endorse the checklisting/protocols/standardization idea. In fact it is a pretty big thought development of our time - I often wonder if one reason it's not a little more widely embraced is that it confronts the medical mystique in a fairly assertive manner, and doctors don't like to think of themselves as technicians.

This analogy, like any analogy, just has its limits. Admittedly what I'm doing is nitpicking, but am just kind of reluctant to extend some of the reasonable conclusions to situations where pricing information is less urgent and less determinativ of actions taken, and consumer choicemaking is more limited.
posted by Miko at 8:57 AM on August 15, 2012


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