I grew up in the restaurant business (my parents ran a restaurant for nearly 30 years) and am an acknowledged health policy junkie, so I was very excited when a colleague sent me an email with a link to Dr. Gawande's recent article comparing a popular restaurant, The Cheesecake Factory, and health care in The New Yorker, “Big Med.” I urge you to read the article; I feel it highlights much of the health policy thinking regarding process improvement that has become popular lately in politics, newsrooms and surgical facilities.
To those who are unfamiliar with Atul Gawande, he is a professor of surgery at Harvard Med and has written extensively on process reforms in the American health care industry such as medical errors and hospital infection reforms. Reputedly, he has been a key adviser to the White House and an architect of the quality pilot components of PPACA, aka Obamacare. In his article, Gawande argues (correctly) that medicine needs better systemic outcomes, such as care standardization, product innovation and information (best practice) dissemination, but ultimately points the finger at the wrong culprit (Big Med). "We've let health-care systems provide us with the equivalent of greasy-spoon fare a four-star prices and the results have been ruinous," he practically sneers at the article's conclusion. That finger pointing sentiment is where I think the "who-is-at-fault" premise of his article goes completely off the rails.
Please imagine, using The Cheesecake Factory example, how the restaurant chain would run with serving a big-eating, full-menu-ordering, government subsidized crowd, with the best tables reserved for them. There would be a food malpractice attorney parked at the entrance, and all the menus and orders would be HIPAA-Protected. Now imagine you boot out the government subsidized customers and the malpractice guy at the door—now you might call the new restaurant Kaiser, which is very Cheesecake Factory-like, producing the very systemic efficiencies that Gawande complains that Big Med lacks. Kaisers and others like it are becoming a very model of large public health care systems. The innovation, while not magical process reform, is a very selective and controlled customer (ahem, patient) base.
The most significant innovation leading to production marvel of The Cheesecake Factory (or Wal-Mart, Olive Garden or other large companies cited by Gawande) isn't the quality control processes in place; it's the credit card stickers, MasterCard, Visa and American Express plastered on the crystal clear front window. Noticeably absent is a sticker welcoming EBT (food stamps) cards, IOUs or discounted Medicare and MediCal cards, which my facility has to accept. I think a lot of medicine would welcome and even embrace the efficiency and outcomes of big corporate entities run like a "Big Med": a thorough Kaiserization if you will, if there were a truly level playing field
The article largely flogs health care providers, hospitals, doctors, nurses and technicians etc.—many largely forced to take all comers—and is a health care reform cheap shot without acknowledging the financing rules involved. Pointing out how bad the American health care system is while ignoring the funding involved is the kind of an idealistic fantasy that plays well in some circles, but essentially lacks the guts to address the rampant, unchecked culture of unfunded promises that makes meaningful health care reform impossible.
Truly, if my hospital used The Cheesecake Factory’s rules to admit patients, we'd not only be operating illegally, Dr. Gawande would possibly take to writing about how monstrous we were in his next article. "Efficiency," we would retort, would require controlling input (money and patient selection) and outputs (patient care).
You don't need an MBA to figure out this elementary business case:
Hello potential customer…let’s see, you don't have any income, cash or credit and you don't produce any goods…ok…but you want to come into my operating room and ICU and take advantage of procedures that cost a million dollars? Oh wow, you want a Stanford educated anesthesiologist? Hmmm…let me get back to you.
Perhaps I should consult my business school notes, or better yet, what would The Cheesecake Factory do?
Beyond the promotional value to the restaurant chain, should Dr. Gawande advise his local Cheesecake Factory to operate like a hospital—opening 24 hours a day, every day, accepting all comers including those unable to pay—he would soon find his table privileges revoked. Because not only would the rules under which hospitals are forced to operate make a family chain restaurant unviable, but also beneath the credit card stickers, in somewhat smaller print is another sticker that says, "We have the right to refuse service to anyone." Ah ha.
If only we had the luxury of living by the economic rules that everybody else does, something that is not possible in the disconnected world of idealistic medicine. In my real health care world, anyone walking into the ED gets me to take care of him/her for free on a Saturday night. Meanwhile, detached elites clink pretty glasses and print articles in The New Yorker about how I and everybody else working in the OR are moral infants, all the while lambasting us on how to improve our "efficiency." Anybody else smelling the spoiled cheesecake?
If you want to ultimately control process outputs, you need to first control process inputs. Academics always like to point out how the marketplace has failed medicine, while never having the guts to publicly consider that perhaps the culprit here is unchecked egalitarianism not Big Med. Gawande correctly concludes that the giant restaurant chain "knows its customers." Well duh.
I know their customers and I know my customers. We are not working with the same group or operating under the same rules. Wait on restaurant tables and grow up to be a doctor (as I have), and you just might know that.
Dr. Harrison Chow is a practicing anesthesiologist based in San Jose and at Good Samaritan Hospital. He is planning to take his family to the nearby Cheesecake Factory in Palo Alto soon for dinner. He is planning to use a plastic credit card for the family outing while leaving the moral posturing and IOUs at the door.