Great article. Before I moved into healthcare, I spent 15 years running companies and had an Econ degree. I’ll admit that the business model of healthcare in the USA is the most convoluted thing I’ve seen. Incentives are misplaced and solutions are out of control of even the administrators due to the interplay with government and insurance.
The surgeons subsidizing the hospital is something I see here in rural IA / MN. It’s hard to attract surgeons to rural area where the weather isn’t always friendly. We’ve seen a lot of consolidation and not always for the better of the community.
With the move into robotics and “remote surgery” it makes me wonder whether that movement will mitigate or exacerbate the problem your essays points pose on smaller communities.
Nick, your vantage from outside healthcare is useful here because the convolution you describe is the piece's point: the cross-subsidy only holds while the incentives beneath it stay aligned, and most of them now pull in different directions.
On robotics and remote surgery, I expect both effects, in that order. A robotics platform's capital cost concentrates volume in the near term; the hospital that can't justify the machine watches those cases leave, which is the same story with a newer mechanism.
The remote promise feels real at this point, but a remote surgeon still needs everything else to be local — the anesthesia care team, OR nursing, sterile processing, an ICU bed if the night goes badly. After twenty years at the head of the bed, I'd argue the surgeon's hands are rarely the only thing keeping a case in a building. Whether remote surgery helps a small community will depend less on the technology and more on whether the local team around it is still standing when it arrives.
Great article. Before I moved into healthcare, I spent 15 years running companies and had an Econ degree. I’ll admit that the business model of healthcare in the USA is the most convoluted thing I’ve seen. Incentives are misplaced and solutions are out of control of even the administrators due to the interplay with government and insurance.
The surgeons subsidizing the hospital is something I see here in rural IA / MN. It’s hard to attract surgeons to rural area where the weather isn’t always friendly. We’ve seen a lot of consolidation and not always for the better of the community.
With the move into robotics and “remote surgery” it makes me wonder whether that movement will mitigate or exacerbate the problem your essays points pose on smaller communities.
Nick, your vantage from outside healthcare is useful here because the convolution you describe is the piece's point: the cross-subsidy only holds while the incentives beneath it stay aligned, and most of them now pull in different directions.
On robotics and remote surgery, I expect both effects, in that order. A robotics platform's capital cost concentrates volume in the near term; the hospital that can't justify the machine watches those cases leave, which is the same story with a newer mechanism.
The remote promise feels real at this point, but a remote surgeon still needs everything else to be local — the anesthesia care team, OR nursing, sterile processing, an ICU bed if the night goes badly. After twenty years at the head of the bed, I'd argue the surgeon's hands are rarely the only thing keeping a case in a building. Whether remote surgery helps a small community will depend less on the technology and more on whether the local team around it is still standing when it arrives.
Dr Wild this is a fabulous analysis - way too many quotables to pull out only a few.