I will try to keep this post short. Let me open with a quote from “The People’s Hospital” by Dr. Ricardo Nuila. It’s an excellent book — interweaving remarkable patient stories with Dr. Nuila’s own journey and with a thoughtful, considered analysis of the healthcare system. Published in 2023, I think it will be considered timeless like “The House of God” by Samuel Shem and other such books because the problems it describes aren’t just endemic to the healthcare system. Over time, those intractable problems have wormed their way into the soul of America.

Dr. Ricardo Nuila & John Boyd — two people who care about function and helping the end user.

Context for the quote: Dr. Nuila works at Ben Taub Hospital in Houston. It’s a public safety-net hospital in Harris County owned and operated by the Harris Health System and staffed by the faculty, residents, and students from Baylor College of Medicine. One of his colleagues who splits time between Ben Taub and a private hospital is explaining to him the difference in the practice.

“The private hospital is set up to be overused.” He explained. He could call a colleague in during a surgery when he didn’t really need an extra set of hands (and, likewise, expect to be called by that colleague.”

Here, Dr. Nuila’s colleague is explaining “over-treatment” — Medicine Inc. (Nuila’s neat formulation that sums up hospitals, doctors, administrators, and health insurance companies) are all incentivized, individually, to do more, spend more, and recoup more but the health outcome for the patient isn’t necessarilly improved. It’s spending more with no change to outcome.

This section reminded me of the excellent biography of John Boyd by Robert Coram. Boyd was a fighter pilot turned plane designer (among many other things) who advocated for simpler fighters that cost less with fewer bells and whistles. He found that, within the Pentagon, people WANTED to spend more and spending was an end in itself because it was more impressive to have a $25 million plane with radar-guided missiles than a lightweight, lower-cost fighter. A lot of the voices pushing for spending more, predictably, came from the weapons manufacturers but people in the military, too, saw opportunities for advancement by supporting expensive, shiny programs.

Dr. Nuila and Boyd noticed the same thing —- both in the military and in healthcare, there was TOO MUCH money already. The problem wasn’t funds. Rather, it was the excess of funds. There was no incentive to do things under budget.

I’ll throw a third thing into the mix even though I need to read more about it but the U.S. education costs per child in 2020–21 were $18,614 nationally, the fourth highest in the world and I’m pretty sure no one thinks we’re getting sufficient ROI. There, too, MORE spending isn’t the answer.

We live in a time when we are inundated with information. And, as consumers, of products, of information, of news stories, we have to come up with heuristics — cognitive shorthand — to get through the day. The idea that “more expensive is better” is a heuristic that many of us, myself included, can default to. But this heuristic is not necessarily true. We must be careful.

The Conclusion Here:

For decades to come, we are going to be arguing about policies like Medicare for All, and about Dept. of Education, and about military spending. I write this short post in the hope that my audience, working in various industries and with a wide range of political beliefs, remembers that — “who is going to pay for it?” and “how much?” are not the only salient questions.

Guiding philosophies. Processes. Simpler, better aligned incentives. These, too, are levers that we can manipulate. Money is not the only lever.

And, read, Dr. Ricardo’s book, please. You will be better for it. And if you have anyone in your family who likes military history, Body is a great birthday/Xmas gift.

Bookshop Link - The People’s Hospital

Bookshop Link - Boyd

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