The Great Cheesecake Robbery

The Great Cheesecake Robbery

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In a well-publicized and well-written article in the New Yorker, Atul Gawande (one of my doctor writing heroes) talks about his visit to the popular restaurant, The Cheesecake Factory, and how that visit got him thinking about the sad state of health care.

The chain serves more than eighty million people per year. I pictured semi-frozen bags of beet salad shipped from Mexico, buckets of precooked pasta and production-line hummus, fish from a box. And yet nothing smacked of mass production. My beets were crisp and fresh, the hummus creamy, the salmon like butter in my mouth. No doubt everything we ordered was sweeter, fattier, and bigger than it had to be. But the Cheesecake Factory knows its customers. The whole table was happy (with the possible exception of Ethan, aged sixteen, who picked the onions out of his Hawaiian pizza).

I wondered how they pulled it off. 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—except the cheesecake, which actually is from a cheesecake factory, in Calabasas, California.

I’d come from the hospital that day. 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. Our costs are soaring, the service is typically mediocre, and the quality is unreliable. Every clinician has his or her own way of doing things, and the rates of failure and complication (not to mention the costs) for a given service routinely vary by a factor of two or three, even within the same hospital.

I think you get the idea: if only medicine were run more like the Cheesecake Factory, health care would cost much less and do much more good.  His story about how orthopedic care can be made into a system are spot on.  Disorganization of care is a huge area of waste in the system (which a recent Institutes of Medicine report likely underestimates – in my opinion – at $750 billion per year), and deliberate systemization is the only way to overcome this problem.  I think his analogy is good, his writing is (as always) eloquent, and following his recommendation would save a lot of money and many lives.

But there is one problem with this article: it misses the main problem in health care.  His system deals mainly with hospital medicine, which is, for lack of a better name, sick care instead of health care.  The mis-labeling of sick care as “health care” is, in my view, the most costly error in all of medicine.

Let’s back up to the restaurant analogy to see where this confusion causes havoc.  The goals of the Cheesecake Factory, like any restaurant are:

  1. To give the best food as cheaply as possible
  2. To give a good customer experience that brings people back repeatedly and attracts new customers
  3. To keep overhead low without compromising #1 and #2

It is point #2 where the health care analogy breaks down.  People want to go to eat at restaurants (for full disclosure, I am a big fan of the Cheesecake Factory and have adipose tissue to verify this fact), whereas they don’t want to go to the hospital.  Yet the “health care” system is not set up with this in mind.  Like the restaurant industry, “health care” is set up to deal with episodes of care, usually centered around illness or injury.  The more people are sick, the more opportunities for income for the medical industry.  This means that to truly succeed as an industry, “health care” has to do the following:

  1. Give the “best” care as cheaply as possible
  2. To take measures to maximize the number of encounters a person has with the system
  3. To minimize overhead.

Gawande’s article focuses on #1 and #3, ignoring the glaring problem in #2.  The other problem the analogy ignores is the definition of the word “best.”  Is the “best” drug for your heartburn a cheap antacid, or is it the $120 bottle of Nexium?  Is the “best” surgery for you the standard procedure, or is it the one using the cutting-edge Da Vinci robot?  Is the “best” care in primary care a SMA-20 blood panel, an EKG, CBC, and PSA (or mammogram) every year, or is it a frank discussion with your PCP about lifestyle changes?  Clearly from a business standpoint, like the restaurant industry, “health care” makes the most money from more, not less.

The 600 pound (Robotic Da Vinci) gorilla in the room is the assumption is that “health care” is, at best, a fixed commodity with a set amount of consumption by “health consumers.”  At worst, “health care” is viewed, like restaurants, as a growth industry.  While it may be in my best interests to minimize my encounters with the Cheesecake Factory, I go there because I want to.  ”Health Care,” on the other hand, is something I hope to avoid, as I would also try to avoid encounters with auto mechanics and plumbers.

As a PCP (especially in my new practice), my goal is to decrease my patients’ encounters with the rest of the health care industry.  In this way, the analogy with Cheesecake Factory is unwittingly accurate.  More is usually not better in health care, and the flawed belief in the more mantra is the basis for the spending that is out of control, now fueled by a hungry industry that perpetuates that mantra.  This is quite similar in the more mantra pushed by the food and restaurant industry, a mantra I do well to get my patients ignore as well.

Health care needs to become centered on health, not on sickness.  It needs to be focused on less consumption, not more.  This will not be good news for our current “health care” industry – the one built around sickness, not health – but will instead close hospitals, turn specialists into primary care physicians, and put many “health related service” companies out of business.  Healthy patients (the purported goal of “health care”) will be extraordinarily unhealthy for the “health care” industry.

There still will be need for sick care, and I sincerely hope that Dr. Gawande’s dream of a lean and efficient system is realized for this.  But limiting the focus on improving the process of dealing with illness won’t stop the main problem: we are eating way too much cheesecake.

Rob Lamberts, MD, is a primary care physician practicing somewhere in the southeastern United States. He blogs regularly at More Musings (of a Distractible Kind) where this post first appeared. For some strange reason, he is often stopped by strangers on the street who mistake him for former Atlanta Braves star John Smoltz and ask “Hey, are you John Smoltz?” He is not John Smoltz. He is not a former major league baseball player.  He is a primary care physician.

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47 Comments on "The Great Cheesecake Robbery"


Guest
Sep 13, 2012

I have a lot of respect for Atul, but I have to say I thought that article was ridiculous. The amount of buzz and adulation that went with it was also just silly. I agree with your comments, Rob, and am happy to see some appropriate criticism.

I understand how much the healthcare industry has gained from aviation and manufacturing, and think there are a lot of areas for ongoing improvement needed. But I think we need to stop being reductive in how we approach things. I thought the restaurant (and an unhealthy and often not service oriented one at that) analogy was not only over-simplistic, but missed a lot of the real issues around quality, cost, and suffering that the healthcare industry deals with. At a time when we need to have nuanced and very practical discussions about delivery models, cost and quality, I thought the article was an unfortunately trivializing diversion.

Guest
southern doc
Sep 13, 2012

Dr. Gawande is the king of lousy analogies.

Guest
Brian
Sep 13, 2012

A car dealership is a better analogy : Complex rater codes for services, insurance is very involved in the transactions for anything beyond routine repair, and the consumer often feels they are getting gouged.
The jobber codes from Mitchell will Rival the CPT book
Maybe a rewrite is in order.

Member
Sep 13, 2012

I’m glad to hear that I’m not the only one who thought that the Cheesecake Factory analogy was a little too weird to be really happening — bordering on massively inappropriate. The piece also seemed a little tone deaf to me, given Dr. Gawande’s (admittedly unofficial) status as writer of extremely long magazine articles describing ideas that will later be adopted and used by the administration and as talking points. I have heard a lot annoyance from people in healthcare about this one. I mean think about how would most people feel if somebody compared their industry to something fairly ridiculous, like industrialized Cheesecake production and distribution?

We’ve heard the oohing and aahing and “oh my!” -ing from the healthcare intelligentisa* – the same people by and large who created the healthcare crisis and then nominated themselves to study it – but I’d be curious to know what kind of feedback Atul has heard in private.

If I was a writer who’d come up with a decent analogy, I’d be be lit!

Guest
Sep 13, 2012

The analogy (in my opinion) works for the orthopedic wards and for other situations where standardization of care can reduce waste and variability of results. The problem is simply that it was applied to “health care” as a whole, which misses the mark. I think the oversight many have made in this area is telling to the view most have of “health care,” which is that it is a system built for sick people and for sickness. Build it and they will come.

Guest
Sep 13, 2012

This response to Gawande’s article is in summary another example of something I learned in my graduate program in conflict resolution: If you do your job well, you work yourself out of a job.

That always seemed like a great line, a great goal. I still like it.

But while that situation in a way seems lofty and positive at first , it is then practically a bad idea for longevity of careers and business because, yes, “Healthy patients (the purported goal of “health care”) will be extraordinarily unhealthy for the “health care” industry.”

Well, I guess if everyone gets all healthy, there will be some enterprising ideas around that?

Guest
MD as HELL
Sep 13, 2012

Six esponses and no on e has said the obvious…The Customer is paying his entire bill.

He orders hat he wants and can afford. If he can’t afford the CheeseCake Factory, then he eats at White Castle.

If he is not paying the bill, then he goes to the ER where the hospital stupidly feeds a meal toeveryone in the waiting room (Lumberton, NC).

Pass the sugar.

Costs are out of control because government and the Joint Commission are running the regulatory show like the EPA. “Clueless on the real world costs” of their actions.

Guest
Sep 13, 2012

Maybe a better analogy would be a chef’s school if you’re talking about care of chronic conditions. Patients and their caregivers do most of the work in that situation – take medications; monitor symptoms; note early warning signs of exacerbations or complications; and a variety of other tasks. They need to be educated on how best to manage their own care – with appropriate resources available when they need them and support when making difficult decisions. That sounds to me more like making their own meals rather than being served as in a restaurant. Going to the restaurant rather than learning how to cook keeps them dependent on the restaurant.

Guest
southern doc
Sep 13, 2012

The Cheesecake Factory’s number one obligation is to maximize return on investment for shareholders.

That’s definitely the way medicine is headed.

Guest
rbaer
Sep 13, 2012

I think Rob’s and HellMDs points are most important, and it also needs to be pointed out that the consumer can judge the quality of the food, while it is often impossible for the layperson to judge the quality of care (yes, you may have had a great angioplasty with friendly docs and in a hospital with a low infection/complication rate and great service, but was the angioplasty indicated to begin with?), unless the layperson is very smart, has a lot of time, excellent judgement and advice when looking up and applying complex health information.

Yes, the cheesecake factory works well for many straightforward services like e.g. joint replacements – complex but very repetitive. Challenging problems in tertiary care are best compared with a legal defense team in an important and complex case – lawyer(s), experts, paralegals need to work together to create a highly individualized srvice. No comparison to CCF or an airline seat – complex services but highly standardized.

Guest
Sep 13, 2012

Spot on.

Guest
Sep 13, 2012

I wonder how important it is to someone’s overall health to have a high quality angioplasty vs. good management of CV risk factors – blood pressure, blood lipids, general conditioning, etc., etc. In any event, concentrating on procedures/surgery/acute treatments (chemo, etc.) is an entirely separate issue from the chronic issues so poorly handled with our current system. I think both are important – limiting post-op and line infections and ventilator -associated pneumonias, for instance – but that really is not the whole of what patients need. They need to take care of themselves before and after their angioplasty (can they avoid it entirely if they do a good job before?), and that’s most of their lives.

Guest
Dr. Mike
Sep 13, 2012

Good preventive care is great and all, but motivated patients already have access to an army of highly trained primary care docs willing to keep them healthy, and unmotivated patients already resist even the best efforts to prevent the illnesses that plague them. These unfortunate facts unfortunately lead to the tendency of collectivists to find ways to impose prevention on the unwashed masses, which of course is very costly and leads to siphoning of monies away from much more expensive acute and surgical care, leading to mediocrity within the system as a whole. There are a multitude of examples one could list that confirm this – health systems with great out-patient coverage and long waiting lists and poor outcomes for the more expensive stuff. There are answers of course, but no one here want to hear them.

Guest
DeterminedMD
Sep 13, 2012

To me it is a crappy analogy because more than not want a “free meal” which you cannot get at The Cheesecake Factory, but people more and more demand at the doctor’s office. “I don’t want to pay a copay”, “I want the best diagnostic study”, “why won’t the best specialist take my insurance”, and one of my favorites of late, “why doesn’t the doctor take my call when I am calling.”

It is nice to have choice, it is nice to be waited on, it is nice to eat a good meal, but, medicine isn’t a business, and I find these faux analogies just more “hear the lie enough and it becomes truth”.

Again, how do you pass PPACA and not address the role of tobacco? You want to promote health and not just chase disease, well, isn’t the stat still 20% of Americans still smoke? Isn’t it time to take this off the menu?

Guest
MD as HELL
Sep 13, 2012

No.

This seems out of character for you, asking gov’t to jump into your life.

Guest
DeterminedMD
Sep 14, 2012

I don’t see it strictly as just a government intervention, but really, where were these politicians’ heads in concocting legislation and, to me at least, conveniently forgetting that tobacco accounts for, what, 20% or more of health care costs?

But what process will marginalize tobacco use most effectively? “Just say No” campaign to the public? No, it is time for governments federal and state to accept the full truth and realize if you want to contain health care costs realistically, you start with saying goodbye to tobacco, or more realistically to me, say goodbye to health care coverage for smokers.

To bring it back to the post, take nicotine off the menu, it only hurts the business anyway. Look at it as The C Factory trying to sell Limburger cheesecake at their front case. Kinda sells the point of smokers, eh?

Guest
DeterminedMD
Sep 14, 2012

I just read about NYC setting limits about the sale of large soft drinks to offset obesity issues. While I think it a bit ludicrous to watch government to go to these lengths, then why not just outlaw smoking that DOES cause profound morbidity and mortality?

Oh yeah, the soft drink lobby isn’t as deep pocketed as the tobacco lobby. Another reason to distrust politicians.

Guest
Barry Carol
Sep 14, 2012

The reason that the current healthcare system rewards more care rather than less no matter how unnecessary or inappropriate it may be is the fee for service payment model. The entire September, 2012 issue of Health Affairs is devoted to payment reform. It’s full of articles about experiments and pilot projects from capitation to bundled payments to shared savings to alternative quality contracts to global budgets within a fee for service framework. The name of the game here is to better align incentives, especially between payers and providers because incentives matter and they matter a lot.

There are separate efforts to better engage patients on the cost issue from high deductible insurance plans to tiered provider networks. Price transparency tools that disclose contract reimbursement rates would be helpful, especially for discrete services like imaging. If bundled payments for episodes of care like a CABG or hip replacement become more widespread, price and quality transparency tools available to both patients and referring doctors could help to control costs there as well.

Other ways to tackle unnecessary care include sensible tort reform to reduce defensive medicine and a more concerted effort to get patients, especially those 55 and over, to execute living wills and advance directives and to talk to their spouse and adult children about what care they want and don’t want as the end of life approaches.

As for the Gawande article being most applicable to hospital based care, we shouldn’t forget that inpatient and outpatient care combined accounts for fully 45%-55% of medical claims for most payers. Standardization of processes in the operating room, consistent protocols to insert a central line, better discharge planning and less practice pattern variation could all contribute to reducing waste. If we’re serious about all this, though, we have to get the payment incentives right.

Guest
Dr. Mike
Sep 14, 2012

“The name of the game here is to better align incentives, especially between payers and providers because incentives matter and they matter a lot.”

This statement is why we will never succeed in reducing costs without imposing significant rationing. You need to align incentives between patient and physician for outpatient services and between patient and insurer for inpatient treatment. The patient/physician dyad’s goal is to avoid hospitalization and expense to the patient through excellent outpatient care and utilization of appropriate screening and health care maintenence. The patient/insurer dyad’s goal is to limit unnecessary and expensive inpatient and specialty care. There is no role for the insurer/physician dyad unless you as a patient like having your options limited without your input.

Guest
Sep 14, 2012

I don’t disagree with most of what you say (in fact I am changing my business model because of these facts). Regarding the last paragraph, the problem I try to shine light on is that the inpatient care (and much of the outpatient care) cannot be assumed to be fixed in the amount needed. We need to prevent it from happening 1st, and then if it is not preventable we can control cost through the application of good systems. That last part is the emphasis of the Cheesecake article, yet in my mind it is a secondary issue. It’s fine to work on standardization of sick care, but let’s not forget that people would do best to avoid being sick in the first place. Until we have an economic model to accomplish this (someone who is not penalized by healthy people), we will remain mired in this mess.

Guest
Barry Carol
Sep 14, 2012

Rob –

I’m with you completely on your emphasis on preventive care and trying to keep patients healthy and out of the hospital. However, while I haven’t seen any hard data, most insurers claim that they have made good progress in recent years in reducing the number of inpatient bed days per 1,000 members. Despite that, patients seem to get more care while they’re there than they should. Also, consolidation among hospitals has increased their market power which keeps driving up costs per unit of service or per DRG episode. Indeed, for at least the past couple of years, insurers tell us that most of their increased costs for hospital care is due to unit cost increases as opposed to greater utilization of services. So, despite favorable trends toward shorter length of stay, price increases well above cost increases and general inflation seem to keep hospital costs as a percentage of payers’ total claims costs in the 45%-55% range despite the best efforts of docs like you. However, ACO’s and global budgets within a fee for service framework as discussed in one of the Health Affairs articles this month suggests that there is a lot of potential to reduce healthcare costs with changes in the payment model to better align incentives between payers and providers.

Guest
Barry Carol
Sep 14, 2012

Dr. Mike –

Most patients don’t know what services, tests, procedures or drugs they need. They rely on their doctor to tell them. For specialist and hospital based care as well as imaging, it would be helpful if doctors knew who the most cost-effective high quality providers in their market are so they could refer their patients to them.

I don’t know how much unnecessary or marginally useful care is driven by specific patient requests or implicit patient expectations nor do I know how often they request inappropriate prescriptions for drugs they saw advertised on TV. Perhaps you or some of the other doctors on the blog could weigh in on this.

Guest
rbaer
Sep 15, 2012

Barry,
I am actually (believe it or not) trying to research that very question, although this is very tough to do, as is the case with all medical decision making – and currently, my (draft for a) pilot study is not taking off. The problem is that there are multiple factors interacting, and only infrequently are things black and white (e.g. the patient explicitely demanding a test and the doctor opposing and explaining) because: there is minimal medical necessity (i.e. the minimal chance of finding relevant pathology that you even may have with a random study), there is patient and family anxiety, there is pressure to be perceived, by pt and colleagues, as “thorough”, there is the knowledge that other docs order the same poor value test – and then there are these other interesting motivators such as money, defensiveness.
IMHO and from my experience, patient expectations, explicit or implicit do matter. This is also supported by the (very limited) literature – for instance, if docs think (they actually may be wrong) that patients want ABx, they will much more likely prescribe them.

Guest
Sep 15, 2012

Do you think it might be because there is inadequate opportunity for communication about these issues? It seems as if patients are not given opportunity to obtain enough information (at least enough detailed information, not just “dumbed down” generalities about what they should do or not do) to meaningfully engage in decision-making. At the 2012 Consumer Health IT Summit last week, one of the major calls was for physicians and other providers to change their perception of their patients’ capabilities to understand their own health issues. I personally think that’s a great idea – but will take changes in the system to allow that to happen. Patients now have access to quite a bit of information, but having an interaction with their physician about what that means to their individual case seems lacking in most cases.