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"


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Dec 27, 2012

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Ruth
Sep 17, 2012

The US model is bottom-line medicine, measured in dollars…not health. This is why the ‘care’ part of the equation ranks 37th in the world (NEJM, Jan 2010), while the business variable is NUMBER ONE! Quite a model!
Medicare (upgraded) For All, with private options available for anybody who wants them, is the best solution.

Guest
southern doc
Sep 16, 2012

Thanks for the reply. I agree with everything you say. I misread your response to Walker above as agreeing with his claim that there are inherent virtues in practices becoming larger.

Guest
Walker
Sep 17, 2012

Perhaps I did not make my point clearly. What I was trying to say is that all of medicine can benefit from the large-scale medical care improvement research that is happening in the large integrated systems that do such research. Dr. Rob as a solo practitioner will have the same access to that research as anyone else who reads the journals.

And for Dr. Rob, who said ‘I must add that “large integrated delivery systems” are very hungry consumers of health care dollars. They are far more interested in the survival of large integrated delivery systems than in cutting the cost of care.” – there are some integrated delivery systems that are also payors. I believe those systems have a different set of incentives to find what works and use it. If they keep their members healthy, the premiums keep coming. One sees a much greater emphasis on primary care, early detection of potentially costly chronic illness, vaccination, and medication compliance is such systems. Why? Largely because it’s cost-effective for those systems. Admittedly, some of the activity is stimulated by hitting targets set by the government, but the patients still benefit, no?

Guest
Sep 17, 2012

Yes, I agree. I do wonder about one organization participating on the market on so many levels, though. Something about it raises my inbred American hackles. While I am no libertarian, I do think that a company like Kaiser runs the risk of being like Wal-Mart, making it impossible for anyone else to compete in the markets they occupy. On the other hand, Wal-Mart has driven the cost of many items down considerably, something that is much-needed in the health care market.

Guest
southern doc
Sep 16, 2012

Would still like Walker or Ms. Raup to give an example of a specific standard of care that is available to docs in “large integrated delivery systems” that Dr. Lamberts will not have access to.

Guest
Sep 16, 2012

Southern doc, I for one do not think there’s anything available in large integrated delivery systems that is not available in any other setting. I believe information, however, does inform improved practices. I think the greatest opportunities for improved outcomes are in better communication with patients and patients’ families. Implementing standards of care often depend on patients understanding and following complex care plans. And new interventions will continue to add to the complexity. Is there any room for improvement in this area? After hearing about patient experiences at the 2012 Consumer Health IT Summit last week, I think there are solutions for some of the communication problems some patients experience. I do think those supportive technologies are used by physicians in all types of practice settings.

Guest
Sep 16, 2012

Not all people over age 70 are created equal. My Dad’s 86 and mother is 82, and both are basically healthy. My father just passed off the last of his business to someone else due to problems with his eyes. While I don’t recommend he get a colonoscopy, thinking 5 years into the future (which a lot of preventive care does) is quite reasonable. They have made me rethink how to take care of “old” people, as their quality of life has remained quite high.

That being said, there are plenty of 70 year-olds who I would not recommend doing anything on, as their life-expectency is much shorter due to disease or misuse of their bodies. It’s my job as a PCP to look at the individual and determine what level of care is appropriate. Unfortunately, it was the people on the political right, not the left who caused all the trouble with Sarah Palin’s bruhaha about “death panels.” I was furious that discussing end-of-life care would be turned into a political football (not surprised, though). Again, I think Washington is more about agendas than governance at the present time. It could just as easily have been the left getting mad at a republican president over the same issue.

That is one of the main reasons I’m making my big change: I have lost all faith that Washington will produce a reasonable solution and so will move to change it myself in my own little health care universe. It’s not a political statement as much as a means to sainity.

By the way, nobody noticed I finally got a better picture, losing the hat. I didn’t really like the hat picture either (but loved the hat itself).

Guest
DeterminedMD
Sep 16, 2012

It is a nice, professional yet personable px. thought it was your way of noting the transition at hand.

Guest
DeterminedMD
Sep 16, 2012

It is nothing less than a fraud to be selling to people over 70 that health care interventions can prolong lives and maintain a strong quality of life for YEARS mind you, and yet costs incurred are NOT paid in any significant amount by said individuals. Come on, what does the average American working for 40 years pay into Medicare, and remember I am asking “average” person here?

$60-80 thousand tops? So what are health care expenses for this same person hitting Medicare eligibility now for the next 13 years, assuming average life span is 78 years old? Hmmm? $100K, $150K, let’s be honest here, at least some commenting here seem to show true fact and candor, there will a sizeable percentage of older people who will cost the system up to $500K and what will be that quality of life, in a private hospital room, isolated, or in an ICU bed with nonstop attention per poking, prodding, lots of conflicting opinions, and with what endpoint, die away from your personal space and limited access to loved ones? Yeah, that is quality of life.

So, instead of dying of heart disease, renal failure, aggressive cancer that will not be remitted, and my least favorite, dementia, let’s run the full court press and keep ’em going to benefit, well, whom in the end? Our business model health care system that has embraced for profit models as aggressively as Wall Street moguls?

It is a fraud to sell people “live to 85 and endure”. That is why that 800 pound hairy dude keeps dancing in the room and just laughing at all of you, the snake oil salesmen and women, the naive providers, the desperate patients and invested loved ones with them, and the innocent bystanders. You know the last member of that audience, the young adults who are getting screwed the most at the end.

I was at peace paying Medicare for my parents and in laws who worked hard and maintained realism what health care could do for them. They didn’t overwhelm the system with their needs, partly for fortunate good health and also setting limits with care interventions. I was raised to minimize dependency, and abhor those who crave it like an addict. You all think PPACA is going to allow more happy endings than not?

Good luck if you say yes. And watch out who says it, because no honest and attentive person would say yes to circumstances as set. One would say maybe, hopefully, preferably, but have a cautious eye on who’s running the show. Democrat partisans don’t want outsiders watching the show.

Hence “let’s pass this bill so we can find out what’s inside later.”. Meet when deeds are words!

Guest
Barry Carol
Sep 16, 2012

“Both (defensiveness and patient expectations) create a culture of “do everything”, every inkling of a benefit becomes near sacred and worth any cost (at least as long as you don’t pay out of pocket). Germans (ON AVERAGE) are more rational in their assessment and tend to question earlier/more often: what for? “

rbaer –

I think you make a very important point here. While the excessive testing may not be a huge percentage of the 30% of healthcare system that is likely wasteful, when you throw in procedures stemming from false positives and all the inappropriate procedures such as back surgery when physical therapy might work just as well, many cardiac stents, overly aggressive late stage cancer treatment, dialysis in elderly patients who may live just as long with medical management, feeding tubes for patients with severe dementia and Alzheimer’s, etc. and we’re talking real money. I’ll bet there aren’t many patients who would spend their own money for this care even if they could easily afford to if they looked at the facts and circumstances dispassionately. Spending someone else’s money is apparently perfectly OK though.

The interplay of patient expectations, both expressed and perceived, and doctors’ efforts to avoid lawsuits at all costs are, in my opinion, totally missed by policymakers in the context of tort reform. It’s too bad that the developed countries can’t get together and develop an international standard of care, which, if followed, would protect doctors from lawsuits in all of the participating countries.

Guest
rbaer
Sep 16, 2012

“The interplay of patient expectations, both expressed and perceived, and doctors’ efforts to avoid lawsuits at all costs are, in my opinion, totally missed by policymakers in the context of tort reform.”

I could not agree more. I want to emphasize that the issue of incentives (fee for procedure) is a strong player as well, maybe even the strongest …. but from the HC policy people I have met or read, defensiveness is mostly silently acknowledged by most MPHs and health econmomists who do practice medicine or have done so, but doubted or ridiculed by many nonMD health econnomists or policy experts. This also is the result from considerable confusion about tort reform/defensive medicine – caps are not tort reform, the defensive physician does not care for what sum (say, 500 K vs 5 Million) he& his insurance is sued, he just wants to avoid being sued at all cost and at least look good in the eyes of the jury if there is a trial (i.e. prove that you made an effort by ordering tests and referrals). And patient expectations? Barely anyone talks about that (for some indirect evidence and speculation, look at http://archinte.jamanetwork.com/article.aspx?articleid=1108766

Books like this one http://www.amazon.com/How-We-Do-Harm-America/dp/0312672977 address the culture ov overutilization, although I read only exerpts and heard an interview, and I don’t know to what extent defensiveness and patient expectations are discussed.

Guest
rbaer
Sep 15, 2012

“your perception of the healthcare system cost impact of both patient expectations and defensive medicine in those two countries vs. the United States” – I thought I expressed in the above post that I think both matter a lot but apparently I wrote with too much understatement. Both (defensiveness and patient expectations) create a culture of “do everything”, every inkling of a benefit becomes near sacred and worth any cost (at least as long as you don’t pay out of pocket). Germans (ON AVERAGE) are more rational in their assessment and tend to question earlier/more often: what for?

I know I am leaning myself (anonymously) out of the window and touting stereotypes based on anecdotes, but I experienced several times that I discuss tests that certainly not or extremely unlikely would change a patient’s management (because the patient is too old/frail to benefit from the intervention that would follow an abnormal test result; the reason why I even mention this test is out of defensiveness and because other docs – hospitalists, PCPs – may discuss the test in question or may have even already ordered it before I am consulted). Here in the US, I quite often hear from patients or families “let’s just do test X and then we’ll see; yes, maybe no intervention, but wouldn’t it be good to know more” (and, unspoken/subconscious/implicit: the test is noninvasive, not painful, I am not ready now to consider limiting efforts for me/my loved one, and medicare pays) – I am near certain that in Germany and likely France, I would more often hear: well, why bother?
I don’t have enough first hand experience to compare end of life care, but I would bet there are equivalent differences.

Guest
Barry Carol
Sep 15, 2012

rbaer –

I wish you the best with your research efforts. Since I know you have first hand experience with the German and French healthcare systems, perhaps you could comment on your perception of the healthcare system cost impact of both patient expectations and defensive medicine in those two countries vs. the United States. Also, I’ve been told that patients and families in other developed countries, especially in Europe, are generally more accepting of death when the time comes than we in the U.S. are. If that’s the case, how does it impact how doctors in Europe approach end of life care and communication with patients and families vs. the U.S. approach? Presumably, defensive medicine is also a factor in U.S. end of life care, especially in the absence of a living will or advance directive.

Guest
Sep 14, 2012

I’ve actually written about that subject, Kilroy. Yes, something about glass houses…We in allopathy should be cautious about how unscientific some of the stuff we do is. However, you should be cautious, as your argument is basically “you are just as bad as we are.” While that is true in more areas than most of those who attack alternative medicine are comfortable to admit, there are some of us who are harsh with drug reps who peddle drugs that meet surrogate endpoints, or of tests done for no other reason but curiosity. Both mainstream and alternative medicine should be judged by their ability to meet meaningful endpoints: the patient lives longer and (or) feels better.

Guest
Killroy71
Sep 14, 2012

You all have no idea how amusing this is to anyone who has worked in “alternative” medicine, to hear you guys actually admit to not only the general lack of standardization, but “…the fact that we have very few standard practices that prove to be valuable when subjected to rigorous analysis.”

Because that’s exactly allopathic medicine’s rap against CAM.

Forget placebo effect for patients, it’s doctors’ beliefs that inform care as much as anything.

Guest
Sep 14, 2012

I must add that “large integrated delivery systems” are very hungry consumers of health care dollars. They are far more interested in the survival of large integrated delivery systems than in cutting the cost of care. I have purposefully avoided our large integrated delivery system because it has a very keen interest in building its revenue on the back of my referrals or the tests I order. While they can capture and study data better than I can, they also have far more vested in huge capital expenditures (like the Epic EHR or the big new wing built on money from coronary stents) and are not interested in cutting their business.

Guest
southern doc
Sep 14, 2012

“large integrated delivery systems develop and implement standard practices published in peer-reviewed journals, measure effectiveness and outcomes through their EHRs and adjust their processes and protocols as new research comes along”

What standard practices would be available to a “large integrated delivery system” that a well-informed solo doc wouldn’t have access to? I don’t want my doc making treatment decisions based on the lousy quality data that comes out of her EHR. (Not to mention the fact that we have very few standard practices that prove to be valuable when subjected to rigorous analysis)