Cheesecake Factory Health Care

The Cheesecake Factory is like Shark Week: Universally beloved and a little bit funny.

Live every week like it’s Shark Week.

Eat every meal like it’s the Cheesecake Factory.

Perform every surgery like it’s at HCA.

Atul Gawande, whose health care reporting is usually the Shark Week of the New Yorker, wrote an essay that’s more like Squirrel Week. About how maybe hospitals can be more like the Cheesecake Factory.

I mean, it’s riveting. Like watching a rabid squirrel attack a bunny in the snow at night. Narratively.

Except for the end, when, after several pages idealizing a halcyon age of big-chain-driven efficiency in health care delivery, he says wait a minute! Big chains aren’t always great!

Yet it seems strange to pin our hopes on chains. We have no guarantee that Big Medicine will serve the social good. Whatever the industry, an increase in size and control creates the conditions for monopoly, which could do the opposite of what we want: suppress innovation and drive up costs over time. In the past, certainly, health-care systems that pursued size and market power were better at raising prices than at lowering them.

Um, yeah? Have you talked to anyone put out of work by Walmart, or Borders, or Barnes & Noble, or Amazon?

Have you eaten at any other big casual dining chain? Like Applebee’s? In which “efficiency” means no fresh preparation of a single item on ones plate?

This article’s lack of balance surprised me.

But what about my manners! I should summarize, for all my readers who are busier than I.

Basically, hospitals are inefficient. Have you noticed? But some management techniques from the Cheesecake Factory (affordable, reliable, universally beloved, delicious) could help inspire health care chains.

Patients are customers and the whole enterprise should focus on their satisfaction.


A large organization’s resources can support increased efficiency and standardization, which will lower costs and improve patient/customer satisfaction.


Grilled miso salmon is delicious.


Gawande uses compelling case studies, as usual, and powerful narrative, as usual, and smart insider reporting, as usual.

But there’s no attempt to justify the need for big chains to accomplish these changes, which are as much about medical culture as they are about process, management, and remuneration style.

The big-chain-lovin’ approach directly contradicts one of his more memorable pieces, “The Cost Conundrum,” about different cultures of health care delivery across the country. The Mayo Clinic has achieved many of the cultural and managerial (and economic) changes that Gawande seeks from the Cheesecake Factory-inspired model.

The Mayo Clinic is not a chain, but I WANT IT TO BE:

Decades ago Mayo recognized that the first thing it needed to do was eliminate the financial barriers. It pooled all the money the doctors and the hospital system received and began paying everyone a salary, so that the doctors’ goal in patient care couldn’t be increasing their income. Mayo promoted leaders who focused first on what was best for patients, and then on how to make this financially possible.

No one there actually intends to do fewer expensive scans and procedures than is done elsewhere in the country. The aim is to raise quality and to help doctors and other staff members work as a team. But, almost by happenstance, the result has been lower costs.

“When doctors put their heads together in a room, when they share expertise, you get more thinking and less testing,” Cortese told me.

See? You don’t need to be a big chain.

One interpretation of the article’s bias is that Gawande sees consolidation as inevitable, and he’s trying to accept what may initially feel like Voldemort taking over his noble profession.

But Steve Denner, at Forbes, disagrees that Big Medicine should, or even will be the answer to our health care woes:

Simply stapling large inefficient organizations together into chains doesn’t make them more efficient. The larger they get, the more the bureaucracy and the hierarchy are likely to get in the way. Chains of hospitals will survive only if they become different, for instance, by differentiating and separating the main jobs-to-be-done that Christensen and Hwang have defined. Because patients will have freedom of choice and good information as to what’s available, the market will steadily eliminate hospitals with mediocre performance.

There will be a future for a hospital than can offer, for instance, the highest quality knee replacement, as in Gawande’s example. But there is no future for either a hospital or a chain of hospitals offering mediocre and expensive care for a wide variety of very different health problems, including structured, unstructured and chronic problems: the hospital will end up doing them all expensively and badly.

Nor is it obvious that the winners of the new health game will be hospitals at all. A facility that does only cataract surgery or only chemotherapy or only diabetes treatment may actually be quite small. … Because it is totally focused on a single function, it can become very good and very efficient at doing it. Because it is the best at what it does, it can attract patients from all around, not just from the neighborhood. These small highly-specialized barracuda-like organizations will be a big part of the future of health care, not just hospitals.

This future for health care delivery is far more appealing, if just as speculative as Gawande’s vision of healthcaremegacorp. Using my academic perspective-glasses, I’d say that the future will likely follow other business trends we’ve seen: the global megacorp yeilding market space for a resurgence of hyper local providers. Both existing side by side, filling different market needs. Like independent bookstores re-emerging to offer wholly different benefits than Amazon.

Denner helpfully outlines different business models to explain the diversity of our health care delivery industry. Different business models require different approaches to reform.

Dare I say, Denner is more helpful than Gawande? At least, in this particular instance.

Meanwhile, Gawande’s conclusions are simultaneously shallow and far-fetched.

Mixed feelings about the transformation are unavoidable. There’s not just the worry about what Big Medicine will do; there’s also the worry about how society and government will respond. For the changes to live up to our hopes—lower costs and better care for everyone—liberals will have to accept the growth of Big Medicine, and conservatives will have to accept the growth of strong public oversight.

It’s as if Gawande ran out of room and had to rush through the actual complicated part of his argument. On the other hand, he’s not a politics writer. Maybe they should have Ryan Lizza write the sequel, articulating precisely how we can use our political system to shape Big Medicine to work for us instead of against us.

To take that last clause about liberals and conservatives, a clause which rings large, loud alarm bells in my head, and turn it into another article.

Till that happens, gimme some cheesecake!

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