August 3, 2020

Culture Eats Strategy for Breakfast…in Healthcare Too

In this blog post, we delve into the often-overlooked issue of how the culture of business in healthcare can have a negative impact on the quality of care patients receive.

The Conundrum of the United States Healthcare System

Undoubtedly, we are blessed to live in a country where the healthcare system has top-flight, trained medical, nursing, and allied healthcare professionals, coupled with access to some of the best health care facilities in the world. Nonetheless, significant problems remain. Thus, while we have it good overall with our health care in this country, we also have significant issues to tackle – and even more so now during the COVID-19 pandemic.

It is not at all my aim to raise all, or even most, of the problems that exist in our current healthcare system in the U.S., especially in this era of the COVID-19 pandemic. There would, of course, be too much to cover. I do, though, intend to call attention to compelling reasons why we – average everyday consumers of health care – should demand more and something different than what we are getting. I want to call attention to a major source of problems within our healthcare system in the U.S. – culture (specifically the culture of business of healthcare) – and what we might do about it.

First, I’ll touch on a few of the big problems, then how they tie to the culture of business in healthcare and, lastly, share thoughts on how we might begin to do something meaningful about this issue of culture.

The Paradox of Cost and Health Outcomes in the U.S. Healthcare System

Our country, indeed, faces profound problems in healthcare, starting with unprecedented high health care costs. And when those costs are viewed through the lens of per capita costs compared to other advanced, economically wealthy countries (Figure 1a) and relative to the health outcomes achieved (Figure 1b), the United States is inarguably not doing great. We deserve better. Everyday consumers of health care deserve better. My three reasons why we deserve better: (1) we pay as much as we do for our health care; (2) it is vitally important to people’s lives; and (3) we can do better, as it is merely a matter of societal will. These three reasons by themselves should compel a U.S. healthcare system – that is rooted in principles of compassion, dignity, and equity, with the forces of constrained capitalism allowed to drive innovation and fair competition, directed by science and evidence – to do what is in the public’s interest of the health of the individual and population.

Is this what we see in our American healthcare system? I would argue, no it is not – at least not entirely.

Figure 1a. High Cost of U.S. per capita healthcare spending versus other wealthy countries


Figure 1b. Less than optimal patient health outcomes in the U.S. compared to other wealthy countries with lower per capita healthcare spending


What Does the Culture of Business in Healthcare Have To Do With Problems We Face in Healthcare?

Please know that I am as enterprising a person as anyone might be – pro-business to be sure. I am unapologetically bullish on business, but with the proper controls and protections that help keep markets fair and competitive and, to the degree possible, principled. Matched to my capitalistic instincts, I am a strongly mission-driven person. But, certainly in health care of all places, while business goals and objectives always remain central, alongside them in importance should be the uncompromised values of equity, compassion, and dignity. While I know these values and high principles do not innately exist in business, these principles are reflected in the United States Constitution and, thus, we should strive towards them in business too – especially business related to healthcare.

Two examples illustrating situations in health care where culture belies mission, and strategy is nowhere to be found.

Example #1 – Current Culture Lacking Accountability and Transparency in Hospitals When Unintentional Medical Errors Occur

In too many of our nation’s hospitals, when unintentional medical errors or failures in processes of care occur and they result in poor outcomes, permanent disability, or death, the fear of litigation often results in a defend and deny posture by leadership in those hospitals. An absence of accountability and transparency within the hospital and among clinical staff and administration as well as directed to the patient and family/caregivers is emblematic of what is typically observed. Consequently, there is a failure to learn from errors or failed processes; and in the end, the lack of remedial action fails to lower the likelihood of mishaps from happening again to other patients.

This is not often talked about, but it is a big problem in healthcare.

Example #2 – Vertically-Integrated Health Care Conglomerates

Corporate mergers and acquisitions are as much a part of the American business landscape as apple pie is to America. Thus, mergers and acquisitions are not in and of themselves bad. The problem arises when such mergers and acquisitions stifle competition, by competing on scale and scope of ownership and not on the quality of care or value of services delivered. Our current business landscape around healthcare is, in my opinion, losing its way with mergers of market-leading retail pharmacy chains with health insurance companies and pharmacy benefit managers (PBMs) all under one organizational umbrella. Single health care organizations are controlling too much of the healthcare supply chain. Health care organizational entities (e.g., small PBMs, independent community pharmacies, regional pharmacy chains, regional health plans, etc.) on the outside of these conglomerates, who may offer the highest quality, patient-centric services, are severely disadvantaged competitively.

This is not right!

Here are bulleted examples of a few others:

  • Why are the quality standards in so many nursing homes and long-term care facilities lacking to the extent they do?
  • Why does our country lean more heavily towards criminalizing (in corrections or community corrections [i.e., parole, probation]) individuals with serious mental illness and substance use disorders versus evidence-based treatment and employment rehabilitation?
  • Why do we not have extensive government-supported programs for families of aged-out youth who are on the autistic spectrum in need of services?
  • Why do we have pharmaceutical companies who set unsustainably high prescription medications prices (followed by regular price increases), where the value is not adequately demonstrated by rigorous clinical and health economic evidence?

I am guessing that many of you can think of others.

Where to Start in Remedying the Culture of Business in the U.S. Healthcare System?

I certainly welcome your comments on the cultural remedies for each of these areas of the challenge I reference. Admittedly, these examples are disparate. Nonetheless, I propose the roots of a remedy are common. I harken back to my most recent Healthcare Quality Insights Blog article, Basics of Health Care Quality, and my reference to the Triple Aim – or as is now more often referred to, the Quadruple Aim.


The Quadruple Aim embodies the four component aims of: (1) improved population health; (2) improved clinician experience; (3) improved patient experience; and (4) better spending (ideally, lower spending).

I put forth this paradigm of the Quadruple Aim as a beacon for our American healthcare system to strive for – not just in its mission, but in its business too.  I challenge us to aim to create and nurture the types of organizational and system-wide cultures that support capitalistic principles, yes, but do not do so at the expense of the values of dignity, compassion, and equity being upheld; or disincentivizing innovation, fair practices, or competition. Simply put, it is good for business to do the right thing – and the culture of business in healthcare should increasingly reflect that.

While I am undeniably sentimental, I am not naïve. I know that the powerful forces presiding over the institutions and conglomerates that too often gravitate towards unhealthy cultural business norms will not innately evolve towards the ideals I lay out here.  Thus, I look to a different group of stakeholders – health care consumers – to lay claim to what they/we deserve and to respectfully demand a different level of accountability, transparency, responsibility – and, frankly, results.

The voices of the public yield enormous power and influence when collectively channeled toward specific aims – especially in this era of social media. So I challenge us all to speak up, speak out, organize grassroots efforts for what is wrong, but more importantly, what is right – and what we rightly deserve from the organizational cultures that deliver our health care to us.

We often look to legislation as the sole lever through which to effect profound change. And this is not wrong-headed. It is, however, incomplete. Grassroots, collective-organizing, social media-driven movements must be considered. Why would we leave this off the table for healthcare? It is the source of the most remarkable cultural paradigm shifts in this country. The best and most current example is Black Lives Matter, and the dramatic culture change the movement is helping empower. A less well known, but nonetheless highly effective grassroots, social media-driven movement leading to profound change was  chronicled in a September 23, 2018 article in The Atlantic.  Katie Fahey, starting with a simple Facebook post in 2016, spearheaded, as a 20-something year old, a social media-fueled campaign to ban gerrymandering in Michigan. This grassroots movement gathered an astounding 425,000 signatures resulting in a proposed constitutional amendment creating a citizens’ commission for redistricting.

Why can’t this happen in healthcare? Why can’t this happen in healthcare where citizens see change is needed and the status quo is no longer acceptable. I, for one, argue that it can…and we can!

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