Hospitals and the Cheesecake Factory fallacy


Atul Gawande is one of the best--if not the best--healthcare journalist in this country. He's brought illumination to many issues that previously lurked in the shadows.

Gawande's pieces don't appear very often--he's a practicing specialty surgeon after all--but when they do, they often make headlines. Perhaps his most important article, published in The New Yorker three years ago, discussed the huge Medicare cost disparities in McAllen, Texas, compared to the rest of the nation. That article created a dialogue on healthcare delivery  costs that indirectly led to the passage of the Patient Protection and Affordable Care Act the following year.

This week, Gawande wrote about the need for hospitals to be more efficient. That's a great topic; many facilities abet massive waste. And, as he detailed in his article, millions upon millions of dollars float out the window for simple reasons such as orthopedic surgeons don't want to use the same hardware for knee replacements.

But Gawande also asked aloud why hospitals can't be more like the national restaurant chain the Cheesecake Factory. He waxed nearly rhapsodic about its ability to replicate a fine dining experience at a low price.

"We can bristle at the idea of chains and mass production, with their homogeneity, predictability, and constant genuflection to the value-for-money god," Gawande wrote. "Then you spend a bad night in a 'quaint' 'one of a kind' bed-and-breakfast that turns out to have a manic, halitoxic innkeeper who can't keep the hot water running, and it's right back to the Hyatt."

His description of the Cheesecake Factory experience was pretty much spot-on, but I take issue with his conclusion: "We've let healthcare systems provide us with the equivalent of greasy-spoon fare at four-star prices, and the results have been ruinous. The Cheesecake Factory model represents our best prospect for change."

Gawande omitted a couple of key facts in his article. One is that the Cheesecake Factory's portions are comically enormous. The "chicken chop," for example, was the same size as a football when it was on the menu. On the rare occasion I have gone there with my family, we always share at least one dish. Sometimes we share one dish among the three of us. We are usually the only people in the place doing this.

Such culinary giantism also leads to extraordinarily caloric entrees. It's not uncommon for a Cheesecake Factory dish to top 1,500 calories. Several contain more than 2,000 calories--as much as what an American woman should consume in an entire day. And many of these dishes are swirling in fat. That chicken chop was deep fried, for example, as are many other entrees. That's even before the diners tuck into their cheesecake. Many of the chain's desserts contain 1,000 calories or more.

The Cheesecake Factory has prided itself on this largesse since it was founded in the late 1970s. Its success in the 1980s and 1990s pressured a lot of other restaurant chains to enlarge their portions. The "supersizing" trend at McDonalds and other fast food outlets has its origins in the Cheesecake Factory.

That these huge portions ensconced in gobs of fat have been made readily available to Americans helped create many of the health problems bedeviling this nation today. It also helped lead to the aggressive cardiac care chronicled by Gawande in McAllen and, as the New York Times just reported, at HCA hospitals in Florida.

That's not to say the article is not informative, particularly as Gawande discussed the uniform design of each Cheesecake Factory kitchen and how its kitchen staff are deployed and modulated to achieve maximum efficiency.

But Gawande only gives a passing nod to the fact that putting together a meal is not nearly as complicated as, say, inserting a central line. Or that line cooks are instantly replaceable (and as food writer Anthony Bourdain has noted, ripe for physical and emotional abuse), and surgeons and other physicians are not. That is the main reason the service and retail industries have become so efficient while yet growing so massively--everyone knows they can be given the boot.

By comparison, virtually every hospital staff member who is not management or a physician is represented by a strong labor union.

Gawande does note that many hospitals are consolidating, but whether or not their margins will be driven by volume of procedures rather than efficiencies remains to be seen. I think volume remains a safe bet, which means costs are likely to continue to rise.

I'd like to think these facts were not lost on as astute an observer as Gawande, but apparently they were. He used the Cheesecake Factory comparison for an obvious reason--it sounds a little ridiculous on the surface, and therefore would draw in readers.

A much more relevant discussion would have been a potential seat at the table for the Lean process, which drove the transformation of Toyota's automotive assembly lines during the 1970s and 80s. Among the primary reasons American and Korean cars are no longer the junkpiles they were 25 years ago is because they adopted Lean techniques in their factories.

Building a single car requires the delivery, coordination and installation of some 20,000 parts, including advanced electronics. It also requires a strong relationship between hourly labor and salaried management. There are many parallels to healthcare delivery there.

Lean is indeed being slowly being adopted at hospitals. I had the privilege recently of speaking at length with Larry Hegland, M.D., who used Lean to prepare the Ministry Health system in Wisconsin for an onslaught of RAC audits.

Put simply, the Lean process when applied to healthcare creates a much better--and palatable--image of efficiency than that of the Cheesecake Factory. Hopefully, the good doctor will revisit this topic down the line with that in mind. - Ron (@FierceHealth)

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