Your Questions, Answered
Health care accountability, Profit vs. profiteering, VBC strategy, and more!
Tough conversations and controversial topics are essential to meaningful discourse—especially in healthcare. It's easy to get lost in the echo chamber of oversimplified narratives, but we can't afford to shy away from difficult questions, even when clear answers are elusive.
This week’s edition of The Surgeon’s Record features answers to reader submitted questions, with no topic off limits. Thanks to all who participated.
[Editor’s Note: Questions have been lightly edited for brevity and clarity.]
Question:
Since so few of the problems in health care are with the actual treatments and care, is there a point that we accept the system is too broken to fix? At what point do we separate the problems physicians own vs. the ones they can truly affect?
Submitted by Marty Nichols
Answer:
I contemplate the “too broken to fix” argument a lot. When you attempt to understand the many facets of our complex and deeply flawed system, the situation seems hopeless. There are simply too many entrenched interests. Sadly, there’s more lip service to change than actual willingness to change.
Then I remember many of us chose the health care field because we relish solving challenging problems. We just figured they’d be clinical problems, not systemic ones. If we accept that the system is too broken to fix, what’s the alternative? Too many people have too much invested to simply give up.
I’m not sure everyone would agree that “few of the problems in health care are with the actual treatments and care.” While I agree with the sentiment, others would highlight limited accessibility, middling outcomes, spiraling costs, and low life expectancy. Do physicians own these problems? Yes and no. In truth, it’s nearly impossible to uncouple what physicians can affect from what they can’t and still have meaningful impact. Change will come from owning both sides of the equation.
In my mind, you’re left with two options: exist completely outside the system (the “Take Your Ball and Go Home” approach) or find willing partners within the system (the “We’re in This Together” approach). To date, neither approach has been widely successful. Existing outside the system is possible but hard to do at scale. Finding willing partners is difficult. We’re much better at assigning blame and being protectionist.
The honest answer is that the more ownership and influence doctors have (clinical and non-clinical), the closer we’ll be to lasting solutions. We can’t do it alone. The system is too complex, and incumbents are too deeply entrenched. But we can find a middle ground adjacent to the current system and aided by like-minded collaborators—the “Let’s Forge a New Path” approach.
Question:
My investment advisor recommended I buy stock in United Healthcare since it has enjoyed regular analyst-topping returns quarter-after-quarter and since 20% of the GDP is wrapped up in health care. Their monopolistic control of insurance, physicians, PBMs, and most other aspects of the revenue cycle offer significant promise of forward growth.
As a health care consumer, I am torn between the desire of index-beating returns in my portfolio versus the moral quandary of investing in a company with a corporate philosophy that prioritizes profits over patient care. I understand that they have a fiduciary responsibility to their shareholders to maximize value and returns. ChatGPT responded that it could not offer investment advice. Can you provide some thoughts on what I should do?
Submitted by Moby Parsons, MD
Answer:
Did you know: If you invested $100,000 in UNH stock on January 1, 2000, your investment would now be worth around $10 million? (According to Ron Howrigon on a recent episode of the 43cc podcast, the number is closer to $64 million when accounting for stock splits).
First, I’m obliged to point out that this answer does not constitute investment advice. Second, UHG’s run of impressive returns may have hit a small speed bump despite a record-breaking year. Each individual investor must decide for themselves what constitutes ethical investing. For the purposes of discussion, I’d like to take this question in a slightly different direction.
Whatever you think about United—their methods, their fiduciary duties, their morality—you must admit they’ve played the game incredibly well. UHG has achieved a degree of vertical integration only dreamed of by other health care interlopers. With a Top 20 market cap, UHG now sits just below corporate giants who have tried their hands at health care and mostly struggled—Apple, Walmart, Google, and the members of short-lived Haven Health (Berkshire Hathaway, JP Morgan, and Amazon).
Should we hate the player or hate the game?
The Department of Justice finally launched an anti-trust investigation into United Health last year. Is it too little, too late? UHG has been building an empire for years—insurance, PBMs, ASCs, physician groups … every industry sector except hospitals. United went public 40 years ago. Presumably, regulators have been aware of its unchecked growth and monopolistic tendencies for some time.
During this same period, physician reimbursement cuts, the moratorium on POHs, the ACA, PBM loopholes, and Medicare Advantage expansion have fueled consolidation and fed the beast. In short, UHG has taken full advantage of regulatory capture while policymakers have been slow to act.
The bigger question here is: should health care be treated like a business? Is it ethical to be motivated by profit in medicine? Where is the line between profit and profiteering? Are the goals of making money and delivering high-quality, high-value, evidence-based care inexorably at odds?
Should health care be a business? I would argue yes … but with qualifications. Let’s be honest: every private practice is a small business that must make a profit to survive. As doctors, we want to be paid fairly for the work we do—and we should be. Hospitals, health systems, pharmaceutical companies, device manufacturers, VC-backed startups, and, yes, insurance companies likely feel the same way.
We can do a better job ensuring value is created, not extracted. Regulations should exist to prevent bad actors, not enable them. In a near $5 trillion industry riddled with middlemen, easily exploitable loopholes, and perverse market forces, there is unquestionably room to make money while delivering value.
The UHG story is a story of unchecked growth, lack of a credible threat, and misguided regulation. It’s a microcosm of why we can’t fix health care and a blueprint for where the opportunities lie. Finding the balance between clinical and fiduciary duties is elusive, but I refuse to believe it’s impossible.
(Besides, quantum computing stocks are where you should be putting your money now! ← Not investment advice.)
Question:
What should hospitals be doing in order not to lose their shirts in a VBC world? We are struggling and trying to do the right thing, but our costs are so high, how do we jump on the VBC train and not get run over by it?
Submitted Anonymously
Answer:
Like it or not, some form of VBC is here to stay. CMS is committed to accountable care, and the next generation of programs is coming: Making Care Primary and the mandatory Transforming Episode Accountability Model (TEAM). CMS is now tying hospital reimbursement to PROMS reporting. If you’re worried about “losing your shirt,” you should be. The Institute for Accountable Care estimates that hospitals could lose an average of $500 per episode of care.
How can you avoid financial pitfalls? Start here:
Perform a SWOT analysis. Experience with prior VBC models like CJR and VBC have taught us that one of the biggest drivers is post-acute care, specifically discharge to rehab and skilled nursing facilities. When appropriate, spine and joint replacement patients should be discharged home. Not only does doing so save money, but it also likely reduces complications and readmissions (themselves significant cost drivers).
Shift mindsets and manage change. Success requires adopting an evidence-based, efficient, cost-effective approach prior to entering a VBC arrangement. Doing so after the fact is a recipe for failure. Find and involve your clinician champions early and often and ensure proper incentivization. Not getting buy-in from stakeholders is another recipe for failure—especially if it creates a principle-agent problem.
Understand your model. What’s at risk? What are your key metrics and targets? How and when does reconciliation take place? For CMS/CMMI programs, the government sets rules with little to no room for negotiation. The good news is that, at least for TEAMs, there are several Tracks offering various levels of upside and downside risk. Getting commercial payors to engage on VBC is more challenging. However, there’s more room for negotiation here—assuming you can get the payor to the table.
Know your numbers. If you aren’t collecting and tracking data—utilization, outcomes, costs, etc—you will struggle. Insurance companies won’t offer favorable terms if you can’t paint a clear picture of how entering into a VBC arrangement makes sense for them. Data is key. You can’t improve what you don’t measure.
(I could go on about this topic forever, but I’ve given away at least $50k in free management consulting already!)
Question:
As a family physician in Canada and as an arthroplasty surgical assistant, I wanted to know your thoughts around how you think primary care and surgeons could work better along the continuum of care from first presentation of a painful joint to surgery and rehab. Some of the best outcomes I’ve had are when I worked very closely with my surgical colleagues across the journey.
Submitted Anonymously
Answer:
Another topic near and dear to me! The collaboration between primary care physicians (PCPs) and surgeons is critical to achieving the best outcomes across the entire continuum of MSK care.
Some key strategies to improve this collaboration include:
Condition-specific bundles and care pathways: Moving away from a siloed approach to a more integrated, condition-specific bundle model can ensure that the entire care journey—diagnosis, non-surgical management, surgery, and rehab—is coordinated effectively. When care is coordinated from the initial diagnosis by the PCP, it leads to better patient optimization and improved outcomes.
Enhanced care coordination: Here in the U.S., upcoming VBC models like Making Care Primary (MCP) and the Transforming Episode Accountability Model (TEAM) aim to emphasize proactive collaboration between PCPs and specialists. The goal is to ensure that patients receive appropriate, high-value care with acuity escalation as necessary
Technology-enabled collaboration:
Asynchronous communication platforms, remote monitoring, and virtual care options allow for more "touches" across the care spectrum. PCPs can engage with orthopedic teams through shared electronic health records (EHRs), chat-based tools, and digital patient engagement platforms to track patient progress in real time.
AI and predictive analytics can assist in identifying patients who might need early intervention, ensuring they are referred appropriately while avoiding unnecessary surgical consultations.
Data-driven decision making: Collecting and analyzing patient-reported outcome measures (PROMs) helps track progress from conservative management through post-operative recovery. Having access to longitudinal patient data helps both PCPs and surgeons make informed decisions about treatment escalation.
Holistic pre-operative optimization: Successful collaboration means addressing the full spectrum of patient needs—such as smoking cessation, weight management, and mental health—before surgery. A more comprehensive approach leads to better surgical outcomes and long-term success.
Patient engagement and education: Providing shared educational resources and digital tools can empower patients to understand their care pathway better, reducing anxiety and increasing adherence to treatment plans from prehab to rehab.
Ultimately, fostering a closer relationship between PCPs and surgeons through structured care models, better communication channels, and data integration will lead to improved patient experiences, lower costs, and better clinical outcomes. Your experience of working closely with surgical colleagues highlights exactly what value-based care aims to achieve—seamless, team-based, and patient-centered care across the continuum. This is the future.
Question:
What advice would you have for an early career MD pursuing side gigs and leadership roles while trying to find work-life balance? Sometimes, I feel like there isn't enough time in the day, and some days I feel like I am living my best life.
Submitted Anonymously
Answer:
The struggle is real. I didn't really pursue side gig opportunities and "extra curriculars" until about 10 years into my career. At that point, experience allowed me to pursue non-clinical roles without sacrificing the quality of care I delivered.
I caution early career physicians not to do too much too soon; Being a good doctor comes first. Otherwise, you risk stretching yourself too thin, and your clinical practice will suffer. Gradually, add more leadership work as you feel comfortable with your clinical responsibilities.
I prefer the concept of work-life harmony over work-life balance. As much as possible, side gigs and extra-clinical pursuits should be natural extensions of your day job. If your non-clinical work feels like a chore rather than a compliment, you risk burning out. Family obligations should always supersede outside activities. Having family support makes pursuing side gigs and leadership roles easier for everyone.
As a corollary: don't be afraid to say no. There's a tendency to think you're missing opportunities by doing so, but it's one of the most powerful skills you can learn. It’s okay to expect compensation for your time and expertise—a consulting agreement, formal advisory role, or other remuneration. Ultimately, it depends on what you're trying to accomplish. If you're pursuing side gigs to supplement your income, make it clear that you expected compensation. If you're doing it to make connections and gain experience, be selective for opportunities that seem interesting and align with your goals.
It's not always easy to differentiate. Be leery of "30-minute meetings" or “virtual coffees” that end up as sales pitches or free consulting sessions. Investors, founders, and others are more than happy to pick your brain while offering advisory roles that never materialize. There’s a bit of trial and error involved—but most people are earnest in their passion to fix health care.
I can’t stress the importance of building a network enough. LinkedIn is great for this. Don't be afraid to share opinions, comment, and post. Once you start to gain some attention, learn how to distinguish between worthwhile connections and people who want to take advantage of your time/expertise.
Finally, build in time for self-care. Learn to recognize when you need to take a step back, focus on your physical and mental health, and relax. Burning out is counterproductive and detrimental to your clinical practice, side gig pursuits, and family life.
That concludes our inaugural “Ask Me Anything” post for The Surgeon’s Record. Many thanks to those who submitted questions. I got a kick out of answering them and hope the column provided some insights on timely topics. I plan to do another AMA session in the future, so keep those questions coming!
Ben Schwartz, MD, MBA
Editor-in-Chief, The Surgeon’s Record
Commons Clinic Senior Clinical Fellow
