By Mary Meyer, MD, MPH & Charulata Ramaprasad, MD, MPH

Every system is perfectly designed to get the results it gets.

It has been said that change only happens with the right degree of crisis. Remember the Challenger explosion in 1986? It was an unmitigated debacle -- one that would go on to trigger a fundamental restructuring of the world's preeminent aerospace program.

Nearly 40 years later, we can't help but wonder if American healthcare is having its own Challenger moment. U.S. patients currently experience the worst health outcomes of any high-income nation, including the lowest life expectancy and highest avoidable mortality. What's more, it's the most expensive health system globally. This has understandably triggered a wave of populist resentment (consider the online vitriol after UnitedHealthcare CEO Brian Thompson's assassination). Meanwhile, burnout and attrition among the healthcare workforce just keeps stubbornly surging. It all seems to add up to a system in crisis.

We're reminded of a truism in systems thinking: every system is perfectly designed to get the results it gets. This reflects the idea that all outcomes, intended and unintended, stem from the functioning of the system that supports them. If you want a different outcome, you have to change the system.

The Rise of Corporate Medicine

To understand our current system, it's helpful to examine the past -- specifically, the transformation of healthcare's business model over the past few decades. Until the 1980s, 76% of doctors owned their practices. But this model became increasingly untenable as medicine grew more complex. And so, by 2021, nearly 70% of all U.S. physicians were employed by a hospital, corporation, or private equity firm.

The move to massive, consolidated healthcare delivery systems offered a lifeline to struggling practices but came with its own complexities, including expanded administration infrastructure and a reshaping of financial incentives. This helps explain why, between 1971 and 2010, the number of physicians in the U.S. grew 150%, while the number of healthcare administrators jumped 3,200%. In fact, administration has become the fastest-growing jobopens in a new tab or window in healthcare (projected to increase another 29% by 2033). There are now 10 healthcare administrators for every physician.

Every System Is Perfectly Designed to Get the Results It Gets

One outcome of this transformation has been a growing disconnect between frontline clinicians and executive decision-makers. Where clinicians once owned their practices, they are now employees in a large corporation with multiple layers of middle management and decreased autonomy. In tandem, administrators have commandeered many health system functions once managed by clinicians, such as setting strategic priorities, managing finances, scheduling staff, and monitoring quality of care. Healthcare decisions rarely involve just the doctor and patient any more.

For clinicians, navigating this complex administrative ecosystem is both frustrating and opaque -- the nuance of who manages what and who reports to whom, not to mention who fixes what, is simply bewildering. To many frontline physicians, healthcare administrators epitomize bureaucratic bloat. Worse, they seem to emphasize cost containment over high-quality care, with calculations that can feel more designed to protect organizations than individual patients. Not surprisingly, recent data suggest trust between frontline physicians and administrators has reached an all-time low.

To Err Is Administration

In 2022, an intensivist at Harvard Medical School coined the term "administrative harm." He argued that as the number and decision-making power of administrators has swelled, so has their ability to make mistakes with serious consequences. Traditional discussions of medical error have always focused on individual clinical decision-making. But in an era of corporate healthcare, argued the intensivist, patient harm is often a result of systems-based risk-management and non-technical errors.

Two years later, another group of physicians set out to determine just how prevalent administrative harm is. They emerged with some startling findings. A full 85% of clinicians surveyed said administrative harm had led to patient harm at least somewhat or to a great extent in their institution. It was perceived to be widely pervasive, and occurred with both nonclinical and physician administrators. Only 38% felt empowered to speak up in the face of this harm. Furthermore, administrative harm was felt to cause workforce injury via eroded clinician trust and exacerbated moral injury, and even hastened staff turnover.

Another fact highlighted by the study is that administrative harm is almost completely anonymous. In the two decades since To Err Is Human, accountability and transparency have permeated every aspect of clinical care -- from morbidity and mortality conferences to quality metrics to patient satisfaction scores -- and medical error has plummeted. In virtually any clinical encounter, there is an identifiable physician linked to a diagnostic test or treatment, discharge summary, or online portal.

By contrast, administrative harm, which tends to occur at a distance from the bedside, is anonymous and often treated fatalistically as unavoidable. There is generally no name attached to a chemotherapy or surgery denial, physical therapy refusal, or even a denial of hospitalization coverage. In the current era of corporate healthcare, a remote decision-maker can override a bedside clinician and remain fully unidentifiable and unreachable. The physician who tries to reverse such a denial is likely to find herself on the receiving end of an overwhelming amount of paperwork or an endless telephone queue. All of which presents a systems problem -- it's hard to fix what we don't measure, and it's nearly impossible to overcome what we don't know.

In Pursuit of a Better System

What we do know is that corporate healthcare has not lived up to all its promises. Multiple studies suggest that consolidation has led to increased expenditures per patient -- as much as 10-to-20% higher than smaller physician-run practices. We also know that massive health systems have sometimes been associated with worsened quality of care and increased adverse events. There is even some evidence that healthcare consolidation is fueling burnout among clinicians.

In the face of overwhelming evidence that our current system is in crisis, we owe it to our patients to examine our design flaws and ask the question, "How can we be better?" It's what we signed up for as stewards of our communities' health. And it's the only thing that will rebuild Americans' trust in our healthcare system.

In the second part of this series, we discuss opportunities to address administrative harm and narrow the gap between frontline clinicians and their administrative infrastructure.

Mary Meyer, MD, MPH, is an emergency physician with The Permanente Medical Group. She also holds certificates in Global Health and Climate Medicine. Meyer previously served as a director of disaster preparedness for Kaiser Permanente Northern California. Charulata Ramaprasad, MD, MPH, is an infectious diseases physician who has worked in academic, private practice, and managed healthcare settings. Ramaprasad previously served as the chair of infectious diseases for Kaiser Permanente Northern California.

This perspective is the authors' alone and does not necessarily reflect that of any institutions or companies with which they are affiliated.