Andrew Shadid’s Post

If you could change one thing about the American healthcare system, what would it be?

I often think there's so many lessons healthcare administrators can learn from surgeons.   One that jumped out at me is about the relationship between sleep and stress.   Most people are really stressed by their jobs, and that stress keeps them awake – which makes them perform worse, continuing the deteriorating vicious cycle day after day.   But one thing I've noticed about surgeons is they often live their lives stressed all the time – so being able to find rest despite being stressed is important.   I admire that ability, and seek to adopt it in my own life. Stress is normal; dysfunction from stress shouldn't be.

In 2014 I had the chance to spend time in Ethiopia during a summer working for Hello Doctor. (Shout out to Elias Schulze and Yohans Wodaje Emiru!)   Given I'm from a healthcare family I obviously paid attention to what I observed about the healthcare system there, especially because Hello Doctor was working to provide telemedicine services to the Ethiopian population, which was one of the first telemedicine endeavors of its time, and particularly the first in East Africa.    One fact about the Ethiopian system that stunned me: Ethiopia has just 1 physician per 32,000 people, while the USA has 1 per 332. That's just slightly more than 1% of our physician density!   And I saw a lot of things that weren't great about the system: lines outside hospitals, people unable to receive treatment who were likely curable, and many other ways that lack of resources shows up in outcomes.   Yet I also saw a grit and persistence among the healthcare community that struck me as unique. With less than 1% of the resources, they had to innovate a different way to provide care.    Yes, there is always a reason to say "we need more resources," and the Ethiopian healthcare community reasonably called for that.    However, it was entrepreneurs in the Ethiopian healthcare community that said: "How do we deliver better outcomes, to more people, with the resources we have?"   One thing I love about our Genesis team is that we often find ourselves asking the same question. Rather than bemoaning the low reimbursement rate of Illinois Medicaid, our team took it upon itself to figure out how to deliver lower-cost orthopedic care (without compromising outcomes in the slightest). And it chose to focus on the hardest to serve populations, among the Medicaid community, while constantly solving how to do more with less.   And one shoutout too, to Andrew DeCort: for opening my eyes to Ethiopia, and for continuing to push the moral conscience of our organization as a core advisory board member!    There is a lot to learn from around the world. It's not just about the innovation the US can export to other countries, but the innovation we can import to drive a better healthcare experience for all.

In light of July 4th yesterday, I recently stumbled across an interesting fact, from the Revolutionary War, that blends military history with the history of public health. Did you know George Washington instituted one of the first government sponsored mass immunization programs? In 1776, during the early stages of the American Revolutionary War, smallpox was a significant threat to the Continental Army. That's the context within which General George Washington made a controversial decision to inoculate all troops who had not previously been exposed to smallpox. This early form of immunization, called variolation, involved deliberately infecting individuals with a mild form of smallpox to build immunity. While risky by modern standards, it was far less deadly than catching smallpox naturally. Washington's decision was groundbreaking for several reasons: 1. It was one of the first large-scale immunization campaigns in history. 2. It was a military secret, as the British Army could have taken advantage if they knew large portions of the Continental Army were temporarily weakened by inoculation. 3. It significantly reduced smallpox deaths in the Continental Army, giving them a strategic advantage over the British, who continued to suffer from the disease.   I recently read Byrne Hobart's newsletter Capital Gains on the subject of "what counts as strategic?" One paragraph jumped out at me as especially interesting, especially in light of this Washington story:   “It's even tricky to define "strategic," but a good working definition might be: any decision a company makes that is not a normal-course-of-business choice, that has a present cost most comparable companies are empirically unwilling to pay, but that the decisionmaker thinks will pay off well long-term. McDonald's opening another McDonald's isn't strategy; McDonald's taking a majority stake in Chipotle as a hedge against shifting dining habits (and a bet on a good concept) was. Fixing a software bug isn't strategic; open-sourcing an internal tool is.”   I'd never thought of vaccination as military strategy. Super interesting stuff :)

Important life lesson: find a mentor, and also be a mentor.   This was shared with me in college and I didn’t know what to make of it at the time, but now I do.   Having a mentor allows you to learn from someone with more experience, more perspective, more practical wisdom. Whereas being a mentor requires you to practice those things that you have learned, are preaching, and must walk the talk to make credible.   Receiving emails like the one attached always inspires me. I’m far from being the person I want fully to be. But teaching requires me to evaluate what I think is important, and make sure I'm showing up in the world in a legitimate way behind those values.

I remember my favorite day of the year growing up was "take your child to work day."   When I was growing up, this was one of the most eye-opening experiences I could ever have had.   Like all kids, basically my whole world was school. We spent the majority of our time in classrooms, yet to begin to understand what happened from 8:15am to 3:30pm in the outside world was like an awakening of sorts.   Reflecting on this recently, I seriously think we need a similar day for healthcare – but rather, cross-job from within the industry.   For example: Most providers have no clue what it looks like to run insurance company. And the same goes for the insurance company: they are too often unaware of what it takes to operate the practice of medicine.   If I organized something like this, who else would be in for an experience like this? I would love to see your prior authorization workflows, or how your credentialing teams load rosters, or the discussion around VBC and other rate agreements at the board table.

We had the opportunity to serve a prison inmate patient at Genesis recently. I can't share any detail about this person (obviously), but it struck me that, years ago, this would've been the type of opportunity Genesis would've known intellectually is the right thing to do, and would have done, had the opportunity presented itself. What was different about this instance is that the facility sought us out, knowing our compassionate providers and staff would willingly care for this patient, as they would anyone else. And that our staff wouldn't balk about the state-mandated logistics of handling an inmate, who was required to stay in handcuffs with officers at their side. I'm so proud that we've created the type of organization that can see patients from all walks of life, to ensure that care is delivered no matter what a patient's circumstances are. And also an organization that is sought out to care for those on the margins. This is why we exist.

How do you manage personal stress in your role?   Some things that have helped me with the stress (good stress, and bad stress) of Genesis includes ice cream walks with my kids, playing rec soccer early in the mornings, and routine of church and breakfast on sundays. Sometimes it’s the rhythms of life that are the most stabilizing and comforting.   Curious what's made the biggest difference for you though?

In a fairly stunning new economic paper, researchers found the following insight:   "Rising healthcare prices have long eroded American wages. They are doing that by eating into jobs. Companies shed workers in the year after local hospitals raise their prices, new research found. Higher hospital prices pushed up premiums for employees’ health insurance, which businesses help pay for."   It's a quirk of the American economy that health insurance is attached to jobs, rather than offered independently. The actual story apparently goes back to the post-WW2 economy intended to stimulate job growth (and could be the subject of a longer post). But ironically, 70 years later, the effect of such job stimulating policy is actually the opposite of its intent: more and more companies are making the purely economic choice to respond to higher premiums (driven by higher hospital prices) by cutting jobs.   Writer Scott Alexander has a remarkable piece about so-called "cost disease" across major sectors of the economy, like education and healthcare. Consider the chart I've attached below. Costs in healthcare are dramatically out of control, and moreover in such a high-inflation environment such as today, less and less tenable (both for individuals and businesses alike).    We're proud of our innovation around the cost model at Genesis to provide care at less than 50% of the cost of traditional MSK practices. But it was certainly intentional, and not an accident. Leaving US healthcare to go its natural (or "accidental" / "default") route will only certainly result in more economic dislocation and job loss.   It's a bit of a bleak situation.

It's a bit of a cliche but I think a core belief I've come to adopt is this: unless you really actually enjoy doing something, you won't want to do it long enough for results to start showing up.   Y Combinator co-founder Paul Graham has a great essay about how it's common to "want to want something" but difficult to actually change what you actually want.   His advice in the essay is therefore to align your life with things that you actually want to do.   Simple, but not always easy.   How have you navigated this conversation of finding where your work meets your natural inclinations? Always curious to hear how others are solving this for themselves!