July 24, 2026
Dear Interested Readers,
Will Physicians Engage In the Effort to Achieve Healthcare Equity?
Last week’s letter reviewed The Coming Healthcare Revolution: 10 Forces That Will Cure America’s Health Crisis, written by David W. Johnson, a former investment banker who is the founder of 4sight Health, a healthcare media and advisory company, and Paul Kusserow, who was noted as the current chairman and former Chief Executive Officer of Amedisys (AMED), which I thought was a publicly traded company that provided home health, hospice, palliative, and personal care. The information about Mr. Kusserow was accurate when the book was published. I took it straight from the book jacket, but I have now discovered that Amedisys is no longer traded on the NASDAQ exchange, and perhaps Mr. Kusserow is just rich and no longer its chairman. Last August, Amedisys became a wholly owned subsidiary of UnitedHealth Group after it was purchased for $3.3 billion dollars. Ironically, it was folded into United’s Optum division, which is the same for-profit location that is now the home of my former practice, Atrius Health.
You might not realize how dominant UnitedHealth has become in American medicine. It is the largest publicly traded provider of medical services and health insurance in America by total revenue and market capitalization. Besides Optum, the medical services division, there is UnitedHealthcare, which provides insurance and has a very large Medicare Advantage offering. You might remember that the CEO of this division was assassinated last year while in New York.
Quoting from Google’s Gemini AI:
UnitedHealthcare covers about 14% to 15% of the overall U.S. health insurance market. In the Medicare Advantage market, UnitedHealthcare is the largest insurer, controlling approximately one-third (33%) of all national enrollments. [1, 2, 3].
“UnitedHealth Group controlled more than 14 percent of the American health insurance market, making it the country’s largest health insurance network.”
I also asked Google’s Gemini about United’s Optum division and what proportion of America’s medical professionals were its employees.
Optum directly employs or aligns with nearly 90,000 physicians and 40,000 advanced practice clinicians operating across more than 2,200 locations nationwide. [1, 2, 3, 4]
To put this into perspective, Optum’s physician network comprises roughly 10% of all doctors in the U.S., making it significantly larger than traditional hospital networks like HCA Healthcare or Kaiser Permanente.
UnitedHealth Group is in the health insurance and healthcare provider business, and not in the for-profit hospital business. Again, according to Google’s Gemini, those are:
The largest publicly traded hospital organizations in the United States operate extensive, integrated networks of acute-care hospitals, behavioral health facilities, and outpatient surgery centers. [1]
The top publicly traded hospital organizations are ranked below by size, scope, and market capitalization: [1]
- HCA Healthcare (NYSE: HCA): The largest pure-play, publicly traded hospital chain in the U.S. As of early 2026, it operates 189 hospitals and approximately 2,600 ambulatory sites across 19 states and the U.K. With a market capitalization exceeding $82 billion, HCA is also one of the most valuable healthcare providers globally. [1, 2, 3]
- Universal Health Services (NYSE: UHS): One of the largest behavioral and acute care providers in the nation, managing over 400 facilities. UHS boasts a market cap around $9 billion and employs over 100,000 staff. [1, 2]
- Tenet Healthcare (NYSE: THC): A diversified healthcare services company operating 50 hospitals alongside a rapidly expanding network of over 535 ambulatory surgery centers. Tenet holds a market capitalization of approximately $17 billion. [1, 2]
- Community Health Systems (NYSE: CYH): A major operator of general acute-care hospitals, particularly in non-urban and mid-size markets. CHS currently operates 60 affiliated hospitals across 12 states. [1, 2, 3, 4]
The largest hospital systems also employ physicians and have outpatient facilities, and in those aspects of our system of care, they are both dependent on UnitedHealthcare for reimbursement for services supplied and are competitors for the provision of medical services. This payer/competitor relationship is a good example of “co-opetition,” which has been a confounding reality in healthcare for decades. I have lived, practiced, and managed in a co-opetition environment. At Atrius Health, we were both dependent on Boston’s hospital systems and competed with them as providers of professional and diagnostic services. Eventually, we moved most of our hospital care from the system dominated by Mass General and the Brigham (where I was trained) to the Beth Israel Deaconess and Lahey hospitals because they were less predatory in a co-opetition environment.
Since co-opetition is such an important reality in understanding current healthcare markets and strategies, and since I believe it is an unrecognized or poorly understood reality by many healthcare professionals today, again, I decided to ask Google Gemini to provide a succinct definition:
Coopetition (a portmanteau of “cooperation” and “competition”) is a strategic business model where rival companies collaborate in certain areas—like research, supply chain, or product development—while continuing to compete aggressively in other areas, such as marketing and market share. [1, 2]
Common Applications
- Rival Partnerships: Two tech companies, for example, might jointly develop a new industry standard or platform, but fiercely compete to sell their own finished products to end-users. [1]
- Shared Infrastructure: Competitors may share logistics, distribution networks, or manufacturing facilities to cut costs, then use separate sales channels to battle for customers. [1, 2]
- Joint R&D: Pharmaceutical giants might collaborate to research and produce a life-saving vaccine, but operate as traditional competitors in other therapeutic markets. [1, 2]
The Core Principle
Rather than viewing the market as a zero-sum game where one winner takes all, coopetition focuses on a plus-sum mentality. By working together, companies can often grow the overall size of the market or reduce shared operational risks, leaving all involved parties more profitable than they would be fighting the battle entirely on their own. [1, 2, 3]
For a deeper dive into the game theory behind this strategy, you can explore the Investopedia Coopetition Guide or read the foundational work by economists Adam Brandenburger and Barry Nalebuff. [1, 2]
I first became aware of co-opetition in the mid to late nineties when I became a student of “non-zero” thinking, game theory, and had the good fortune to hear Barry Nalebuff speak not long after the publication of Co-opetition: A Revolution Mindset that Combines Competition and Cooperation… The Game Theory Strategy that’s Changing the Game of Business.
I have learned that my comments about The Coming Healthcare Revolution generated some confusion on the part of at least one reader; the person who had given me the book as a birthday present. Shortly after the letter was published, I received a brief email saying:
Gene,
I just read your newsletter. I had… no idea whether the book that I sent would be realistic or relevant…I thought the title sounded hopeful – which is why I bought it. What you wrote truly describes the healthcare situation, and that doesn’t feel hopeful at all.
I’ll choose more wisely the next time!
xxxx
My benefactor was partially right; the book is incredibly realistic and relevant. It is a very accurate description of our inequitable hospital and procedurally dominated, expensive system of care that delivers the worst overall outcomes, considering all patient populations, of any economically developed nation on earth. It even gets results that are worse than much poorer nations. Remember that Paul Batalden, working with Don Berwick at the IHI, stated over 25 years ago that every system is perfectly designed to get the results it gets. Again, I asked Google Gemini to comment and was pleased with its confirmation. Google responded:
That famous axiom—often called the “first law of improvement”—is widely associated with the Institute for Healthcare Improvement (IHI) and its founders, though its exact wording and lineage trace back through industrial quality thinkers. [1, 2, 3, 4, 5]
Origins and Attribution
- Paul Batalden & Don Berwick: Both leaders popularized the phrase during the foundational years of the Institute for Healthcare Improvement (IHI) to explain that patient outcomes emerge directly from structural designs rather than individual failures. As noted in healthcare improvement analyses, `“Every system is perfectly designed to achieve the results it achieves.”, as highlighted by The Human Stream. [1, 2, 3]
- W. Edwards Deming: The core philosophy heavily mirrors the teachings of quality-management pioneer W. Edwards Deming, who taught that worker performance is bounded by process capabilities. [1, 2]
- Arthur Jones: Historical tracking of the phrase indicates Batalden adapted the concept from Arthur Jones’ earlier statement, `“All organizations are perfectly designed to get the results they get!” according to The Anna Reich Substack. [1]
Core Meaning
- Structure Dictates Outcome: Flawed or inefficient results are symptoms of underlying structural processes, not bad people.
- Need for Redesign: To get different outcomes, the system itself must be intentionally changed rather than simply working harder within the old structure. [1, 2]
Dr. Robert Ebert, Dean of Harvard Medical School and founder of Harvard Community Health Plan, was emphasizing the same principle when he wrote in 1965:
The existing deficiencies in health care cannot be corrected simply by supplying more personnel, more facilities and more money. These problems can only be solved by organizing the personnel, facilities and financing into a conceptual framework and operating system that will provide optimally for the health needs of the population.
From my perspective, as we contemplate how to change our system of care, a major question is whether the change will occur spontaneously through market forces as Johnson and Kusserow imply, or whether the evolution will require political will that is translated into public policy through the elections of 2026 and 2028. I believe that the controlling powers of the status quo in healthcare have been resistant to market forces, and that real improvement will require legislation that favors the evolution of a system designed with policies and regulations that will support a better financial infrastructure and a more efficient operating system for care delivery. Further extension of legislation like the ACA that continues our journey toward better access, finance, and organization of care will be required to deliver the results that most of us desire despite the power of the corporate status quo that is dominating care delivery to deliver greater profit, and now employs a majority of healthcare providers under suboptimal working conditions. I agree with Paul Krugman when he states that the first step of many steps in the right direction will be the adoption of a “public option.” I can’t imagine UnitedHealth Group ever embracing a public option as a competitor. There is a role for markets, but markets in a capitalistic economic system without adequate regulation create both oppression and inequality.
I felt a need to let my benefactor know that I really appreciated the book, so I wrote:
I thought the book was great! I really appreciated it as a gift. It was thoughtful and interesting. The foreword by Zeke Emanuel was excellent, and the 10 points are accurate. What I believe is unlikely is that the market forces that they identify are powerful enough to drive a change, but the destination they say we need to reach is exactly right. It was a great setup for my letter and the points I try to make.
Thanks again for a great gift.
As I told my benefactor, I was in total agreement with the trends that the authors identified. So much so that I think it is worth emphasizing their importance by returning to them. The authors discuss their importance by presenting the status quo as the “assumptions” of “Old Medicine” and the necessary changes to reach the desired future state, which they label as “New Medicine.”
Contrasting the assumptions of “Old Medicine” with those of “New Medicine” across ten dimensions:
| Leadership Dimension | Old Medicine | New Medicine |
| Mindset | Individualistic | Team-based |
| Worldview | Hierarchical | Outcomes-driven |
| Orientation | Autonomous | Collaborative |
| Focus | Specialized | Broad |
| Attitude | “My way” | “Our way” |
| Decision Bias | Trust myself | Trust others |
| Action Bias | Do it myself | Delegate |
| Trust | Assumed | Earned |
| Communication Style | Command | Persuade |
| Recognition / Accountability | Personal | Group |
As ChatGPT commented when I asked it to prepare the graphic:
The authors’ central message is that healthcare’s future will depend less on the traditional image of the heroic, autonomous physician and more on clinicians who can lead teams, share responsibility, and manage complex systems.
In other words, one could argue that the catalyst for actualizing the movement from Old Medicine to New Medicine will be a change in the activities and attitudes of the great silent majority of physicians. In my mind, and consistent with my experience-driven biases, the great accomplishments in quality and safety and the momentum leading up to the passage of the ACA were driven by a very focused and committed minority of physicians and nurses, and a very small number of healthcare leaders, consultants, board members, and executives, that you probably have never heard of like Vin Sahney working at IHI and Clive Kilingsworth, CEO of Massachusetts Blue Cross and Blue Shield to name two.
Although thousands of people contributed their intellect and passion to the effort to improve healthcare, the majority of physicians were, at best, supportive non-participants. In my organization, there was a committed minority willing to do the extra work to promote improvement while the majority were uninvolved, unless you count complaining about the status quo as involvement. Physicians who do procedures as their principal care activity seem to have less interest in change or perhaps have less time to participate. Financially, proceduralists have fared much better than those in primary care. It seems to me, as a generalization, that for many proceduralists, it is possible for me to surmise, bolstered by my biased opinion, that our failing system of care remains personally beneficial, and any change would be perceived as a financial threat.
The term “Great Awakening” in American history usually refers to the series of religious “revivals” in the 18th, 19th, and early to mid twentieth centuries, but I think it could also be applied to the movements to abolish slavery, the suffrage movement to give the vote to women, the progressive movement of the early twentieth century to ban child labor, and obviously the Civil Rights movement. If we are to ever have the care that is imagined in the Triple Aim or even more precisely the Quintuple Aim advocated by the IHI and referenced by Johnson and Kusserow, as well as others, then I would expect that we will need another “great awakening” that moves more physicians and their healthcare colleagues to be motivated to practice the principles of “New Medicine.”
Until now, the majority of American physicians have not made an effort to support the Triple Aim, much less the Quintuple Aim, which includes advancing health equity and improving workforce experience in addition to the three original goals of the Triple Aim: Improving the experience of care, lowering per capita costs, and improving population health. What will it take for a movement to begin that will be focused on these goals? How many physicians will need to be demoralized by burnout from undoable workloads or morally injured by complying with corporate policies designed to increase shareholder value at the risk of undermining the care experience before an effective movement or awakening occurs? Those will be important questions to consider as we approach the elections of 2026 and 2028.
My Trump Derangement Syndrome and Coneflowers
For the past several weeks, as the unnecessary but costly conflict in Iran continues with announcements one day that the war is over and the next day that it is back on again, I have tried to avoid any direct reference to the president’s continuing inability to perform as an adequate or even marginally competent leader. I am not sure whether I live in a declining democracy, an evolving autocracy, or perhaps a well-established and formidable kleptocracy. Whatever we are now doesn’t make much difference until we can see some form of consistency or strategic direction in the daily proclamations of our leader. I doubt that we will ever get to clarity about any positive road forward without Congress and the Supreme Court again performing their functions as checks on the powers of the executive.
One reason I have held my words is that I really can’t think of a succinct way to express my concerns. I see no lasting benefit in using four-letter words or artfully constructed slurs. I have recently absorbed the inside stories and reminders of obvious violations of norms that have characterized the first year and a half of the president’s second term as described by Jonathan Swan and Maggie Haberman in their recent book, Regime Change: Inside the Imperial Presidency of Donald Trump. The experience was like pulling a bandage off of a festering wound. I am not recommending the book to you if you are easily upset by the reminder of troubling experiences or suffer, as I do, from crippling Trump Derangement Syndrome (TDS).
As the temperature of the war in Iran rises, along with a second surge in gas prices, and with the midterms approaching, the president has a new strategy: to try to initiate a new “red scare.” The Joe McCarthy red scare years are part of the remembered glorious past to which the president’s MAGA policies would have us return. Now anyone, not just AOC, Bernie, Mayor Mamdani, or Senator Elizabeth Warren, liberal politicians who favor progressive policies like DEI initiatives or providing basic healthcare for everyone, is likely to be labeled by the president as a Communist and be considered a threat to the nation when viewed through a MAGA lens. New York Times political pundit Jamelle Bouie had a great column this week entitled “Trump’s New Insult Won’t Save Republicans.” I resonated with the elegant put-down of his last three paragraphs:
Of course this president, and this administration, would want to emulate the anti-communist hysterias of the 1910s and the 1950s. Of course he and his administration would want to resurrect the fear, bitterness and paranoia that marked the hunt for alleged subversives.
Both Trump and his movement are, as you might surmise from the slogan “Make America Great Again,” fundamentally derivative. His vision of the future rests on a rotten nostalgia, and his plans for getting there were drawn from the wreckage of a shameful past.
The president’s attempt to drum up a third Red Scare is certain to fail. If it matters — if it is interesting — it is only because it gives us a glimpse into the stunted imagination of a man who seems to value only the worst this country has to offer.
I will try to restrain my comments over the next few months as the critical 2026 election approaches. I share the fear that many have that through some contrivance the elections won’t occur. If they are flawed, my bias is that the attack on election integrity will come from the administration and its sycophants and not from the demonized progressives. Enough said.
As I have said so many times before, my relief comes from the beauty around me. As you can see in this week’s header, the coneflowers are still dominant in our garden, but you can see a couple of black-eyed susans joining their larger and more aggressive relatives, along with some Queen Anne’s lace. Summer is moving along fast. I fear it will end before I have had enough. I hope that rest and relief await you this weekend.
Be well,
Gene
