You want to blame the reimbursement model?
Fine.
Lauren Murray has decades of experience in health plans and life sciences. She went to the ER with cardiac issues. Her cardiologist never called. No phone. No visit. Silence.
She connected the dots to money. Then she used my own logic against me. I’d praised a heart failure program. It kept patients out of hospitals. Leadership called it a revenue problem.
Murray’s take was harsh. She wrote that “no margin, no mission” sounds like a budget line. It actually means patients getting better hurts your bottom line. You want leaders to be brave.
Courage doesn’t survive in a system that punishes it.
Brave people leave. Or they get pushed out.
Nancy Paynter had the receipts. Life science companies spent millions. They moved oncology care out of clinic walls. It worked. Outcomes improved. Patients lived longer.
Then leadership killed the scale. Why? You can’t bill for it well enough. Not viable. Better care doesn’t matter if it doesn’t fill the quota.
Are these facts real? Yes.
Is two-sided risk rational? Absolutely.
Do boards prefer safety over change? Always.
I know this economics. I’ve lived in it. Individual virtue can’t outrun a broken payment model.
But look at what that objection actually does for you.
The Real Reason Healthcare Professionals Blame The System
“The incentives made me do it” is the ultimate alibi.
It works because it’s partially true. The explanation upgrades itself into an excuse.
- The payment model explains why you stayed silent.
- Your silence keeps the payment model alive.
Nobody in the loop owns the loop.
Everyone involved is decent. They act rationally. That is why the chain never breaks.
The incentive is just the environment. It is not the decision.
Someone set that reimbursement rate. Someone wrote the policy. Someone sat in a room where Nancy Paynter’s oncology program died. That person decided unbillable meant unwise.
Was it a spreadsheet? No.
It was a guy. With a mortgage. A title. A perfectly defensible rationale.
He went home. He didn’t think, I just helped end a program that let cancer patients live longer. He thought, I was realistic.
That is what the healthcare system is built on.
Not villains.
Realists.
And who pays for that realism? Not the executive.
Murray’s cardiologist didn’t call. The structural analysis is airtight. But she still sat alone in that ER.
Your explanation isn’t a defense. It’s a description of the crime scene, while you watch it happen.
How Organizational Silence Becomes Corporate Culture
Mark Young argues bodies adapt to dysfunction. Orgs do the same.
People learn what to ignore. They learn which problems to work around instead of fix. Accommodation becomes culture.
Young says transformation needs people who speak. It needs systems that listen.
He’s right about the first half.
He’s wrong about the second.
There is no such thing as a “system” that listens.
A listening system is just a room full of humans. Humans who decided to hear you. Or decided they had heard enough.
There is no abstract system.
There are executives who take your meeting. There are executives who don’t.
This is a demand. It is not an escape.
If you hold power—over a contract, a policy, a pay model—be courageous isn’t advice. It’s the job description.
Asking junior staff to use their last drops of courage is a luxury. It’s what leaders do when they have titles.
What You Can Actually Do About Healthcare Dysfunction
The objection says courage dies. Some people disagree.
Sherita Golden is a physician. A health system leader. She spends her social and reputational capital constantly. She fights policies that hurt clinicians.
Is it risky? Yes.
Exhausting? Yes.
Necessary? Absolutely.
Here is the antidote to moral distress: Watching a patient get a better outcome because you fought for it.
Read that again.
We treat moral injury like a wound. We offer wellness apps. Pizza parties in the breakroom. Resilience training.
That’s not treatment. That’s a band-aid.
Golden describes the mechanism. The distress doesn’t come from the dysfunction.
- The distress comes from watching yourself accept the dysfunction.
- The treatment is action.
Jon Higginbotham put it simpler:
The things you stopped pushing back on five years ago? You just call them how it works now.
Nobody voted for that status quo. It accumulated. One reasonable silence after another. Each silence defensible. Each explained by “the incentives.”
Together they make a system everyone hates. And no one fights.
Amy Paez, a Medicare agent, asked the hard question in a recent thread.
What is one thing you can personally do to improve healthcare? What is stopping you?
You can answer the first part easily.
The second part is where the alibi hides.
I’ll answer mine.
What could I do?
Stop treating low-utilization programs as margin problems. Stop letting the internal finance argument win. Treat that argument as the enemy to defeat.
What stops me?
The argument comes from good people. They have real budgets. Real accountability.
Overruling them costs me.
That is not a system constraint. That is a personal choice.
The system doesn’t tolerate dysfunction. We do.
Every silence is a vote for exactly what you say you hate.
The next meeting you go to?
You have a vote.
I have a vote too.
Do you plan to use it?
