A reader sent me a link to a New York Times article about a healthcare operation on a nearby island figuring, correctly, that it might appeal to me. (Warning! It’s paywalled.)
https://www.nytimes.com/2025/03/25/climate/hawaii-health-nature.html
Twenty years ago, Ho‘oulu ‘Āina was neglected, overrun with garbage and invasive plants. But today, it’s thriving.
And the volunteers and patients who spend long hours there, removing nonnative plants and growing vegetables, fruit and herbs, have experienced a restoration of body and soul.
It got me thinking about why it is that I have seen so many so good ideas in innovative healthcare, but so few long-term successes. Then I thought back about my own experiences. I replied to him as follows (lightly edited):
Nice article. There is a whole genre of stories about rather obvious medical interventions that work extraordinarily well in their niche. We need a lot more of that. Inevitably, it seems, when something like that works then someone will come along and ask how it will scale.
Where “scale” means grow to mega-proportions while becoming a vehicle to extract maximum value.
Where “value,” unfortunately, means monetary profit (yes, even in the government and “not-for-profit” sectors) not that squishy feelgood stuff like “health” and “quality of life.”
I was once medical director a small public program for the homeless mentally ill that followed a “housing first” model — basically, get someone sheltered and then start working on their mental health and substance use issues. It seems that living in a makeshift tent on public parkland somehow isn’t conducive to sobriety and healthy habits. I would hike through the [parks] and meet the people camping there and work with them. Previously, the model was to tell people to go home (did I mention “homeless”?) and come back when they were 90 days clean and sober and stable on psychiatric medication and then we’d work on getting them housed. Naturally, the housing first model worked somewhat better, and some straightforward statistical analysis showed that our program saved the local government a huge pile of money. So they proposed expanding the program tenfold but, of course, they couldn’t quite come up with much (if any) additional resources so it all collapsed. To my knowledge, assistance for homeless people with serious mental illness remains in disarray to this day and the area has a tragic homelessness problem.
The next program I started with (targeting folks being released from jail or prison with suspected mental illness but no healthcare linkage) was also successful from an outcomes and economic perspective. I joked that I gave the local government entities two years before they flooded us with all their other patients (“cases” to them) without additional funding. I was wrong, it actually took three years before they gave us a TWENTY-FOLD increase in patients with virtually no increase in funding.
From there I went into private practice, where we used a concierge model but at low cost. We started out charging $79/month to provide primary care and psychiatric services. I saw, at the very most, two patients per hour. Again, it was wildly successful in terms of patient outcomes and cost-effectiveness (though we did have to raise our prices to stay in business). Though it was a completely private company, the county, the state, and even my (minority) business partner pushed to scale the operation. I steadfastly refused until my retirement. What made it work simply wasn’t scalable, in that you’d have to find people to staff the whole operation who believed in the mission above their own enrichment. I ended up working for about ⅓ the income of my colleagues, and don’t regret it for a moment, but find 10 or 100 doctors willing to do that in a big, bureaucratic organization? Unlikely.
So it’s fantastic that Ho‘oulu ‘Āina — and the hundreds of other tiny, human-centric holistic healthcare operations out there — exist even in public-sector healthcare. But if you find yourself thinking “why can’t we do this on a bigger scale; why can’t all medicine work this way?” be assured that there are very good reasons. It seems that governments, “hospital systems,” and insurance conglomerates just won’t ever be able to create these things and then leave them alone to do the good work that they do.
—2p