Learning Health System: A Response to Linkedin Comments

Sofia Ramirez

David, earlier this week, we shared an episode that sparked some comments on Linkedin. I mean, people are really digging into the ideas around radically transforming our health system, but let’s just say, not everyone agrees it's feasible—or even fair. And I think it’s worth taking some time to respond to those concerns directly.

David Caldwell

Before we dive into that, Sofia, Dr. Swanson wanted to share a message. He said: "Hey, everyone. Dr. Swanson here. There have been a number of responses on social media about how people just can't tolerate the AI voices. I totally hear you. Frankly, I would never have thought that I would be making a podcast like this a month ago. I just keep wondering if the benefits outweigh the downsides. Here's the deal: I work fulltime in the ER. And I'm writing a book: a true story of a brilliant, visionary black doctor who lived in the 1890s. So my time is limited. But I also think that I have a perspective to offer to the world. The combination of ER, complex systems, public health, transformational change, and history is unique and needed. So using AI gives me the time to create a podcast that is relevant to current events, responsive to your comments and questions, focused on historical transformation, and relatively unbiased. But I may not continue this for more than a couple more months unless I really get the sense that it provides value. So here's what I ask of you: If you really like what I'm doing on this podcast, reach out to me. Let me know on Tiktok, YouTube, Linkedin, or email me at rchadswanson@gmail.com. If you like the content, but can't stand the AI, then also let me know, but do me a favor, and listen to at least 3 episodes to see if it grows on you. And if you just can't stand it, please let me know. My hope is that we can create a community of people that learn together over time, and make and impact. Thanks! Now back to my AI hosts, David and Sofia": You know, the idea of changing the system at such a fundamental level—it’s overwhelming. But the underlying principles we talked about—whole-system coordination and outcome-based incentives—are actually designed to tackle those very concerns. Let’s break this down a bit. Please. I think we need a crash course here, or at least, I do!

Sofia Ramirez

Fair enough. Okay, let’s start with coordination—which some commenters flagged as impossible. The truth is, a healthcare system that doesn’t coordinate is inefficient by design. Patients slip through the cracks, duplicate tests get ordered, and costs skyrocket for no reason. And we’ve seen examples globally where better coordination works: countries like Sweden or the Netherlands have systems that prioritize communication and integration. When we implement data-sharing, aligned incentives, and cross-discipline care teams, the results are better for everyone. It’s not easy, but it’s far from impossible.

David Caldwell

Okay, but what about equity? Some folks mentioned that focusing on efficiency and system-wide changes might inadvertently hurt the people who are already struggling the most—low-income communities, for example.

Sofia Ramirez

That’s such a crucial point, David. And it comes down to designing the solutions with those communities in mind from the start. For instance, we talked about health as a shared responsibility, right? That means investing in things like community health workers, expanded access to preventive care, and ensuring rural or underserved areas get the resources they need. It’s not a one-size-fits-all approach, but one where equity is baked into the system design.

David Caldwell

I gotta say, I really like how you tie it back to prevention too. I mean, those investments upfront seem like they’d save money and improve outcomes in the long run. But... finances. That came up a lot, didn’t it?

Sofia Ramirez

Oh, absolutely. People are—justifiably—worried about who’s gonna foot the bill for all this. And here’s where outcome-based incentives change the game. Instead of paying for the volume of care—for surgeries, tests, or hospital stays—we shift to paying for results. Did the patient get better? Did we prevent that diabetes case? Those are the outcomes we’re focusing on. And this model has shown it can actually lower costs while improving care. It’s not cheap to implement, but over time, the savings can be significant.

David Caldwell

Wait. So, you're saying we’re we’re not just throwing money at the system but restructuring the financial incentives? That sounds like a huge cultural shift too, not just economic.

Sofia Ramirez

Exactly! It is cultural, economic, and operational. It's all interconnected. But here’s the thing: small changes won’t cut it. That’s the hard truth. Transformation has to be big and systemic to actually address these issues.

David Caldwell

So, building on what we talked about with systemic change and outcome-based incentives, there's this claim that's caught my attention recently. It argues that health outcomes are essentially locked in by the time we hit age 8. The idea is that trying to intervene later becomes both expensive and ineffective. Honestly, that feels a bit... fatalistic?

Sofia Ramirez

It really is. And while there’s a kernel of truth—early childhood definitely plays a critical role in lifelong health—the idea that later interventions are futile? That’s not supported by the evidence. The data actually shows that investments across the entire lifespan can make a significant impact. It’s not either/or. It's both/and.

David Caldwell

Okay, but why does this narrative keep coming up, then? Like, is there some big study that people are clinging to, or is it more of a... convenient excuse to avoid spending?

Sofia Ramirez

It’s a mix. There are studies that highlight the outsized influence of those first eight years—especially in brain development, socio-emotional skills, and resilience. But the problem is, some folks interpret that as a reason to front-load all our resources into early childhood and abandon later stages of life. It’s reductionist thinking, honestly.

David Caldwell

And what’s the counterpoint? I mean, where do we see proof that stepping in later still makes a difference?

Sofia Ramirez

Oh, there are countless examples. Take smoking cessation programs for adults—those have been shown to significantly reduce the risk of heart disease and cancer, even if someone quits in their fifties or sixties. Chronic disease management, like helping patients adhere to medication for conditions like hypertension or diabetes, can massively curb complications later in life. And let’s not forget mental health interventions—therapy and treatment for depression or PTSD—that can improve quality of life no matter when they’re initiated.

David Caldwell

Wait, that’s wild. So even in cases where damage has already been done, interventions still pay off? Kind of flies in the face of that whole “too little, too late” mentality.

Sofia Ramirez

Absolutely. And think about policies like increasing access to higher education or job training programs for middle-aged workers. These types of social determinants of health—education, income stability, housing—can trigger dramatic health improvements even well into adulthood. The data supports this, time and time again.

David Caldwell

But let me play devil’s advocate here: Is there a concern about diminishing returns? Like, does the cost of later-stage interventions outweigh the potential benefits?

Sofia Ramirez

It’s a valid question. But we need to look at the broader picture. Preventive care undoubtedly gives us the best bang for our buck, which is why early life investments are so important. But the return on investment from later interventions isn’t negligible—it’s highly dependent on how and where the money is spent. Take rehabilitation programs for stroke survivors, for example. They might be costly upfront, but they significantly reduce the need for long-term care and improve patient independence. It’s not about choosing one stage of life over the other; it’s about building a system that invests appropriately across all stages.

David Caldwell

You know, as we’re talking about system-wide changes and making this investment work at every stage, I keep hearing concerns about rural areas. Some folks worry that these big reforms might actually make things harder for them. What do you think, Sofia?

Sofia Ramirez

That’s a really legitimate concern, David. Rural areas already face significant challenges—limited healthcare infrastructure, longer travel times for patients, and fewer specialists. And the truth is, if we’re not careful, broad changes could widen those gaps instead of closing them. It’s all about how we design the system.

David Caldwell

Right, and when people say this could hurt rural communities, are they mostly talking about access, or is it also a funding issue?

Sofia Ramirez

It’s both, but let’s start with access. If you’re in a rural county, you're already more likely to face delays in getting care. And when funding models prioritize efficiency without exceptions for geography, rural hospitals often struggle to stay open—because they’re serving smaller populations, right? This has been happening for years, with rural hospitals closing at an alarming rate.

David Caldwell

Wait, like, what kind of numbers are we talking about here? How many hospitals are we losing?

Sofia Ramirez

Since 2005, over 180 rural hospitals have closed in the United States. And that’s not just a statistic; it’s—well—it’s lives. Because once those closures happen, people are left without timely access to emergency care, let alone routine or specialist treatments. It intensifies health disparities for millions.

David Caldwell

That’s, uh... honestly devastating. But I guess my question is, how do you fix that without undermining the whole idea of cost efficiency?

Sofia Ramirez

Great question. One way is to build incentives that account for these geographic realities—a kind of “equity adjustment,” if you will. Take telemedicine, for instance. It has enormous potential to bridge the gap, ensuring rural patients can see specialists or get mental health care without traveling hundreds of miles. But that requires investing in broadband infrastructure, too. It’s not a one-step solution.

David Caldwell

And what about the financial viability of hospitals themselves? How do you keep them above water?

Sofia Ramirez

That’s where funding formulas need to shift. For example, we could introduce payment models that reward rural hospitals for outcomes and community health improvements rather than just the volume of procedures they perform. It’s about recognizing their unique context and ensuring they have the resources to function as essential lifelines for their regions.

David Caldwell

Okay, so it sounds like any system change has to be kind of... individualized. Like, you can’t just apply the same rules to New York City and a tiny town in rural Kansas.

Sofia Ramirez

Exactly. And that’s where this critique gets it right: applying blanket policies across vastly different regions is a recipe for exacerbating disparities. System-wide change has to be flexible enough to account for local needs.

David Caldwell

Right, but can we actually create a system that’s both efficient and flexible?

Sofia Ramirez

It’s challenging, but not impossible. It means engaging local stakeholders—those who know their communities best—and aligning national policies with grassroots needs. The evidence shows that, when we do that, we can create solutions that are tailored yet scalable.

David Caldwell

That makes sense. But it feels like—

David Caldwell

So, thinking about what you said regarding funding for rural hospitals, it’s got me wondering—how does this idea that cutting health spending could actually improve outcomes fit into the picture? I just, I don’t see how that works. Wouldn’t less funding make things, you know, worse?

Sofia Ramirez

You’re absolutely right to question that, David. And the evidence consistently shows that when we reduce health spending without strategic reinvestment, the outcomes almost always decline. Think about it: if you cut funding for primary care, for example, you’re not actually saving money—you’re just shifting costs downstream to emergency rooms and hospitals, which are far more expensive to run.

David Caldwell

Right, because people can’t just stop needing care. They’ll—they’ll end up in crisis and need even more resources, right?

Sofia Ramirez

Exactly. And what typically happens is those crises put more strain on the system, creating a cycle of inefficiency. You reduce access to preventive care, people get sicker, and the financial burden shifts to the most expensive parts of healthcare.

David Caldwell

So, basically, it’s kinda like sealing a leak with, uh, duct tape. It’s cheap upfront, but costs you big time when the pipe bursts?

Sofia Ramirez

That’s a great analogy, actually. And to add to it—you’re not only risking a burst pipe but also ignoring how those leaks might be impacting the entire system. Cutting budgets blindly often means fewer resources for frontline workers, fewer public health initiatives, and fewer safety nets for vulnerable populations.

David Caldwell

But, okay, let me push on this for a second. What about the argument that healthcare spending is, like, way out of control? I mean, the U.S. spends more per capita on healthcare than any other country, and we’re not exactly getting the best outcomes to show for it.

Sofia Ramirez

It’s a valid point. The U.S. does spend an astronomical amount on healthcare—over $4.3 trillion in 2021 alone. But here’s the thing: it’s not just how much we’re spending; it’s how we’re spending it. A lot of that money goes toward administrative costs, fragmented care, and redundant services. So, when people say we need to cut spending, what they really mean—whether they realize it or not—is that we need to spend smarter.

David Caldwell

Interesting. And by “smarter,” you mean what exactly?

Sofia Ramirez

Investing in areas that produce the highest returns, like preventive care, mental health services, and chronic disease management. And it’s not just about direct health interventions—we’re also talking about upstream investments, like housing, education, and nutrition programs. These are the social determinants of health that keep people out of the hospital in the first place.

David Caldwell

So, wait, are we we basically saying that health spending is, uh, like... an investment strategy? Put money in the right places and you see better returns down the road?

Sofia Ramirez

Exactly. And to your point earlier about the U.S. not having the best outcomes—that’s partly because we treat healthcare spending as a cost to be minimized rather than an investment to maximize. Countries with better outcomes tend to view health spending this way, and it shows.

David Caldwell

Alright, but here’s my question: if it’s so obvious that investing smartly works, why isn’t that happening? Like, what’s stopping us?

Sofia Ramirez

Oh, David, where do I even start? There are so many barriers—entrenched interests, fragmented systems, and, honestly, political will. It’s easier, unfortunately, to sell budget cuts in the short term than to make the case for long-term structural change. But the data is clear: when we prioritize investment over cuts, the benefits far outweigh the costs.

David Caldwell

Alright, building off what we were discussing about spending smarter—here’s something I’ve been chewing on: nurses are, like—correct me if I’m wrong here—but they’re the backbone of every hospital, right? But hospitals don’t actually bill specifically for nursing care. Is that true?

Sofia Ramirez

It’s absolutely true, David. And it’s one of the biggest blind spots in how we value—and I mean financially value—healthcare work. Right now, hospitals bundle nursing services into the overall cost of patient care, but there’s no direct line item that says, “This is what nursing care is worth.” Which, frankly, is a huge disservice to the profession.

David Caldwell

Wait, so nurses—who, let’s be honest, are probably the most hands-on with patients—don’t directly generate revenue for hospitals?

Sofia Ramirez

Exactly. And it creates this cascading effect where their contributions are systematically undervalued. Nurses are managing patient care, catching errors before they happen, and essentially acting as the glue that holds the entire system together. But under the current reimbursement model, their work isn’t seen as a revenue-generating activity.

David Caldwell

That’s bananas. I mean, if you look at the amount of work they do—everything from monitoring vitals to educating patients—it feels like they’re running the show half the time.

Sofia Ramirez

Oh, they are. In fact, research shows that better nurse-to-patient ratios lead to lower mortality rates, fewer complications, and reduced hospital stays. But because we don’t bill for nursing the way we bill for surgeries or diagnostic tests, it’s harder to quantify their financial impact—despite all the evidence that investing in nursing improves both outcomes and efficiency.

David Caldwell

Okay, but how did we even get here? Like, why isn’t nursing treated as its own standalone part of the billing process?

Sofia Ramirez

Great question. Historically, the healthcare system evolved to prioritize procedures and interventions—things you could easily measure, assign a cost to, and bill for. Nursing, on the other hand, has always been seen as part of the “room and board.” It’s woven into the fabric of care but not accounted for as a distinct service. And that’s shaped how the entire system views—and compensates—nursing.

David Caldwell

So, basically, it’s stuck in this outdated mindset where what gets billed is what gets valued?

Sofia Ramirez

Exactly. And that mindset has real consequences. It limits hospital investments in nursing staff, contributes to burnout, and hampers recruitment and retention at a time when the nursing workforce is already under enormous strain. If we started treating nursing as a key revenue stream, it could shift the entire landscape.

David Caldwell

Okay, so how would that actually work? Like, what would billing for nursing care look like in practice?

Sofia Ramirez

One idea that’s been floated is creating nursing-specific billing codes—something akin to how we bill for physician or therapist services. Hospitals could document the time and intensity of nursing care, tie it to patient outcomes, and justify the costs within value-based care models. It would also shine a light on the critical role nurses play in preventing complications and improving recovery times. But implementing that kind of system would require a seismic shift in how we think about healthcare financing.

David Caldwell

I don’t know—I feel like that would also give nurses more visibility, right? Like, people would finally see their work for what it is: essential.

Sofia Ramirez

Exactly, David. It’s about visibility, respect, and fairness. By recognizing nursing as a revenue-generating service, we’d not only empower the profession but also align incentives to deliver better, more comprehensive care. And honestly, there’s no downside. But—

David Caldwell

Alright, so building on what we just discussed about rethinking how hospitals value care—let’s shift to Value-Based Care. I mean, it’s been, what, thirty years since it first came onto the scene? And, uh, I think it’s fair to say the results have been... mixed. Like, if it hasn’t worked by now, why would we expect it to work in the future?

Sofia Ramirez

That’s a valid question, David, and one that gets raised a lot. On paper, Value-Based Care sounds like the perfect solution—shifting the focus from the quantity of care to its quality. But in practice? The implementation has been fragmented, inconsistent, and—honestly—riddled with misconceptions about what “value” actually means.

David Caldwell

Okay, but why? Like, is it just a logistics problem, or are we talking about something, I don’t know, more fundamental?

Sofia Ramirez

It’s both, really. From the start, Value-Based Care was thrown into a system that wasn’t designed to accommodate it. Think about it—we’ve had decades of fee-for-service models, where providers were incentivized to, well, do more. More tests, more procedures, more hospital stays. VBC tried to flip that script without addressing the underlying infrastructure, like data-sharing capabilities or coordinated care systems, that would actually make it work.

David Caldwell

So, basically, we we put a Band-Aid on it without fixing the underlying issues?

Sofia Ramirez

Exactly. And it didn’t help that the way VBC was rolled out created winners and losers. Larger healthcare systems often had the resources to adapt, but smaller clinics or rural providers? They struggled to keep up. And then there’s the issue of measurement. Imagine being a provider trying to hit these vague, moving targets about “value” without clear definitions or benchmarks. It’s frustrating and unsustainable.

David Caldwell

Right, but isn’t the whole point of VBC to reward better outcomes? Like, if this is such a great idea, why wasn’t it measurable from the get-go?

Sofia Ramirez

Because the healthcare system loves complexity. Seriously, the metrics kept evolving—readmission rates, patient satisfaction scores, quality-adjusted life years. While those are all worthwhile to track, they don’t always align with what providers actually control. And even when there were metrics, smaller practices didn’t always have the tools to track them effectively. It’s like setting a goal without giving anyone the right roadmap to get there.

David Caldwell

Okay, so if you’re, uh, a smaller provider, VBC probably feels less like a win-win and more like one of those games that’s rigged against you?

Sofia Ramirez

Pretty much. And that’s one of the reasons adoption has been so uneven. For a lot of those providers, the risks outweigh the benefits, especially when you don’t have the resources to invest in electronic records or care coordination teams. And yet, despite all this, I wouldn’t say VBC is a failure—it’s just been misaligned. It still has potential, but not without significant changes.

David Caldwell

Misaligned how? Like, what would need to change for it to actually, you know, work?

Sofia Ramirez

We need to rethink the entire framework—what “value” means, who gets to define it, and—actually—how we support smaller providers in achieving it. But there’s no silver bullet here. It’s going to take structural updates, clearer incentives, and—

David Caldwell

Alright, Sofia, you mentioned rethinking the framework for Value-Based Care—like redefining “value” and supporting smaller providers to make it work. So, let’s tie that into the bigger picture here. Over the past hour, we’ve talked a lot about what a transformed health system might look like. But before we sign off, let’s recap the high points. What’s our big proposal here?

Sofia Ramirez

Sure, David. At its core, what we’re talking about is building a system that learns, adapts, and evolves constantly—a true learning health system. And our approach emphasizes five key pillars. First, lifelong health investment. We know health isn’t just about what happens in a doctor’s office. It’s built from birth to death, and our system has to reflect that by investing at every stage of life.

David Caldwell

Right, right. And, uh, the second one—geographic equity. That’s huge, especially with how underserved rural and low-income communities are right now.

Sofia Ramirez

Exactly. It’s about designing policies that meet people where they are, whether they’re in a bustling city or a small rural town. Equity isn’t just a buzzword—it’s a principle that should drive resource allocation and access.

David Caldwell

And then, of course, strategic investment. Not cutting budgets willy-nilly but spending smarter—investing in prevention, social determinants, and better care coordination.

Sofia Ramirez

Absolutely. When we treat health spending as an investment, the returns come in the form of healthier individuals, stronger communities, and, ultimately, lower costs down the line.

David Caldwell

Okay, and then there’s this team-based compensation piece, which, honestly—kinda blew my mind. Like, how have we gone this long without properly valuing the role of nurses and other team members?

Sofia Ramirez

It’s a systemic oversight, David, but one we can address by aligning compensation with the actual value these roles bring. Team-based care works best when compensation models reflect everyone’s contributions toward better health outcomes.

David Caldwell

And finally, Value-Based Care. Which—you know—I feel like we gave it the tough love it deserved, but there’s real hope for realignment.

Sofia Ramirez

Exactly. VBC isn’t dead; it just needs a serious recalibration. We need clearer incentives, better support for providers, and a system that actually reflects what patients need and value most in their care.

David Caldwell

So, when you put it all together—lifelong interventions, geographic equity, strategic investment, team-based models, and value-based care reforms—it feels achievable. Like, this isn’t just an idealistic wish list, you know? These are practical, tangible steps forward.

Sofia Ramirez

Exactly. And while the road to transformation isn’t simple, the evidence is clear: a learning health system is not just the future—it’s the only way forward if we want meaningful, sustainable change.

David Caldwell

Well, Sofia, I gotta say, I’ve learned so much today—about the system, the challenges, the opportunities. And honestly, it gives me hope. Like, if we start pushing for even some of these changes, we’re setting ourselves up for something better.

Sofia Ramirez

Absolutely, David. And you know, this isn’t just theory—it’s a call to action. Everyone listening has a stake in this, whether it’s as a patient, a healthcare worker, or an advocate for change. We all have a role to play.

David Caldwell

And on that note, I think that’s a wrap. Thank you to everyone who stuck with us through this deep dive. It’s been a pleasure, Sofia.

Sofia Ramirez

Likewise, David. And to our listeners—thank you for being part of the conversation. We’ll see you next time on “It’s Time.”