Is Greed Driving Our Health Systems Woes?

David Caldwell

So, Sofia, let’s dive right in. You know, when most people talk about why the U.S. healthcare system is so, uh, broken, they point to one thing—greed. Like, greedy insurance companies, greedy pharma execs, greedy everyone. How much of that is actually true?

Sofia Ramirez

It's a tempting explanation, David, and honestly, you’re not alone in thinking it. On the surface, blaming greed feels, well, emotionally satisfying. But the truth is, it’s far more complicated than just the actions of a few bad actors. The health system is—think of it as, um, a massive interconnected web. It’s shaped by economic incentives, sure, but also by inefficiencies, behavioral psychology, social norms, and even group dynamics.

David Caldwell

So you're saying it's not just the big villains we love to hate? Like drug companies hiking up prices overnight?

Sofia Ramirez

Exactly. Those headlines grab attention, no question. But if we laser-focus only on greed, we end up glossing over deeper issues that are baked into the system. Take inefficiencies, for example. Some of them are, you know, unintentional byproducts of how fragmented our system is. Others stem from policy choices we’ve collectively made—either consciously or through neglect.

David Caldwell

Wait, hang on. What do you mean by "policy choices we’ve made"? Are you saying we, like, did this to ourselves?

Sofia Ramirez

Well, in a way, yes. Think about it—policies or cultural attitudes around healthcare affect everything. They influence access to care, the way payments are structured, even the behaviors of patients and providers. The point is, these issues aren’t new; they’ve developed over decades, and they reflect priorities that society has—or hasn't—chosen to address. Blaming individuals or single entities kind of lets the system, as a whole, off the hook.

David Caldwell

Okay, okay. I get that we’re talking about this huge, complex web, but—

Sofia Ramirez

—It’s overwhelming, I know.

David Caldwell

Totally, yeah. I mean, is there any way to untangle that? Or are we just, I don’t know, doomed to inefficiency and finger-pointing forever?

Sofia Ramirez

Well, the good news is we can untangle it—at least partially—but it starts with recognizing how deeply interconnected the system is. And, David, here’s where complexity theory comes into play. By shifting our focus away from just identifying "bad guys" and looking instead at systemic patterns, we can start to see opportunities for real change.

David Caldwell

Mm, hold up—complexity what?

Sofia Ramirez

Complexity theory. It’s this idea that systems, like healthcare, are made up of many moving parts that interact in unpredictable ways. It’s not about solving one problem—it’s about rethinking the whole structure so that everything works better together. But more on that later. For now, just know that some of the problems we face aren’t accidental or the result of greed—they’re structural, and that’s actually empowering.

David Caldwell

Wait, hang on—you’re saying structural issues can be empowering? You gotta explain that one for me.

Sofia Ramirez

I know it sounds counterintuitive! But understanding the structure means there are—well, ways to adjust it. Even small policy shifts or shifts in collective behavior can ripple outward and create big improvements. The key is knowing where to focus our efforts. And when we consider history, that’s where the lessons start to make sense.

David Caldwell

Alright, so, if these structural issues are as big a deal as you’re saying, where does that leave greed? I mean, let’s be real—those outrageous price hikes we keep hearing about can’t just be ignored, right?

Sofia Ramirez

Oh, absolutely. For example, there was a case where insulin manufacturers were charged with hiking prices far beyond production costs. One report showed that insulin prices tripled within a single decade—even though the actual formulation of insulin hasn’t really changed. These kinds of practices are clearly, well, profit-driven. But the real question is, why is this allowed in the first place?

David Caldwell

Hm. So it’s not just bad actors—it’s, like... the system makes this possible?

Sofia Ramirez

Exactly. Consider this: in the U.S., we don’t regulate drug prices the same way other countries do. Pharmaceutical companies can set prices as high as the market will bear, and there’s no universal cap. Combine that with limited transparency in pricing negotiations between insurance companies and providers, and you’ve created this perfect storm for price gouging.

David Caldwell

Okay, but it’s not just pharma, right? I read something about private equity groups buying up rural hospitals and basically running them into the ground.

Sofia Ramirez

Oh yes, that’s another example. Rural communities really suffer from this. Private equity firms often acquire struggling hospitals, promising to turn them around. But their main goal is profit—so they cut costs wherever they can, sometimes even eliminating essential services like maternity care or ER facilities. When a hospital isn’t profitable enough, they close it altogether, leaving entire areas without local healthcare access.

David Caldwell

Yeah, that sounds... pretty heartless. But doesn’t that hurt their reputation? Like, isn’t there a risk in being seen as the villain?

Sofia Ramirez

You would think so, but here’s the thing—those decisions often happen quietly, under the radar. Most people don’t realize how private equity operates, or they think, oh, it’s just bad management. But, fact is, private equity owns a growing chunk of the healthcare system. And their interests? They don’t always align with patient care.

David Caldwell

Let me jump in here, Sofia with our mandatory disclaimer. This podcast is generated by AI, and hosted by AI clones, all with creation, guidance, and editing by Dr. Chad Swanson, a full-time ER physician with a passion for transformational change in our health system. Dr. Swanson considers this daily podcast an informal conversation with the world on transformational health systems change. As such, while he edits the AI generated text, and follows up on sources, this should not be considered a definitive source of knowledge. Alright. so back to greed. Hm, it's there—but it’s hiding in the shadows?

Sofia Ramirez

Exactly. These actions might not make splashy headlines, but they have real consequences. Take surprise medical billing, for instance. That’s when patients end up with massive out-of-pocket costs from providers they didn’t even know were out of network. It happens because-of, uh, loopholes in regulations that some companies exploit for profit. And while some states are cracking down, it’s still a widespread issue.

David Caldwell

Surprise bills, insulin hikes, rural hospitals closing... okay, yeah, there’s plenty of greed here. But it’s not just one big bad guy—it’s more like, a whole lot of smaller bad guys all playing the same game.

Sofia Ramirez

That’s right, but it goes even deeper than that. If anything, greed is like... the symptom of a bigger disease. We’ve built a system that rewards these behaviors, and that’s—

David Caldwell

So, if greed is just the symptom of something bigger—like you said—then what’s actually driving all of this? What’s at the root of these issues?

Sofia Ramirez

Misaligned incentives, mostly. Think about it—each player in the healthcare system has their own goals. Insurers care about controlling costs. Pharmaceutical companies and device manufacturers focus on profits. Physicians and hospitals, well, they’re usually motivated by patient care, but they also have to juggle financial viability. All these competing interests create a fragmented system that, honestly, just doesn’t... align.

David Caldwell

So it’s like everyone’s pulling in their own direction, and no one’s really steering the ship?

Sofia Ramirez

Exactly. Let me give you an example—fee-for-service payments. We've talked about this lots because it's a huge factor. This is the most common way providers are reimbursed in the U.S. healthcare system. It means getting paid for every test, procedure, or consultation you perform. It sounds fair on paper, but in practice, it incentivizes volume, not outcomes. Providers aren’t rewarded for keeping you healthy; they’re rewarded for doing more.

David Caldwell

Wait, so, more tests, more procedures—that’s... that’s where the cash is?

Sofia Ramirez

Exactly. Imagine being told you make more money by doing more—even if, sometimes, less would be better for the patient. And, while most clinicians do their best to avoid unnecessary care, the incentives, you know, kind of push them in the other direction.

David Caldwell

Okay, but isn’t this kinda like, I don’t know, just human nature? Wouldn’t anyone follow the money if it’s, uh, right there in front of them?

Sofia Ramirez

Oh, that’s absolutely part of it, and it’s a key issue. When you set up a system where people can benefit financially from certain decisions, most of us—clinicians, administrators, companies—are going to act rationally within that framework. It’s not necessarily about greed; it’s that the structure itself practically invites these choices. And it’s true not just for providers but for every layer of the system.

David Caldwell

So, in a way, the system is kind of setting us all up to fail?

Sofia Ramirez

It’s more like... it sets everyone up to succeed in ways that don’t actually improve health outcomes. Let’s take insurance companies, for instance. They negotiate prices with hospitals and pharmaceutical companies, and theoretically, they’re supposed to control costs. But their business models also prioritize maximizing profit margins. And then there’s... let’s say, pharmaceutical reps incentivized to pitch the latest high-cost drugs, even when older, cheaper options might be just as effective for patients.

David Caldwell

Alright, so fee-for-service payments, unchecked pharma costs, rural hospital closures from private equity—it’s like, every part of the system is out of sync.

Sofia Ramirez

Exactly, David. And what makes it worse is that these incentives aren’t isolated—they interact with one another. For example, say a hospital invests in expensive new technology, expecting it’ll attract more patients, and they’ll recover costs over time. They might perform more high-cost procedures to cover the investment, even if those procedures aren’t strictly necessary. It’s a ripple effect that spreads inefficiency throughout the system.

David Caldwell

And we all just, like, kinda go along with it?

Sofia Ramirez

Well, I’d argue most of us don’t even see it happening—or, if we do, it seems too complex to tackle. Think about it: when was the last time you really questioned why your doctor ordered certain tests or why your insurance denied coverage for something you needed? It’s systemic, and we’re all players in some way.

David Caldwell

So, if everyone’s just acting on the incentives they face, does that mean... if I were in their shoes, I’d probably be making those same decisions too?

Sofia Ramirez

Honestly, David? Probably, yes. Studies in behavioral economics show that, overwhelmingly, people act in ways that align with their self-interest when the system is set up that way. It’s not necessarily a failure of morality—it’s the structure that’s guiding those decisions.

David Caldwell

Wait, wait. So if the system says "here’s the opportunity to make more money," we sorta... just take it?

Sofia Ramirez

That’s exactly it. Let me give you an example. There’s this famous study from 2015—researchers found that in financial transactions, even people who self-identify as ethical or altruistic were much more likely to make decisions that benefitted themselves... when the system rewarded those choices. Their morality didn’t vanish, but the incentives pulled them in a different direction.

David Caldwell

Huh. So we’re all just, I don’t know, products of the system?

Sofia Ramirez

In a way! And here’s the kicker—the same data holds true in healthcare. For example, studies show that physicians in fee-for-service payment models order more procedures than those in value-based models, where the incentives are tied to patient outcomes. It’s not necessarily greed—it’s rational behavior within a flawed system.

David Caldwell

Okay, so even the "good guys" are kind of trapped by it?

Sofia Ramirez

Exactly, David.

David Caldwell

Wow. That’s... kind of depressing.

Sofia Ramirez

It can feel that way, but it’s also enlightening. Understanding that most of us behave within the parameters set by our environments—it shifts the blame away from individual actors. And that’s crucial for reform. If we focus only on punishing “bad behavior” without changing the system that drives it, we won’t see lasting change.

David Caldwell

Alright, so how do you fix that? Like, can you just rewrite the rules and say, "Okay, everybody play nice now"?

Sofia Ramirez

In theory, yes. But in practice, it’s more complicated. Take an organization like Medicare—when they experiment with value-based care models, we see reductions in unnecessary procedures and improvements in outcomes. It’s proof that changing incentives does work, but scaling those changes across an entire system? That’s where things get sticky.

David Caldwell

Okay, so scaling the fix is the problem?

Sofia Ramirez

It’s one of them. The other big challenge is that, well, systems like ours aren’t designed to adapt quickly. They’re kind of resistant to change by nature.

David Caldwell

Huh. So we’re stuck in a system that keeps... reinforcing itself. That’s a little terrifying to think about.

Sofia Ramirez

It is! But it’s also why understanding systems is so powerful. If we can pinpoint the leverage points—small changes with big ripple effects—we can start to shift those dynamics. But behavior is only part of the picture. The science of human psychology gives us even deeper insights into why these dysfunctions persist.

David Caldwell

Okay, Sofia, you mentioned the science of human psychology giving us deeper insights—so is it just about people responding to the rules? Or is there something deeper in human nature itself that’s driving all this dysfunction?

Sofia Ramirez

Oh, absolutely, David. Human psychology plays a huge role here. Take cognitive biases, for instance. Those are the mental shortcuts we use to simplify decision-making. They can be incredibly useful, but in healthcare, they sometimes lead to inefficiencies or even harmful outcomes.

David Caldwell

Wait, like what? What biases are we talking about?

Sofia Ramirez

Well, one good example is the availability heuristic. This is when people make decisions based on information that’s most readily available to them, rather than what’s statistically significant. So, a physician might order a test or treatment because a recent case comes to mind—even if that particular test isn’t really needed in most cases.

David Caldwell

Oh, wow. So, they’re just, like, relying on gut instinct instead of data?

Sofia Ramirez

Sometimes, yes. And it’s not just physicians. Patients do this too. Like, if your neighbor shared a scary story about a missed diagnosis, you might demand extra tests from your doctor, even if the chances of having the same issue are incredibly low.

David Caldwell

Oh, I’ve definitely done that. It’s like... you think you’re being careful, but you’re actually just adding to the mess.

Sofia Ramirez

Exactly. But it’s not just heuristics. There’s also loss aversion, which is this idea that people are more motivated to avoid losses than to achieve gains. We see this a lot in hospital administrators or policymakers—they’re hesitant to implement changes that might, you know, disrupt established workflows, even if those changes would ultimately improve outcomes.

David Caldwell

So, they’re sticking with the devil they know?

Sofia Ramirez

Pretty much. And then there’s status quo bias. People tend to prefer things to stay the same, even when the current system isn’t working. It’s easier to maintain the familiar than to embrace the uncertainty of change.

David Caldwell

But isn’t that just human nature? All of us kinda want things to stay comfortable, right?

Sofia Ramirez

Oh, absolutely. It’s completely natural, but in healthcare, the stakes are so much higher. These psychological factors create inertia—and, over time, they reinforce systemic inefficiencies.

David Caldwell

Okay, but what about the people trying to make change happen? Are they fighting against these same biases too?

Sofia Ramirez

They are. In fact, behavioral science shows that even when people want to make the right choices, things like decision fatigue can get in the way. For example, clinicians making hundreds of decisions in a single day might unintentionally default to the easiest or most familiar option, which isn’t always the best one.

David Caldwell

Wow, so by the end of the day, they’re just too tired to think critically.

Sofia Ramirez

Exactly. And it’s not just fatigue—it’s also about how decisions are framed. Behavioral economists have shown that subtle differences in how information is presented can dramatically influence choices. Something as simple as calling a procedure "routine" versus "optional" can change how likely a patient is to agree to it.

David Caldwell

Okay, hold on. So you're saying that just changing the wording can sway someone’s decision?

Sofia Ramirez

Absolutely. It’s called “framing bias,” and it’s incredibly powerful. It works on all of us—even policymakers, clinicians, and hospital leaders. The way options are presented can either nudge people toward better decisions or steer them toward maintaining the status quo.

David Caldwell

Huh. So we’ve got biases, fatigue, framing—it’s like we’re hardwired to make things harder for ourselves.

Sofia Ramirez

It can feel that way. But understanding these psychological factors is the first step to addressing them. Once we know how humans behave in these systems, we can start designing solutions to work with, not against, our natural tendencies.

David Caldwell

Right, Sofia, we’ve unpacked how individual incentives and biases shape decisions. But what happens when you scale this up? Like, do those same dynamics change when people are working in teams or as part of institutions?

Sofia Ramirez

They absolutely do, David. Group dynamics can amplify individual behavior—or completely shift it. For instance, when you’re in a group, you’re much more likely to conform to the prevailing culture, even if that culture isn’t efficient or productive. It’s something we often see in large healthcare organizations.

David Caldwell

Wait, so the group actually makes things worse?

Sofia Ramirez

In some cases, yes. It’s what we call institutional inertia—the tendency for organizations to resist change, even when continuing the same way is clearly a problem. This inertia stems partly from group behaviors like herd mentality, where decisions are made based on what seems safest—or what everyone else is doing—rather than what’s actually most effective.

David Caldwell

Oh, that reminds me of, like, those meetings where everyone’s nodding along, even when, deep down, they all think the plan won’t work.

Sofia Ramirez

Exactly! It’s called groupthink. And when you combine that with bureaucratic structures that are designed to maintain stability, not adaptability, you end up with a system that doubles down on its current ways, even at the expense of improvement.

David Caldwell

Alright, but... why? Why are these systems so resistant to change?

Sofia Ramirez

Well, part of it is about risk aversion. Large institutions—like hospitals or public health agencies—tend to avoid anything that might disrupt operations or create uncertainty. Change, even positive change, introduces unknowns, and that makes people uncomfortable. So they stick with what’s familiar, even if it’s inefficient or outdated.

David Caldwell

So it’s like, better the devil you know?

Sofia Ramirez

Exactly. And then there’s hierarchy to consider. In many organizations, decision-making is top-down, which can slow responses to new information or prevent innovation from surfacing. Have you ever heard the phrase, "we’ve always done it this way"?

David Caldwell

Oh yeah, definitely. That’s like the motto of every meeting I’ve ever been in.

Sofia Ramirez

It’s a common refrain in healthcare too. And it’s not just frustrating—it’s costly. Institutional inertia means good ideas or evidence-based practices often take years, even decades, to gain traction. Meanwhile, outdated practices persist, and those inefficiencies ripple throughout the system.

David Caldwell

Okay, but can’t leaders just, like, step in and shake things up?

Sofia Ramirez

Sometimes they try. For example, when leaders champion reforms like value-based care models, it can push institutions to think differently. But even then, change is hard. People, at every level, tend to prioritize short-term stability over long-term gains—especially if the gains aren’t immediately obvious.

David Caldwell

So, basically, inertia is just baked into the system?

Sofia Ramirez

It is, but it’s not impossible to overcome. If you understand the underlying group dynamics—like how organizational culture shapes behavior—you can start to challenge that inertia. It requires both strong leadership and buy-in from every part of the organization.

David Caldwell

Alright, so it’s the culture that keeps things stuck... but also the key to moving forward?

Sofia Ramirez

You nailed it. Change has to address both behaviors and systems, and that includes tackling the cultural norms that reinforce inertia. But the other part of this equation is looking beyond the walls of healthcare institutions. The system isn’t just about what happens in hospitals—it’s tied to much broader determinants of health.

David Caldwell

Alright, Sofia, so you’ve really opened my eyes to how culture and group dynamics keep systems stuck. But then you brought up something intriguing—that it’s not just about what happens inside hospitals. Can you unpack that a bit more?

Sofia Ramirez

What I mean, David, is that health isn’t just about healthcare services—it’s shaped by what we call social determinants of health. These are the conditions people live in, like their access to education, housing, nutritious food, and even safe neighborhoods. These factors have a much bigger impact on our health outcomes than how often we go to the doctor.

David Caldwell

Wait, seriously? You’re saying a trip to my doctor matters less than, like, where I buy my groceries?

Sofia Ramirez

In many cases, yes! Think about it—poor nutrition or unsafe housing can lead to chronic conditions that no amount of medical care can fully fix. For instance, someone with asthma might get all the medications and treatments they need, but if they live in a moldy apartment or near a major highway, they’re never really going to get better.

David Caldwell

Wow. That’s... frustrating. So the problem isn’t just fixing the healthcare itself—it’s everything around it?

Sofia Ramirez

Exactly. And the data backs this up. A landmark study in public health found that only about 10 to 20 percent of health outcomes are determined by clinical care. The other 80 to 90 percent? That’s tied to social, environmental, and behavioral factors, like income, education, and where people live.

David Caldwell

Alright, so let me ask this—if we know this, why aren’t we pouring resources into those other areas?

Sofia Ramirez

It’s a great question, and the short answer is that our system isn’t set up that way. Right now, most funding goes toward clinical services, not toward addressing the root causes of poor health, like poverty or food deserts. It’s easier to prescribe a pill than to overhaul someone’s living conditions, you know?

David Caldwell

So we treat the symptoms but ignore the disease. Got it. Typical.

Sofia Ramirez

It’s a tough cycle to break. Just to give you an example, countries that invest heavily in social safety nets tend to have better health outcomes overall. In Denmark or Norway, for instance, the government prioritizes affordable housing, universal education, and access to fresh food. The result? Healthier populations with fewer costly medical interventions.

David Caldwell

Huh. So we’re kind of doing things backwards here in the U.S.

Sofia Ramirez

In many ways, yes. And this isn’t a new revelation. For decades, public health experts have been advocating for a shift in priorities, but realignment is difficult because so many players in the system are focused on short-term outcomes—or tied to the financial incentives we talked about earlier.

David Caldwell

Alright, let me throw out a hypothetical. If we suddenly got our act together and, like, dumped a ton of money into these social determinants—what kind of changes are we talking about?

Sofia Ramirez

The changes would be dramatic. We’d see fewer hospital admissions, lower rates of chronic illness, and even improvements in things like school performance or job productivity. In fact, one estimate suggests that if the U.S. reduced income inequality to the level of some European countries, we’d save over 1 million lives every year.

David Caldwell

A million lives? That’s... I don’t even know what to say. Why isn’t this a bigger conversation?

Sofia Ramirez

It’s partly because these changes take time, and our healthcare system is very reactive, not proactive. We tend to focus on emergencies or immediate needs rather than investing in preventive measures that pay off in the long run.

David Caldwell

So we’re stuck waiting for things to go wrong before we actually do anything?

Sofia Ramirez

In many cases, yes. And that’s why addressing social determinants of health requires a shift not just in funding but in mindset. It’s about recognizing that healthcare is only part of the solution—and that the system can’t fix problems it wasn’t designed to address.

David Caldwell

Alright, Sofia, we’ve gone from incentives and group dynamics to the life-changing impact of things like housing and food access. With all that in mind, my big question is... where do we even start? It all feels so massive, almost overwhelming.

Sofia Ramirez

I get it, David. It is massive. But the first step is understanding that no single solution is going to fix this. Healthcare, as we’ve seen, is a complex system. You can’t just patch one part and expect the whole thing to work better. Real change requires addressing multiple layers—structural, cultural, and, well, human.

David Caldwell

Right, but how do you even prioritize? Like, do we tackle incentives first? Or focus on social determinants? Or what about fixing institutional inertia?

Sofia Ramirez

Great question. And honestly, it’s not an “either-or” situation—it’s all of the above. Reform efforts have to target the root causes, not just the symptoms. That means addressing the misaligned incentives that reward volume over value, while also acknowledging how cognitive biases and group dynamics reinforce inefficiencies.

David Caldwell

So basically, we’ve gotta fight dysfunction from every angle at the same time?

Sofia Ramirez

Exactly. But it’s not impossible. In fact, there are already examples of progress. Some value-based care models, for instance, are starting to shift incentives toward better outcomes rather than just more procedures. And more public health programs are recognizing the power of addressing social determinants—things like housing, education, and community supports—to improve health at the source.

David Caldwell

Okay, but these don’t seem like quick fixes.

Sofia Ramirez

They’re not. And that’s part of what makes systemic change so challenging—it’s often gradual, and it requires ongoing commitment. But every small improvement—every policy shift, every program that makes care more accessible—adds up. The key is recognizing the interconnectedness of these issues and working toward solutions that reflect that complexity.

David Caldwell

So you’re saying there’s hope... but we have to be patient?

Sofia Ramirez

I am. But sometimes it can happen very quickly. So we have to stay engaged. These problems weren’t created overnight, and they won’t likely be solved overnight either. But understanding the system—and our role within it—can empower us to make meaningful changes, whether that’s as individuals, organizations, or societies.

David Caldwell

Well, Sofia, I gotta say, this has been eye-opening. And I, uh, I think I speak for a lot of listeners when I say it’s easy to feel overwhelmed by all this. But you’ve really helped break it down in a way that makes it feel... I don’t know... manageable?

Sofia Ramirez

I’m glad to hear that, David. That’s really the goal—to show that while the problems are complex, the solutions don’t have to be impossible. With the right vision and the courage to take action, we can make this system work better for everyone.

David Caldwell

Alright, I guess on that hopeful note, we’ll wrap it up. Sofia, as always, it’s been a pleasure—and, well, my brain’s full. Thanks for walking all of us through this.

Sofia Ramirez

Thank you, David. And thanks to all our listeners for joining us on this journey. Remember, even the most complicated systems can change, one step at a time. Until next time!