The Impossible Math of Healthcare Relationships
Attend any healthcare conference or listen to senior executives discuss the path to affordability, and the same themes surface repeatedly. Alignment. Consumer-centricity. Partnership. Integration. Value-based care.
At a conceptual level, these ideas are obvious and compelling. In practice, the system is structured in a way that makes this outcome extraordinarily difficult to achieve.
The U.S. healthcare system is not a single system. It is a fragmented web defined by a many-to-many-to-many relationship structure that makes consistent execution nearly impossible.
Start with the patient.
Any given provider panel includes patients covered by dozens of health plans. Each plan operates across multiple lines of business. Commercial. Medicare Advantage. Medicaid. ASO. Fully insured. Each line of business carries its own benefit designs, medical policies, payment models, quality measures, care management programs, and reporting requirements.
That is before layering in employer customization.
Employers deploy their own point solutions for disease management, MSK, oncology, behavioral health, navigation, advocacy, and digital therapeutics. At the same time, health plans offer parallel programs addressing the same conditions and use cases. These efforts often overlap, occasionally compete, and are rarely coordinated.
And who sits in the middle of this structure. Providers.
From their vantage point, there is no single operating environment. There are hundreds of micro-systems running simultaneously, each with different rules, incentives, and definitions of success.
The result is operational impossibility.
A physician cannot reliably know which patient qualifies for which care management program, which incentives apply, which referrals are preferred, which sites of care are encouraged, or which services trigger downstream penalties or bonuses. Front-office teams cannot navigate benefit designs that vary by employer group within the same health plan. Care teams cannot standardize workflows when every payer defines “high value” differently.
Even when providers are motivated to do the right thing, the signal is incoherent.
Quality measures differ by line of business. Incentives conflict across plans. Documentation requirements multiply. Reporting cycles fragment attention. The cognitive load required to operate “correctly” across all payer and employer combinations exceeds human capacity.
Patients experience the consequences directly.
They are told to seek high-value care, yet receive different guidance depending on who they contact. They are enrolled in multiple programs without understanding how they differ or which one matters. They are asked to manage authorizations, referrals, and billing issues that no single clinician fully understands either. Confusion becomes the default experience.
This is not a provider performance problem. It is a system design problem.
Healthcare has created a marketplace where success requires simultaneous compliance with dozens of incompatible rulebooks. The industry then expresses surprise when variation persists, costs rise, and experience deteriorates.
The typical response has been to add more layers. More programs. More incentives. More vendors. More “solutions.” Each addition increases complexity for providers and patients, further diluting impact.
The hard truth is that scale does not come from multiplying programs. It comes from simplifying the operating environment.
Providers cannot optimize across infinite permutations of benefits, incentives, and care models. They can execute consistently only when expectations are clear, incentives are coherent, and pathways are standardized across populations.
This reality helps explain why more provider organizations are narrowing their focus. Concentrating on defined populations. Seniors in risk-based Medicare arrangements. Commercial self-funded employers. While still difficult, these strategies reduce the number of competing rulebooks providers are asked to follow.
Until health plans and employers confront the many-to-many-to-many structure they have created, most provider-led transformation efforts will continue to underperform. Not because the strategies are flawed, but because the system they are deployed into is fundamentally unworkable.
The edge in healthcare will not belong to those who add the next layer. It will belong to those who redesign the system so it can be operated reliably, at scale, by real clinical and operational teams.