I would posit that good healthcare is more analogous to a restaurant than most large corporations. From Michael E. Porter’s Competitive Strategy: Techniques for Analyzing Industries and Competitors:
If close local control and supervision of operations is essential to success the small firm may have an edge. In some industries, particularly services like nightclubs and eating places, an intense amount of close, personal supervision seems to be required. Absentee management works less effectively in such businesses, as a general rule, than an owner-manager who maintains close control over a relatively small operation. Smaller firms are often more efficient where personal service is the key to the business. The quality of personal service and the customer’s perception that individualized, responsive service is being provided often seem to decline with the size of the firm once a threshold is reached. This factor seems to lead to fragmentation in such industries as beauty care and consulting.
Healthcare has seen those fragmentation factors dissolve since the 1990s and especially since the ACA.
In Redefining Health Care: Creating Value-based Competition on Results, Porter then argues:
Competition has taken place at the wrong levels, and on the wrong things. It has gravitated to a zero-sum competition, in which the gains of one system participant come at the expense of others. Participants compete to shift costs to one another, accumulate bargaining power, and limit services. This kind of competition does not create value for patients, but erodes quality, fosters inefficiency, creates excess capacity, and drives up administrative costs, among other nefarious effects.
Over the years since I returned to the area, the local university medical center has progressively moved away from individualized service into a predictably depressing corporate marketshare grab. If this is “The Future of Medicine Today,” the future is bleak.
If policymakers want to improve US healthcare, the easiest lever to pull first is to enable physician ownership and make it feasible to stay small without needing to opt out of the system entirely by going direct pay.