The $5 Trillion Dollar Mirror

This post is sponsored by:

Saatva Mattresses (my link gives you 15% off all purchases, a discount that stacks on any discount Saatva is running at the time!) If you are purchasing in a showroom and not online, let them know Dr. Dana Strauss sent you and you will receive the same 15% discount.

Policy Pulse

We Aren’t Getting a Good ROI From Our Ballooning Healthcare Spending in the U.S.

Find all sources and additional context here.

The 2026 National Healthcare Expenditure data reports are out, and it is another sobering reflection of our current system. Personal healthcare spending has surged by over 8%, and our healthcare spend as a share of the GDP has followed that same aggressive trajectory.

For years, we’ve found comfort in blaming "the boogeyman"—pointing at payers and their perceived runaway profits. But the data tells a different story. As Michael Chernew, PhD, Chair of MedPAC, highlights in his recent Health Affairs Forefront piece and Health Affairs This Week podcast appearances (see this post’s references here), payer margins aren’t the engine behind this spike.

The engine is us. The driver is utilization volume and intensity. I see this as a reflection of the continued blurred lines between what a patient (and a clinician) wants and what a patient needs.

*Table created with Google Gemini Pro using Health Affairs’ January 2026 article (see references)

*Made with Google Gemini Pro using National Health Expenditures data (see references)

Reminder that Our Nation is an Outlier in the Worst Way

We spend more and have the worst outcomes 🥴of all wealthy nations. Read my guest post, an educational blog I did for OT Potential, and learn more about this!

The ROI Crisis: Paying More for Less

The most troubling takeaway from the 2026 report is the lack of a "health dividend." Despite an 8% increase in spending, we aren’t seeing a corresponding 8% increase in longevity, wellness, or chronic disease management. People aren't getting significantly healthier; they are just getting more "care." And that “care” isn’t always good care, or the right care, or care by the right type of clinician, at the right time, in the right setting.

The ROI for every dollar spent is essentially plummeting. We are stuck in a cycle of high-intensity utilization. While we as clinicians (and often our employers) often complain about declining reimbursements, the quiet but systemic response by the healthcare community on the “providing care” side has been to "make it up on volume." But not all volume is created equal, and that is actually just making the problem worse. The more volume of services, the less the payer can pay for each unit if they want to stay inside the budget of dollars they receive from the plan sponsor.

The Volume Trap: Time-Based vs. Procedure-Based Care

In a Fee-For-Service (FFS) world, the incentive structure is skewed. Cognitive, time-based services like the difficult conversations about lifestyle and chronic disease management, having dialogues about options for care, the complex coordination of care, are hard to scale and are either not valued or valued at low reimbursement levels in terms of reimbursement. They are also services that are based on time spent on the service, so there’s a limited amount a clinician can “add more volume.” There are only so many hours in a day.

The fact is, it’s often “easier” to order an MRI, a specialized lab panel, or refer for or perform a minor procedure than it is to spend thirty minutes navigating the nuances of a patient’s chronic pain. This has led to a common normalization of "intensity" that doesn't always correlate with "necessity."

The “Wants vs. Needs” Framework

In 2016, I presented a simplified framework for value-based care to health system leadership. I argued that the most practical way for a physician to understand this value-based approach to care plans and patient management is to master the distinction between wants and needs.

This actually applies to both sides of the proverbial stethoscope 🩺 👇️ 

• The Patient Want: May be driven by fear, direct-to-consumer marketing, or a desire for a "quick fix" (e.g., "I need an MRI for my back today").

• The Clinician Want: May be driven by FFS incentives, the path of least resistance, or the fear of a negative patient satisfaction score or Google review.

• The Actual Need: What the evidence actually supports as medically necessary and likely to improve the outcome.

The Cost of Clinical Compliance

We sometimes unconsciously justify unnecessary care by saying we are "advocating for the patient." But when we order that MRI for acute low back pain without red flags, for example, we aren't helping. We are often triggering a cascade of "normal abnormals,” (I think I made that term up 😁 ) or incidental findings that lead to unnecessary interventions.

We see this same pattern in advanced illness. When we pursue aggressive treatments for life-limiting conditions without a transparent discussion with patients and their care partners about the likelihood of success of a given treatment or care plan, we aren't providing care; we are providing intensity of billable services. If we fail to share the various options and the potential results of those choices, we effectively make the decision for the patient by omission.

When we accept third-party reimbursement, we also commit to a set of rules regarding medical necessity. Yet, we frequently bypass these rules, justifying "non-medically necessary" care through creative charting or by simply not saying "no."

Looking Inward for the Solution

The 2026 data proves that we are paying for some care that is unnecessary, uninformed, and often avoidable. If we don’t look inside ourselves to understand the role we play in this continued utilization and spending growth, we can never contribute to the solution.

Real value-based care means:

1. Communicating and Connecting: Having the hard conversation about why a "want" isn't a "need."

2. Empathetic Honesty: Letting patients know when care isn't medically necessary and that it won't be covered by their insurance based on payer requirements for covered services.

3. Informed Agency: Giving patients with serious illnesses the full picture—the "grey areas"—and allowing them to decide what a "good" result looks like for them.

The $5 trillion we spend is partly a reflection of our collective clinical choices. It’s time we start choosing differently if we ever want to slow the growth of spending.

Find all sources and additional context here.

Career Moves

The Power of Project and Process Skills

In last week’s post, I talked about the "clinical stagnation" trap. We often think that to move into a non-clinical role, we need a new degree or a complete identity overhaul. But the truth is, the bridge to your next career isn't built with more credentials—it’s built with foundational non-clinical skills that you can start honing right where you are today.

This week, we’re looking at one of the most vital “languages” of the non-clinical world: Project and Process Skills.

The Translation Gap

Clinicians are used to saying we "manage a caseload" and "coordinate a discharge." But in the corporate and tech worlds, for example, those activities are viewed through the lens of processes (how the work flows) and projects (how a specific goal is achieved within a timeline).

If you want to move into a non-clinical trajectory, you must stop merely "doing the work" and start "observing the system."

Grow Your Pre-Move Superpowers

Most clinicians are masters of "workarounds." If a piece of equipment is missing or a referral form is confusing, we find a way to get it done anyway. In a non-clinical role, that "workaround" mindset can sometimes be a liability. Companies value process improvement by identifying the friction point and building a system so the workaround is no longer necessary.

That being said, it is sometimes different in a start-up where you have to find solutions to get things done without the bandwidth or tools to structure a formal process upon which you can improve. You have to be scrappy and resourceful. Clinicians have that covered! You may need that skill even more in a start-up.

By developing these skills while you are still in your clinical role, you are training your brain to see healthcare as a series of interconnected systems rather than a series of individual patient encounters.

How to Practice "In the Sandbox" (Before You Leave Your Clinical Role)

Don't wait until you have a new job title to act like a Project Manager. Use your current clinical environment as a low-stakes sandbox:

Map a Workflow: Pick one routine task in your clinic that feels "clunky" (e.g., patient intake, prior authorizations, or room turnover). Literally draw out every step. Where is the "waste"? Where does information get lost?

Standardize One Thing: Create a "Standard Operating Procedure" (SOP) for a task you do every day. If you were to leave tomorrow, could someone else follow your document and do the job perfectly?

Adopt a Digital Tool: Move your personal task list or a small committee project into a tool like Notion, Trello, or Asana (I’m particularly fond of Notion. It can serve as a life hub, too, not just something for a work project.). Getting comfortable with the "logic" of these platforms is essential, and you only need YouTube videos to learn enough to become a pro over time. Learn to be comfortable in project management and knowledge management tools. And have FUN with it! Here’s an intro tutorial if you want to check it out! 👇️ 

Lead a "Mini-Project": Volunteer to lead a small initiative—like updating the clinic’s patient education materials or organizing a staff training. Treat it like a formal project: set a goal, a timeline, and a way to measure success.

The Bottom Line

The goal of this preparation phase isn't to add a line to your LinkedIn—it’s to change your professional lens. When you eventually sit down for a non-clinical interview, you won't just say, "I'm a great clinician." You’ll say, "I identified a 20% inefficiency in our intake process and implemented a standardized workflow that reduced clinician burden and improved productivity."

Learn to speak the language of autonomy.

This Week, Try This

Check out PainScience.com The site owner and author, Paul Ingraham, is dedicated to the science of pain and examining what works and what doesn’t from studying and disseminating the scientific evidence. He covers topics in great depth. Some of his recent articles.

From his “About” Page:

Paul is also the Assistant Editor Emeritus at Science-Based Medicine.

Why This Resonates With Me

We should have a healthy sense of skepticism of what any clinician tells us is the right treatment path for pain and be willing to question them. Evidence-based practice of particularly musculoskeletal care is hard for the public to distinguish from pseudoscientific medicine.

But there’s a distinction I want to point out. A treatment may be evidence-based but not be the right treatment for a specific patient. That’s different from pseudoscience but may be just as useless when it comes to helping facilitate outcomes the patient believes they will receive from a care plan.

For example, a patient may have a torn rotator cuff that could be repaired, but it may not be an intervention that would lead to better outcomes for that patient vs. a strengthening program with a PT for a wide variety of reasons.

Or a patient may be given Vicodin after dental surgery, and that medication has real risks associated with it. An alternative option with fewer risks could have been provided if clinically appropriate and the patient may have preferred it if the options were discussed.

Pseudoscience of Pain Management and the Patient

Patients rarely know when treatment being offered to them is not evidence-based, and it isn’t uncommon for clinicians not to share with a patient when something they suggest as part of the treatment plan is not evidence-based or when there’s scant or poor evidence.

Even worse? Clinicians commonly:

• don’t know something isn’t evidence-based

• know but don’t know what else to do

• know what else to do but think it won’t be enough

• are comfortable providing pseudoscientific care for pain and choose comfort

Artificial Intelligence and Hope

As clinical decision support tools become standard features within EHRs, the bar for clinical excellence is being raised. I expect all clinicians committed to mainstream medicine to leverage these tools to move away from pseudoscientific practices.

For my fellow PTs and OTs, this evolution includes us. While our specialized platforms might trail behind major medical EHRs, and full interoperability may not be fully realized today, it is rapidly approaching.

CMS is aggressively advancing data-sharing standards, meaning total transparency is no longer a distant goal. Ask yourself: when other clinicians, patients, and payers eventually have seamless access to your records, what story will your documentation tell about the quality and evidence-based nature of your care?