Mexico: When Getting Sick Means Paying
Recently, a friend asked why I had left Mexico. She told me that the private practice group I founded at ABC Medical Center was, in her view, now the most successful group in the hospital. Everyone was doing very well. What could the United States offer me that I did not already have in Mexico?
It was a sincere question. It also reflected a definition of medical success I know well: a full practice, a good income, and social standing. Seen that way, leaving was hard to explain.
I left to take a leadership role at NYU. I wanted not only to operate but also to train surgeons, conduct research, and build a service that could benefit more patients than I could ever treat myself. In the 2022–2023 U.S. News & World Report rankings, NYU Langone placed third among U.S. hospitals, while NYU Grossman School of Medicine ranked second for research.[1] Dean Robert Grossman captured his view of that combination with an intentionally impossible equation: “3 + 2 = 1.” He believed it made NYU the country’s leading academic health system.[2] For me, the appeal was the chance to work where clinical care, education, and research could strengthen one another.
That record has continued. In 2026, NYU remained on the U.S. News Honor Roll, with 12 specialties in the national top ten and a tie for the most first-place specialties.[3] Its Manhattan campus topped Vizient’s comprehensive academic medical center cohort for the fifth consecutive year.[4] NYU also reports that its medical school consistently ranks among the top three research-intensive schools in active NIH funding per investigator.[5] These measures assess different things. Together, they help explain the institutional capacity I valued.
Rankings have limits. What mattered to me was having a structure that supported the work I wanted to do. It was a privilege to be part of it. I am pleased that my former colleagues have succeeded. My decision reflected a different professional ambition.
I thought of that conversation as I read Guillermo Torre Amione’s LinkedIn post on the need to develop a new generation of medical leaders in Mexico. His question deserves an answer that considers how we fund care, which work we reward, and who benefits from the medicine we can provide.
Mexico has an opportunity. To seize it, we need to stop judging the success of our doctors and hospitals without asking what the population gains.
The Cost That Falls on Families
In 2023, roughly 41% of Mexico’s current health spending came directly from patients’ pockets, according to the Commonwealth Fund’s country profile and the WHO data series published by the World Bank.[6,7] The OECD continues to place Mexico among the countries where households pay more than a third of health spending directly.[8] That is a heavy burden for a country with a public healthcare system.
We should be clear about what this means. It does not mean that every family spends 41% of its income on health or pays that share of every bill. It means that, of every hundred pesos spent on health in Mexico, roughly forty-one are paid directly when people receive care or buy medical goods. Private insurance premiums are counted separately.[7,9]
Nor does a lower out-of-pocket share prove that American healthcare is affordable. To compare the actual burden, we must account for spending levels, premiums, deductibles, and household income. One percentage cannot settle the comparison.
But Mexico’s figure raises an urgent question: why must so many people pay out of pocket for healthcare that, in a functioning system, should be covered by public financing or insurance?
Some private spending reflects choice, while some reflects delays, distance, inconvenient hours, and a lack of trust. An analysis of the 2022 National Health and Nutrition Survey (Ensanut) found that 71% of the reasons people gave for not using the services to which they were entitled concerned access, and 21% concerned perceived quality.[10] Registering someone as a beneficiary is not enough if that person cannot get the care they need.
The problem is not limited to expensive elective surgery. The OECD reports that medicines accounted for more than 60% of Mexico’s out-of-pocket spending in its 2023 comparison.[8] Often, paying means buying medicine and getting back to work.
Recorded spending also has a limit: it does not, by itself, capture the care someone needed but could not afford. A person who skips a consultation may spend nothing and remain unprotected. We must therefore measure both what families pay and the needs that go unmet.
In 2024, INEGI, Mexico’s national statistics institute, identified 44.5 million people, or 34.2% of the population, as lacking access to health services under its deprivation measure. That was an improvement from 39.1% in 2022.[11] We should acknowledge it. We should also be clear that this indicator does not directly measure care quality or wait times.
These findings must be considered together: Mexico has a high burden of out-of-pocket payments, documented barriers to access, and large gaps in protection. When public care does not arrive and a family must buy it privately, the patient bears the cost of that failure.
Excellent Hospitals, Unequal Access
Those of us who have worked at ABC Medical Center or know TecSalud’s hospitals, such as Zambrano Hellion, know that Mexico can provide excellent medical care. The same is true of many public and private services. The mistake is to treat that capacity as evidence that the country already provides adequate access.
A family paying for a consultation at a pharmacy clinic does not thereby gain access to a hospital stay at ABC, TecSalud, or Ángeles. Being able to pay for one part of treatment does not mean being able to complete it. In my experience, that distinction often disappears when we talk about “private medicine.”
As I have argued elsewhere on this blog, declaring healthcare a right is not the same as financing it, and financing it is not the same as ensuring that a patient receives care.[12] Excellent hospitals alone do not solve that problem.
We must also distinguish among institutional models. ABC describes itself as a nonprofit institution. TecSalud brings hospitals, training, and research together within its academic model.[13,14] Ángeles belongs to Grupo Vazol, which describes it as Mexico’s largest private hospital network.[15] Whatever measure of size we use, the distinction matters: a commercial hospital network and an academic institution need not have the same priorities.
The business surrounding a hospital can include real estate, medical offices, retail space, and parking. The environmental filing for the Hospital Ángeles Polanco project describes hospital facilities alongside medical offices, a shopping center, and parking.[16] The commercial model extends beyond clinical care. The filing does not tell us how much profit each activity earns.
A hospital café is not the problem, nor is revenue itself. Profit does not prove poor medicine, just as nonprofit status does not guarantee good management. As I argue in my book project, Mission Requires Margin, a mission cannot survive without financial strength. The same principle informs my writing here: the questions are how money is earned, who decides how it is used, and whether it strengthens the mission.[17]
In healthcare, I would add three questions: How much does the institution contribute to professional training? What clinical results can it demonstrate? Who does it exclude?
The Success We Learn to Recognize
My friend’s question stayed with me because I have encountered versions of it elsewhere. In some parts of Mexican private medicine, income and visible prosperity serve as evidence of prestige. That is a personal observation, not a description of every physician in the country.
I have seen social media videos in which a doctor arrives in a Mercedes or BMW before promoting the treatments they offer. The car becomes part of the professional introduction. We can debate whether that advertising works. As a patient, I would rather know when those treatments are appropriate, what risks they pose, and what results they deliver.
Having money does not discredit a physician. Using it as evidence of competence, however, confuses the issue.
The harder question is what opportunities we offer to someone who wants to spend part of the week teaching, reviewing complications, or answering a clinical question. If that work reduces their income and does not count toward promotion, we are asking them to subsidize it with their time. It then seems odd to lament a shortage of researchers or the departure of talent.
I am not suggesting that Mexico lacks academic medicine. That would ignore its national institutes, universities, public hospitals, and the physicians who have devoted their lives to training others. IMSS itself maintains a research structure and a clinical journal published since 1962.[18] The question is how to expand and sustain those careers and how to make that work part of more institutions.
This is where Guillermo’s proposal has practical value. In 2026, TecSalud described a model that integrates care, teaching, and research within clinical institutes.[14] We should expect that investment to yield useful knowledge, rigorous training, and benefits that extend beyond its own hospitals. We should also enable other centers to adapt the model to their patients and resources.
IMSS Needs Continuity and Public Accountability
Any national transformation must include IMSS, the Mexican Social Security Institute. Its scale alone makes that unavoidable: at the end of 2024, 62.6 million people were registered with its family medicine units, equivalent to 47.3% of Mexico’s population.[19] Its doctors, nurses, researchers, and hospitals are indispensable to reform. That is precisely why its performance deserves scrutiny beyond support for or opposition to the government of the day.
Its political ties have a concrete basis: Mexico’s Social Security Law provides that the president appoints the director general. It also establishes a Technical Council with representatives of the government, workers, and employers.[20] That structure does not prove that every decision is partisan. It does require us to ask what protects clinical decisions, professional careers, and the continuity of programs from political or sectoral pressure.
I want an IMSS where a good project can survive a change in administration; where positions of responsibility require proven ability; where reporting a delay or complication helps correct it; and where patients can find out who is accountable when a referral goes nowhere.
We should also distinguish the contributory IMSS system from IMSS-Bienestar, the separate body that serves people without social security coverage. Sharing part of a name does not erase differences in the populations served, funding, and organization.[6]
The Universal Health Service proposal announced in 2026 aims to coordinate access across institutions through a phased rollout.[21] That is a sensible direction. Its success should be judged by the care people actually receive, rather than by the number of cards issued.
More Resources, with Clear Obligations
Mexico needs to invest more in health care. The OECD’s 2025 report places total health spending at 5.9% of GDP, compared with an average of 9.3% among its members.[22] Calls for efficiency must not become an excuse to leave services understaffed, without equipment, or without medicines.
A larger budget should also include commitments that can be verified. I would start with what patients can recognize: medicines in stock, timely appointments, completed referrals, full courses of treatment, and fewer unexpected payments. Publishing those results by institution and region would show where care is improving and where action is needed.
I would apply the same approach to quality. Counting consultations and operations describes activity. To assess their value, we need to know about complications, recovery, readmissions, and outcomes that matter to patients, with adjustments for case complexity. Centers that treat the most difficult cases should not be penalized for doing so.
Training and research need dedicated budgets, protected time, technical support, and promotion criteria. Adding “academic” to a hospital’s name is not enough. We must pay for the work that commitment requires and assess what it produces.
Public-private collaboration can be part of the answer if it meets specific needs, with transparent pricing, enforceable quality standards, and protection against additional charges to patients. Its purpose should be to provide the care that is missing. Contracts and results must be open to scrutiny.
Guillermo is right to call for institutions capable of training new leaders. I would add that we need a definition of success that recognizes those who teach well, produce useful evidence, improve public services, and expand access, alongside those who build a good private practice.
Mexico has left patients bearing too much of the financial burden without ensuring adequate access or quality. It has the talent to change that. It needs to fund that talent, organize its work, and demand results.
A country’s medical success must also be measured by the care available to those who cannot afford to pay.
References and Further Reading
1. NYU Langone Health. NYU Langone Health Ranks No. 1 in New York & No. 3 in the Nation. July 26, 2022. Rankings for 2022–2023; the medical school ranking is for research. View source
2. NYU Langone Health. 3+2=1. Impossible Math? It All Adds Up at NYU Langone Health. Fall 2022. View source
3. NYU Langone Health. NYU Langone Health Once Again Holds the Most No. 1–Ranked Specialties in the Nation in U.S. News & World Report Rankings. August 4, 2026. The first-place distinction is shared with other institutions. View source
4. NYU Langone Health. NYU Langone Health Is Named No. 1 Health System for 5th Consecutive Year by Vizient. September 24, 2026. View source
5. NYU Langone Health. About Us. Research section; institutional report of active NIH funding per investigator. Accessed October 23, 2026. View source
6. Commonwealth Fund. International Health Care System Profiles: Mexico. 2026; Cost Sharing and Out-of-Pocket Spending section, using 2023 data. View source
7. World Bank / WHO. Out-of-pocket expenditure (% of current health expenditure) — Mexico. Indicator SH.XPD.OOPC.CH.ZS; series through 2023, with an update dated December 2025. View source
8. OECD. Health at a Glance 2025. Financial hardship and out-of-pocket expenditure. Comparative data for 2023 or the nearest available year. View source
9. World Bank. Mexico: Health Financing Profile. Definition of out-of-pocket spending and exclusion of insurance premiums. View source
10. Utilización de servicios de salud en México: cascada de atención primaria en 2022 [Health service utilization in Mexico: the primary care cascade in 2022]. Salud Pública de México. 2023. PMID: 38060950. View source
11. INEGI. Pobreza multidimensional 2024 [Multidimensional Poverty 2024]. Press release 118/25, August 13, 2025, section VII, p. 6. View source
12. Castañeda P. Mexico’s Health Is a U.S. Strategic Interest: A healthier Mexico strengthens North America. Texican Health Consulting. 2026. View source
13. Centro Médico ABC. La labor social dentro del Centro Médico ABC [Social outreach at ABC Medical Center]. July 16, 2021. Institutional statement of nonprofit status. View source
14. Tecnológico de Monterrey. Instituciones del Grupo Educativo informan avances [Educational Group institutions report progress]. 2026 Board Meeting; section on TecSalud’s plans to transform healthcare in Mexico. View source
15. Grupo Vazol. Olegario Vázquez Aldir presenta la visión de Grupo Vazol: una nueva identidad para un legado que mira al futuro [Olegario Vázquez Aldir presents Grupo Vazol’s vision]. Corporate statement about the size of its hospital network. View source
16. SEDEMA, Mexico City. Environmental filing for the Hospital Ángeles Polanco project, published on the transparency portal. Description of hospital facilities, medical offices, shopping center, and parking. View source
17. Castañeda P. FIFA Is a Nonprofit. It Is Not Naïve: What the World Cup can teach healthcare about the money required to keep a mission alive. Texican Health Consulting. June 29, 2026. View source
18. IMSS. Revista Médica del Instituto Mexicano del Seguro Social. About the journal; volume 64, 2026. View source
19. IMSS. Programa Institucional del Instituto Mexicano del Seguro Social 2025–2030. Diario Oficial de la Federación, August 29, 2025. Registered population at the end of 2024. View source
20. Ley del Seguro Social [Social Security Law]. Text indicating its latest amendment as January 15, 2026. Articles 258, 263, and 267: General Assembly, Technical Council, and appointment of the director general. View source
21. El País. Así será el Servicio Universal de Salud que unirá al IMSS, ISSSTE e IMSS-Bienestar [The Universal Health Service that will link IMSS, ISSSTE, and IMSS-Bienestar]. April 7, 2026. View source
22. OECD. Health at a Glance 2025: Mexico. View source
Not Every Hospital Program Should Make Money: But every loss should be deliberate, funded, and measured.
In my last essay, I used FIFA and the World Cup to argue that mission requires margin. The harder question is what leaders should do with it.
Not every hospital program should make money. Some should. Some never will. Some should close.
That last sentence is the one healthcare leaders avoid. We are comfortable defending a program because its purpose is worthy. We are less comfortable asking whether the program still works, whether another model would better serve patients, or whether history is its only strategy.
I have spent much of my career building clinical programs, research, education, international care, and the systems that support them. I have also sat in the rooms where those programs are reduced to a line on a financial report. Once the slide appears, the language shifts. Green services become good services. Red services become problems. The color feels conclusive. I have never trusted that slide.
A margin report is essential but incomplete. It can show where money is earned and lost, but it cannot tell us whether the loss reflects poor design, a deliberate mission subsidy, or an investment whose value will appear later. Leaders must make that distinction. The spreadsheet cannot make it for them.
Here is the controversial lesson: a noble mission does not rescue a flawed operating model. Mission should make us more disciplined, not less. Sometimes the most responsible act is to fund a program that will never support itself. Sometimes it is to close one that everyone loves.
The Red Column
Healthcare organizations often divide service lines into two columns. The green programs generate margin, while the red programs consume it. Then the budget discussion begins as if the colors have already answered the strategic question. They have not.
A negative margin tells us that a program costs more than it directly earns, but not why. Billing may be weak. The schedule may waste expensive space. Leadership may be absent. Staff may spend hours repairing a process that should have been designed correctly from the start. Cases may be canceled because the patient entered through the wrong door, the authorization arrived late, or the equipment was never ready. That is an operating failure.
Another program may lose money because the payment system undervalues the care. Pediatrics is the clearest example. In the United States, Medicaid covers nearly four in ten children, while its fee-for-service physician rates average about two-thirds of Medicare rates. A pediatric service can remain busy, deliver excellent care, and still lose money.
But Medicaid is only the American version of a wider problem. In public, insurance-based, and mixed systems, children’s services often require specialist teams, family support, dedicated equipment, and constant readiness. Much of their value appears years later and outside the hospital budget. The same problem affects psychiatric emergency care, community diabetes programs, trauma readiness, and language access.
That is not failure. It is a deliberate subsidy for work the institution, or the health system, has decided must exist.
A third program may be in the red because it is building capacity the institution will need next: a registry, a fellowship, a new surgical service, a better clinical front door, an international partnership, or the shared data required to use artificial intelligence safely.
That is an investment, but only if leaders define what it should produce, who owns it, how long it should take, and when they will judge the results. Without those conditions, “investment” becomes a convenient label for an expense no one wants to challenge.
Failure, subsidy, and investment can all appear in red. They require different decisions. Failure needs repair or closure. Subsidy needs an explicit source of support. Investment needs a time frame, milestones, and someone with enough authority to protect it through the first difficult quarter.
Calling everything mission protects poor management. Calling everything a loss destroys useful work.
Strategy begins by telling them apart.
This Is a Global Problem, Even When the Payment Rules Differ
Funding models vary from country to country. My career has spanned Mexico, the United Kingdom, and the United States. Public budgets, national insurance, commercial insurance, philanthropy, employer funding, and direct payment create different pressures. The financial language changes. The allocation problem does not.
In the United States, for example, Medicare covers only part of the direct cost of graduate medical education. Its separate adjustment for teaching hospitals also recognizes duties such as treating more complex patients and maintaining standby capacity for trauma and burn care, according to the Association of American Medical Colleges.
Other countries fund teaching and readiness through different channels. None has found a way to make staff, training, equipment, data, and time appear without cost.
Every system therefore makes the same choice, whether it admits it or not: which work will be supported even when the revenue attached to the patient does not cover it?
A system can make that choice openly. It can also bury it in an annual budget and pretend that no choice was made.
The second approach is common. It is also why supposedly essential programs disappear when the margin tightens.
Two Systems, One Lesson
At NYU Langone Health, I learned that a program can succeed clinically and still carry limited financial weight within a large academic system.
Our pediatric orthopedic division grew. More patients came. Referring physicians trusted us. Clinical care, teaching, and research improved. Yet pediatric orthopedics remained small relative to cancer, transplant, cardiovascular care, adult reconstruction, imaging, neuroscience, and the many other demands on capital.
That was not a criticism of the program. It was a lesson in scale. Clinical importance does not automatically produce financial influence. Physician leaders must understand both.
At Shriners Children’s, I learned the opposite risk.
Shriners has sustained a clear charitable mission for more than a century. Philanthropy and endowment income protect care from some of the pressures created by fee-for-service medicine. But donated money is not free money. It carries an obligation. Someone gave it because they believed the institution would use it well.
That makes discipline more important, not less. A philanthropic model does not excuse weak data, outdated processes, idle capacity, or programs that persist without clear results. Waste does not become acceptable simply because the money came from a donor rather than an insurer.
The two systems taught me the same lesson from opposite directions. At NYU Langone, clinical importance could not replace a sound financial case. At Shriners Children’s, available resources could not replace discipline.
Mission needs a financial model. The financial model needs a reason.
The Next Mission Investment May Be Invisible
The next essential investment may not be another clinic, operating room, or building. It may be the shared data and technology that help every existing service work better.
That investment is difficult to defend because its first appearance in the budget is often unattractive. Clean data cost money. System integration costs money. Redesigning intake, scheduling, prior authorization, follow-up, supply management, and the revenue cycle takes time from people who already have full workloads.
The return does not arrive because someone purchased software. It arrives only when the work changes.
Health systems have repeated the same error for years. They buy a tool, run a pilot, count the pilot as progress, and leave the operating model untouched. The tool sits alongside the old process. Staff now manage both. The institution has added technology and created more work.
Artificial intelligence gives us the chance to stop doing this. It also allows us to repeat the same mistake faster and across the entire institution.
A March 2026 McKinsey report on health-system operating models surveyed 100 U.S. health-system leaders. Seventy percent ranked operating-model redesign among their five highest priorities, while 81 percent said their current model was neither effective nor efficient. The report also identified inconsistent use of technology and AI as part of the problem, not a cure sitting outside it.
That finding matches what I have seen. Most struggling systems do not lack effort or tools. They lack a clear account of how work gets done, who owns each decision, where patients get stuck, and which measures show whether the process works.
Adding AI before answering those questions does not modernize the system. It automates its confusion.
Technology Is Not a Strategy
A hospital can now buy ambient documentation, automated scheduling, denial management, patient messaging, supply forecasting, image analysis, and clinical decision support from multiple vendors.
Each may solve a real problem. Together, they can also create another set of disconnected systems, contracts, dashboards, and handoffs.
The wrong question is: Where can we use AI?
That question produces a list of tools.
The useful question is: Which part of the operating model must change, and what role should technology play in that change?
McKinsey makes this point directly in The Health System CEO Imperative. Health systems have focused on isolated tools. Greater value comes from choosing one or two important areas and redesigning the work from beginning to end.
A second report, The Real Future of Work in Healthcare, states the risk plainly: AI placed on top of a broken system can increase the inefficiency already present.
Consider the clinical front door. A weak front door sends patients to the wrong clinic, hides urgent cases among routine referrals, loses outside records, repeats imaging, and forces specialists to spend time sorting demand that should have been organized before the visit. Installing a chatbot does not fix that.
A serious AI-supported front door would begin with a redesigned pathway. What information is required? Which warning signs change urgency? Who owns the triage rule? Which cases require a specialist? Which can be handled elsewhere? What happens when the system is uncertain? How does the clinician view the recommendation, correct it, and improve the system? Who confirms that the patient reached the next step?
Only then does the technology have a role. It can organize records, identify missing information, flag risk, route demand, prepare the clinician, and track whether the patient completed the pathway. It should reduce delays before the visit and protect time for judgment during it.
The same logic applies to operating rooms, supply chains, the revenue cycle, and follow-up. The goal is not to speed up a single task. It is to remove the delays, duplication, and uncertainty that keep the entire pathway from working.
AI also needs limits. The National Academy of Medicine’s AI Code of Conduct calls for accountable, safe, reliable, and human-centered use. In practical terms, that means a named owner, visible performance metrics, a way to detect changes in performance, a clear path for human review, and the authority to stop the system when it behaves badly. A vendor’s assurance is not governance.
Cross-Subsidy Is a Choice
A service with a strong contribution margin generates more revenue than the direct cost of delivering care. That surplus helps pay for shared hospital functions, reserves, capital, and services that the institution considers essential, even though they cannot cover their own costs.
There is nothing shameful about that. If the institution believes both services are needed, reallocating resources from one to the other is not a strategic distortion; it is strategy.
The danger lies in keeping the subsidy invisible. When no one defines the subsidy, the supported program may stop tracking its costs. The service generating the surplus can be weakened without anyone acknowledging what else depends on it. A new leader can remove a red line and later discover that the line contained access, training, coordination, or clinical readiness that had never been measured.
Technology investment faces the same problem. A dozen small pilots may each seem affordable, while their combined licensing, integration, security, training, and support costs remain hidden. A shared data system may seem expensive even though it can replace several disconnected products and support the entire institution.
Poor accounting can make fragmentation look cheap and shared infrastructure look wasteful.
Leaders must name the trade-off. What are we supporting? Why? For how long? What is funding it? What result are we buying?
If the institution cannot answer these questions, it does not have a strategy. It has inherited a collection of old decisions and new subscriptions.
The Mission Investment Statement
Every program receiving institutional support should have a one-page Mission Investment Statement. So should every major technology program.
This should not become another committee document. It should force a decision stated in plain language.
1. What are we buying?
State the purpose precisely. “Supporting pediatrics” is too vague. Are we buying access for children with complex disease, trauma readiness, training capacity, care coordination, a research registry, or a referral pathway that keeps urgent patients from waiting behind routine cases? For technology, specify the work that will change. Do not describe the software. Describe the work.
2. Is this failure, subsidy, or investment?
A structural payment shortfall is different from poor scheduling. A five-year effort to build new capacity is different from a program that has missed its targets for a decade. The category determines the response.
3. What does it truly cost?
Include staff, space, integration, maintenance, security, training, support, and the time clinicians and operators must spend changing the process. Do not pretend that donated money is free or that software costs end with the license fee.
4. Where will the support come from?
Name the source: another service line, unrestricted philanthropy, a restricted gift, public funding, endowment income, an industry partnership with proper safeguards, or operating funds. “The hospital” is not a funding plan. It is a refusal to identify the trade-off.
5. What work must change?
This is the question most technology proposals avoid. Which steps will disappear? Which roles will change? Who owns the exceptions? What old tool or process will stop? If nothing stops, the institution has likely added cost rather than capacity.
6. What result should the investment produce?
Use measures that align with the purpose. Access may require waiting time, referral completion, and proper routing. A navigator may reduce cancellations and patients lost to follow-up. AI-enabled scheduling may improve use of appointment slots, reduce manual steps, and shorten the time between referral and care.
Financial results belong on the page, but so do quality, access, staff time, and whether patients complete their care.
7. What are the clinical and ethical limits?
State where human review is required, how errors will be detected, which data may be used, who can override the system, and what would trigger suspension. Clinical accountability cannot be outsourced through a software contract.
8. Who owns the decision, and when will it be reviewed?
Name one accountable leader. Set the time frame. State what evidence would justify expansion, redesign, partnership, or closure. Programs survive with vague ownership because no one has the authority to stop them. Good investments die for the same reason because no one has the authority to protect them.
Some Programs Should Close
There is a risk in this argument. Clinicians may use it to justify every program they value, and technology leaders may do the same for every platform they have already purchased, which misses the point.
Some programs should close. Some pilots should end. A service may have low demand, poor outcomes, excessive costs, weak leadership, or no clear place in the institution. Another hospital may provide the service more effectively. A partnership may make more sense than ownership.
The patient need may be real while the current program remains the wrong answer.
Likewise, an AI tool may work technically and still fail strategically. It may save minutes in one department while adding work elsewhere. It may produce a convincing demonstration but never connect to the medical record, the scheduling system, the people doing the work, or the measures leaders use.
The correct decision is not another pilot; it is to stop. Closing a weak program is not always a betrayal of mission. It can free staff, space, attention, and capital for work that delivers greater value. Ending a failed technology project is not resistance to innovation. It is evidence that someone is paying attention.
The test is simple: knowing what we know now, would we build and fund this program in this form today?
If the answer is yes, support it deliberately.
If the answer is no, history and sunk cost should not become strategy.
Physicians Have to Enter the Room
Physicians often arrive at budget meetings with clinical stories, while finance arrives with numbers. Both are incomplete. Only one usually controls the decision.
Physician leaders do not need to become accountants. They do need to understand contribution margin, payer mix, cost per case, budget variance, restricted and unrestricted funds, and the source of the subsidy supporting their work.
They also need to understand enough about data, workflow, and AI to challenge a technology proposal that lacks a clinical owner and an operating plan.
Financial ignorance does not protect patients from finance. Technical ignorance will not protect them from technology. Both simply remove physicians from the decisions that shape care.
Finance leaders have a matching duty. A CFO should distinguish between expenses, subsidies, and investments rather than treating every dollar without immediate revenue as waste. Technology leaders should show how the work will change, not just what the product can do. The board should protect long-term capacity even when the quarterly report cannot yet reflect its full value. The chief executive should make the trade-offs explicit. The physician leader should keep the investment tied to clinical reality.
That is governance. It is also the difference between praising a mission and funding one.
Margin Creates the Choice
A hospital must generate enough surplus to maintain staff, equipment, reserves, data, training, and the capacity to respond when conditions change. Without that room, every difficult quarter threatens the work that does not bill well but matters greatly.
The harder question is what the institution does with the margin once it has it.
It can chase profitable volume without asking whether the care is needed. It can preserve cash while research, teaching, access, and coordination weaken. It can buy technology without changing work.
Or it can use financial strength to fund services the payment system undervalues and build capacity the institution will need before the crisis arrives.
That choice should not be buried in an overhead allocation, a philanthropic fund, or a technology budget. It should be named, funded, measured, and governed.
Not every hospital program should make money.
But every loss should be a decision.
Margin creates the ability to choose. Mission is the discipline to choose well.
That is the central argument of my book, Mission Requires Margin: A Physician's Guide to Building Healthcare Organizations That Work. Margin is not the mission, nor is it proof of virtue. It is the financial room needed to protect useful work, stop failed work, and build what patients will need next.
Selected Sources
1. KFF. Medicaid and Children’s Health: 5 Issues to Watch Amid Recent Federal Changes.
2. Medicaid and CHIP Payment and Access Commission. Provider Payment and Delivery Systems.
3. Association of American Medical Colleges. Graduate Medical Education: Payments to Teaching Hospitals.
4. McKinsey & Company. What It Takes to Build a High-Performing Health System Operating Model. March 2026.
5. McKinsey & Company. The Health System CEO Imperative: Turning AI’s Promise into Performance. June 15, 2026.
6. McKinsey & Company. The Real Future of Work in Healthcare. July 2, 2026.
7. National Academy of Medicine. Health Care Artificial Intelligence Code of Conduct. 2025.
FIFA Is a Nonprofit. It Is Not Naïve: What the World Cup can teach healthcare about the money required to keep a mission alive.
I once made a room uncomfortable by saying that a nonprofit is not the same as a charity.
I did not mean that mission did not matter. I meant the opposite: a mission that refuses to understand money eventually hands control to people who do.
Nonprofit is a legal and tax status. It tells us, in broad terms, that no shareholders are taking the remaining surplus home as dividends. It does not mean there is no revenue. No payroll. No debt. No reserve. No capital plan. No bad quarter. No hard decision.
It does not mean innocence, which is why the World Cup is worth watching with a hospital leader’s eye.
FIFA is a nonprofit association. It is also one of the most formidable commercial machines in the world. This summer, it is running a tournament across three countries, featuring 48 teams and 104 matches. It sells broadcast rights, sponsorships, hospitality, licensing, data, tickets, merchandise, and the scarce privilege of being associated with the largest sporting event on earth.
Football begins with a ball and a patch of grass. The World Cup does not.
FIFA’s revised revenue target for the 2023–26 cycle is $13 billion. That number sounds almost absurd until you put it alongside institutions that healthcare professionals know.
Texas Children’s reported roughly $6.2 billion in annual operating revenue in fiscal year 2024. NYU Langone, where I spent much of my academic career, reported $15.4 billion in revenue for fiscal year 2025.
All three are nonprofits.
All three operate at a scale that demands adult financial management.
The comparison is not perfect. FIFA sells a global spectacle. Hospitals are paid to care for sick people, train clinicians, conduct research, support communities, and maintain the capacity to respond when things go wrong. But the arithmetic makes one point unavoidable: mission-led institutions do not survive on sentiment.
They survive because someone builds the financial structure beneath the sentiment.
FIFA has expanded the World Cup from 32 teams to 48, from 64 matches to 104, and from a tournament that once dominated one month every four years into a year-round commercial platform. That expansion irritates people for good reason. Players worry about the schedule. Fans resent ticket prices. Host cities bear the costs. Critics see an institution that keeps finding new ways to monetize the game. None of those criticisms is frivolous.
But football did not become global because people loved it. People have loved football for more than a century.
Football became global because someone paid for the dull, expensive work: pitches, lighting, coaches, referees, youth leagues, women’s competitions, travel, medical support, training centers, technical staff, and the administrators who keep a federation running after the television cameras leave.
Romance fills stadiums, but it does not maintain them.
FIFA understands this. The World Cup is its commercial engine, and that engine funds football beyond the countries with major domestic leagues, major television markets, and major sponsors. Through its Forward program, FIFA has made funds available for facilities, technical centers, domestic competitions, coaching education, referee development, women’s football, youth pathways, and the basic operations of member associations that could not sustain these activities on their own.
Some of those projects are large, but many are not.
A pitch in a small federation. A coach-education program. Travel for a women’s team that otherwise would not compete. A modest national training center that gives talented players a place to train instead of another reason to quit.
That is where the money matters. It is also where the story becomes uncomfortable. Money on this scale creates capacity, but it also creates temptation.
FIFA’s revenue and reinvestment do not make it clean. No serious account of the organization can avoid the corruption cases that exploded into public view in 2015 or the criminal prosecutions that followed. The allegations involved bribery, commercial rights, racketeering, fraud, and money laundering. FIFA has also faced sustained criticism over governance, ticket access, human rights, executive power, and the political incentives created when those receiving distributed funds also elect those controlling the institution.
These are not side issues; they are the point. Revenue does not prove virtue. A nonprofit label does not cleanse an organization. Money, power, prestige, and weak controls create a dangerous mix in football, medicine, universities, charities, governments, and professional societies alike.
The question is not whether an institution makes money. Of course it should. The real question is what happens next: how the money was earned, who controls it, who audits it, what is disclosed, who benefits, what happens when someone abuses the system, and whether the organization can show what its surplus actually built.
Those are governance questions. They matter more than the tax status. I learned the healthcare version of this lesson slowly, and not always comfortably.
Physicians are trained to view money as slightly contaminating. We are taught to care about patients, outcomes, ethics, equity, science, and service. We should. Those are the reasons most of us entered medicine. But many doctors absorb a second lesson without anyone saying it aloud: that financial fluency somehow compromises the mission.
I believe that is wrong. The controversial lesson is this: financial illiteracy is not moral cleanliness. It is abdication.
A physician who refuses to understand margin, payer mix, capital allocation, philanthropy, or the economics of a service line does not protect patients from finance. He simply gives more power to people who may understand the spreadsheet better and the patient less.
I saw this clearly in my time at NYU. Our pediatric orthopedic division grew. More patients came. Referring doctors trusted us. The clinical work improved. Education improved. Research improved. By every measure that mattered to the people in the room with us, the division was succeeding.
But in a large academic health system, success exists at different scales.
A child with a complex hip problem may be the most important patient in the world to that family. A pediatric orthopedic program may be clinically excellent. It may still be a small financial signal inside an enterprise driven by cancer, transplant, adult reconstruction, imaging, cardiovascular care, neuroscience, and a thousand other demands on capital.
That did not diminish our work; it clarified the map.
Clinical importance and financial weight are not always aligned. A physician leader who understands that can make a better case for the program: not just that it is good, but why it deserves investment; what it enables; what it protects; what it will cost if it is allowed to drift.
That is a more difficult argument than “this is the right thing to do.” It is also the argument that institutions act on.
At Texas Children’s, as in every large nonprofit hospital system, the mission is real. So is the financial burden required to sustain it. Operating rooms need equipment. Nurses need to be recruited and retained. Data systems need to function. Fellows need teaching time. Research needs coordinators. Families with difficult diagnoses need someone to help them navigate care rather than being handed a phone number and a follow-up date.
None of that happens because the mission statement is inspiring. It happens because someone paid for it. And when margin disappears, the first losses are often invisible.
It is the nurse navigator who catches a missed preoperative test before a family arrives at the hospital. It is the person who calls after surgery and learns that a wound looks wrong. It is the research coordinator who turns 300 cases into a usable database, then a paper, and eventually evidence that helps the next 3,000 patients. It is the fellow who carries a program’s technical standards into the next hospital, or the quality analyst who spots a complication pattern before it becomes a scandal.
These are not administrative luxuries. They are the scaffolding. A hospital can cut them, and the spreadsheet will often show a saving. The patient sees the bill later.
Bad profit is real. It should be called out without hesitation. It is unnecessary surgery driven by good reimbursement. It is a hospital chasing volume without measuring outcomes. It is a company burying bad data. It is a service line built around what pays best, while the community’s real needs go unanswered.
That is not mission.
But no margin is a different failure.
No margin means the program runs on goodwill until goodwill runs out. It means the next idea must be built in someone’s spare time, which is usually another way of saying it never gets built properly. It means that when a key person leaves, equipment breaks, reimbursement changes, or demand suddenly rises, the organization has nothing left to absorb the shock.
Bad profit exploits. No margin abandons.
One takes too much. The other stops building.
Neither should be defended.
This is the argument behind my forthcoming book, Mission Requires Margin. Margin is not the mission. It is not proof of virtue, nor is it permission to treat patients as customers with diagnoses. It is fuel.
A well-run nonprofit should generate revenue ethically, retain enough margin to remain resilient, and reinvest that margin in the work the market alone will not fund well: access, teaching, research, quality, care coordination, workforce stability, and the programs that matter deeply, even when they do not produce the strongest immediate return.
That is cross-subsidy. It is not an accounting trick. It is a statement of values.
A profitable surgical service can support a pediatric program. A donor’s unrestricted gift can fund the coordinator’s role, even though no one will name a building after it. A hospital reserve can protect a mission-critical service during a difficult year. A successful World Cup can fund a training center, a girls’ competition, or a national pathway in a country where commercial football cannot yet pay for itself.
The decisions must be deliberate.
That is the standard I would apply to FIFA, to Texas Children’s, to NYU Langone, to any children’s hospital, to any university, and to any nonprofit that claims to exist for more than its own survival.
The test is not whether the institution makes money. It is whether it earns that money honestly, governs it properly, and can explain who gains when the surplus appears, and what disappears when it does not. Then look at what the institution built.
The World Cup is on our screens because FIFA learned to sell football to the world. It has made serious mistakes. It deserves scrutiny and strong governance. It deserves critics who understand that a game belonging to everyone can still be captured by those closest to the revenue. But the answer is not to pretend that football could spread globally without an engine.
Nor can healthcare. Mission needs more than good intentions. It needs cash, controls, and the discipline to put both back to work. That is not a retreat from mission.
It is the price of keeping it alive.
Mexico’s Health Is a U.S. Strategic Interest: A healthier Mexico strengthens North America.
Pablo Castañeda, MD
There is a familiar way to talk about healthcare in Mexico, and it usually begins with failure. Hospitals are saturated. The public sector is underfunded. Patients wait too long. Families pay out of pocket. Private care is unequal. Reforms come and go, usually with a new acronym and the same old promise that this time access will finally be universal.
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All of that is true enough, but it is not the whole story. In fact, it may not even be the most useful one.
The more interesting question is not why Mexico’s healthcare system struggles; it is why Mexico, of all countries, has not yet turned its advantages into a better healthcare model. Mexico does have advantages. It has geography. It has scale. It has medical talent. It has private capital. It has large public institutions. It has a young and still-growing workforce. It has industrial momentum. It has proximity to the United States, the largest and most expensive healthcare economy in the world. And it has a population that already moves every day among public care, private care, cash-based medicine, employer-based solutions, family advice, pharmacy clinics, and cross-border opinion.
That is the contradiction. Mexico does not lack ingredients. It lacks organization.
I say this as someone who left Mexico, trained in the United Kingdom, and built much of my academic and surgical career in the United States, first in New York and later in Texas. I have seen the NHS from the inside. I have seen the extraordinary power of American academic medicine. I have seen elite private hospitals in Mexico that rival serious international centers. I have also seen public Mexican physicians do heroic work with too little support, too much demand, and too few ways to make the system around them behave rationally.
No health system gets to be smug. The United States has astonishing medical care, but it is expensive, fragmented, and often brutal to navigate. The NHS has a moral clarity I still admire, but access suffers when capacity lags behind demand. Mexico has its own pathology: it has the talent and the need, but it still asks families to solve too much on their own.
That is where the opportunity begins.
Mexico occupies a geopolitical position that most countries would envy. It shares a border with the United States, but that sentence understates the relationship. The two countries are not separate economic stories. They are linked through labor, manufacturing, agriculture, migration, remittances, supply chains, energy, family networks, education, travel, language, and culture. Nearshoring is often framed as a manufacturing story, but it is also a human story. Factories require workers. Workers have families. Families need care. Industrial corridors eventually need medical corridors. If Mexico is going to matter more to North American production, Mexican healthcare will also matter more to North American productivity.
This is where the healthcare argument becomes larger than healthcare itself. The United States has benefited for decades from having Mexico next door: a younger workforce, industrial complementarity, geographic depth, lower-cost production capacity, and a population tied to the U.S. economy in ways that are not always visible from Washington or New York. But a workforce is not an abstraction. It is made of bodies. It is made of pregnancies, injuries, chronic disease, trauma, diabetes, hypertension, mental health, musculoskeletal pain, disability, and aging parents. If the Mexican workforce becomes sicker, delayed, untreated, or financially crushed by avoidable healthcare spending, the North American production story weakens.
That is the part the United States needs to understand. Mexico’s health is not only Mexico’s issue. It is a U.S. strategic interest.
A healthy Mexico supports a more resilient North America. A sick Mexico does the opposite. If nearshoring is to be more than a slogan, the health of the Mexican worker, the Mexican family, and the Mexican healthcare system must matter to American companies, policymakers, insurers, and health systems. The U.S. cannot speak seriously about supply-chain security, border stability, manufacturing resilience, and North American competitiveness while treating Mexican healthcare as a domestic Mexican footnote.
Geography matters. Demography matters. Proximity matters. The United States needs Mexico more than many Americans admit, and Mexico needs the United States, but not as a model to copy. That distinction is important. Copying American healthcare would be a catastrophic lack of imagination. The American system is powerful, innovative, and scientifically dominant, but it is also bloated, administratively costly, and often hostile to patients. Mexico should study it carefully, borrow selectively, and avoid much of its cost logic.
Mexico’s opportunity is not to become a cheaper version of the United States but to become a smarter version of itself.
That requires starting with an uncomfortable observation. Mexico has spent decades debating coverage, but coverage is not care. Seguro Popular, INSABI, IMSS-Bienestar, and now the renewed promise of a more universal health service all belong to a long political effort to answer a moral question: who has the right to care? That question matters. A civilized society cannot ignore it. But the bedside question is different. Can a sick person actually reach the right place at the right time with the right information before delay turns a manageable problem into a dangerous one?
That is the real test. A card does not treat pneumonia. A registry does not operate on a fractured hip. A constitutional promise does not staff an operating room, interpret an MRI, supply medication, or move a child with cancer to the right team before the disease advances. Affiliation is not the same as access. Access is harder. Access requires staff, beds, imaging, medicines, records, transportation, referrals, accountability, and judgment.
This is where Mexico still struggles. Not in the poetry of reform, but in the mechanics of movement.
The country is large enough that poor design becomes destiny. Mexico is not a boutique healthcare market. It is a nation of more than 130 million people, where births, trauma, diabetes, cardiovascular disease, cancer, pregnancy, disability, aging, surgery, rehabilitation, and chronic illness occur at the national scale. A weak referral pathway is not a minor inconvenience when millions depend on it. A missing medication is not an isolated failure when families begin buying privately what the public pathway was supposed to provide. Repeated studies are not merely waste when capacity is already tight. A late diagnosis is not only a clinical tragedy; it is evidence that the system failed before the right doctor ever saw the patient.
Anyone who has worked in Mexican medicine knows the scene. A family waits. A patient pays. A mother tells the story again. Someone carries imaging on a phone. Someone asks a cousin where to go. Someone pays for one private consultation but cannot afford the treatment pathway. Someone enters a public clinic, then a pharmacy clinic, then a private lab, then a specialist’s office, and then tries to return to the public system with loose papers and hope.
That is not a healthcare pathway. It is a maze.
The private sector is often misunderstood in this discussion. People outside Mexico hear “private healthcare” and imagine a well-insured patient walking into a modern hospital with seamless access. That exists, and at its best, private medicine in Mexico can be excellent. It can be technically strong, fast, and personal, and, in some ways, more humane than many American institutions. But that is not what private care means for most Mexicans.
Private care in Mexico is not a single thing. It is a set of layers. At the top are sophisticated hospitals, leading specialists, premium facilities, and patients with the ability to pay. In the middle are regional private hospitals serving industrial cities, middle-class families, and local employers. Below that is a vast cash-based layer of pharmacy-adjacent consultations, small clinics, labs, imaging centers, emergency deposits, and partial solutions.
Families move between these layers constantly. Sometimes they do so by choice. Often, they do so because the public route did not move quickly, clearly, or reliably enough. That distinction matters. Private spending in Mexico is not always driven by consumer preference. Sometimes it is a distress signal, the sound a system makes when the official pathway fails.
The public systems, for their part, carry the moral weight of Mexican healthcare. They serve the majority. They absorb poverty, late-stage disease, trauma, pregnancy, disability, chronic illness, and social complexity. They train physicians. They preserve national memory. IMSS remains one of the country's great organizing structures. When IMSS works, Mexico works better. When IMSS saturates, everything downstream feels it: longer emergency room waits, longer specialty wait times, increased private cash spending, employer frustration, and patient distrust.
The problem is that a public mission does not automatically create operational discipline. A system can be morally essential and structurally strained at the same time. That is the Mexican reality. IMSS, ISSSTE, IMSS-Bienestar, state systems, national institutes, military and naval systems, Pemex, employers, insurers, private hospitals, pharmacies, labs, and family networks all form part of the real healthcare map. But for the patient, this is not one map. It is a federation of doors.
People adapt. Doctors call friends. Families carry out studies. Nurses quietly solve problems. Administrators bend rules. Patients pay privately when the public route stalls. Employers create parallel solutions. Insurers negotiate. Hospitals improvise. The system continues because people work around it.
But workarounds are not strategy. They are warning lights.
This is where I think the usual public-versus-private debate becomes too crude. Mexico needs the public sector. It also needs the private sector. It needs insurers, employers, universities, public hospitals, private hospitals, and cross-border partnerships. But none of them matter much if patients cannot move intelligently between them. The issue is not whether Mexico should be public or private. The issue is whether Mexico can build a usable system from the hybrid reality that already exists.
That is the controversial lesson I have learned after seeing Mexico, the United Kingdom, and the United States from within medicine: Mexico should stop pretending that all access is equal. Universalism matters, but pretending that every facility can do everything harms patients. It creates a quiet cruelty. It wastes time, obscures risk, and shifts the burden from institutions to families.
Some care should be close to home: vaccines, prenatal care, diabetes follow-up, hypertension management, medication refills, basic rehabilitation, simple imaging, low-acuity pediatrics, and first-line evaluation. Other care must be concentrated: pediatric oncology, complex congenital disease, high-risk pregnancy, major trauma, neonatal intensive care, severe infection, complex spine surgery, rare disease, advanced imaging interpretation, and major reconstructive surgery.
That is not elitism. It is safety.
The real equity question is not whether every town has every service. That sounds noble, but it is false. The real equity question is whether every patient can access the appropriate level of care before delay causes harm. That is a harder promise, but it is the only one worth making.
Mexico’s threats are structural. Demand will keep rising. Institutional churn will keep creating confusion if reforms change names without changing operations. Uneven capacity will keep sending patients to the wrong level of care. Household finances will remain exposed when public pathways fail. Private-sector fragmentation will produce more options without necessarily producing better navigation. Trust will erode when patients wait, pay, repeat their story, and still do not know where to go.
The threat level is high, not because Mexico lacks talent, but because the pressure is real and the design is behind.
And yet, that is exactly why the opportunity is so large. Mexico has the rare combination of scale, need, capability, and underdesigned flow. In an overbuilt system, improvement is expensive and marginal. In an underdesigned system, the right redesign can yield large gains quickly. Better referral logic. Better specialty concentration. Better employer pathways. Better use of private diagnostic capacity. Better public-private coordination. Better chronic disease programs. Better surgical pathways. Better rehabilitation networks. Better data on where patients get stuck. Better cross-border second opinions. Better navigation for families already living in a hybrid system.
This is not about importing American healthcare. It is about building a Mexican model that accepts Mexican reality.
The United States will matter in this model, but not as a master plan. It will matter as a market, a neighbor, a training partner, a technology source, a pressure point, and a source of demand. Cross-border medicine should not be reduced to medical tourism. That term is too narrow. The bigger opportunity is cross-border health infrastructure: second opinions, employer pathways, specialty networks, rehabilitation, surgical planning, chronic disease management, imaging review, quality systems, referral relationships, and international patient navigation. Done poorly, this can deepen inequality. When done well, it can generate revenue, training, standards, and institutional relationships that strengthen care within Mexico.
Private hospitals also have a choice. They can compete on buildings, lobbies, and prestige, or they can compete on whether care is easier to access, safer to navigate, and more predictable to complete. A beautiful hospital that most of the country cannot access is not a national solution. It is an asset. A valuable one, but still only an asset. The strategic question is how to make that asset matter beyond its walls.
Public systems face a parallel challenge. They do not need another speech about the mission. They need capacity maps, referral rules, records that move, waiting-time data that matter, and metrics that show whether patients reached the right care. A consultation count does not tell you whether care worked. A surgery count does not tell you whether the right patients were operated on. A waiting list does not tell you who is deteriorating. A coverage percentage does not tell you whether the patient reached care.
Mexico needs better questions. Where is the delay? Where is the duplication? Where is the avoidable cost? Where is the unnecessary referral? Where is the missed diagnosis? Where is the family paying for something the system was supposed to provide? Where is the clinician wasting time because the pathway failed before the visit even began?
These are not abstract questions. They are the anatomy of reform.
I care about this because I have seen both Mexicos. I have seen the Mexico where a child receives extraordinary care from excellent surgeons, careful anesthesia, thoughtful nursing, and a family able to absorb the cost. I have also seen the Mexico where a family arrives late because the referral was delayed, the money ran out, the diagnosis was not explained, or the first doctor did not know where to send them.
I have also seen enough of the United States and the United Kingdom to know that no country has solved this. The American system can save a life with astonishing sophistication, only to bury the same family in cost and bureaucracy. The NHS can defend care as a public good and still leave people waiting when capacity fails. Mexico can produce world-class physicians and still leave families coordinating their own care with cash, contacts, and persistence.
So the useful question is not which system is best. That question is too simple. The useful question is what Mexico can build from where it actually stands.
My answer is that Mexico can build a serious North American healthcare platform because it has the ingredients: population, talent, geography, private capacity, public need, employer demand, U.S. proximity, and enough pressure to make change unavoidable. But it cannot get there by confusing coverage with care, by confusing private medicine with elite medicine, by counting buildings instead of capability, by importing American waste, or by asking families to coordinate their own way through a maze.
Mexico’s healthcare problem is bigger than healthcare. It is a national productivity problem, a household finance problem, an employer problem, a public-sector credibility problem, a private-sector strategy problem, and a U.S.-Mexico integration problem.
That is why the opportunity is also bigger than healthcare.
Mexico is protected by geography, but geography does not organize care. Mexico has talent, but talent does not automatically create access. Mexico has private hospitals, but hospitals do not automatically create pathways. Mexico has a public obligation, but obligation does not automatically create operational reality. And the United States, if it is honest about its own future, should want Mexico to solve this. A healthier Mexico is not a charitable wish. It is part of North American resilience.
The next stage is not another slogan. It is execution. Mexico needs to turn scale into systems, talent into access, private capacity into usable pathways, public obligation into operational discipline, and proximity to the United States into a strategic advantage.
Mexico does not need to become the United States. It needs to become the best version of itself: a large, capable, hybrid, North American healthcare platform that understands how its patients live, pay, wait, choose, travel, and seek help.
Coverage is the promise.
Flow is the proof.
Field Notes on Healthcare Strategy
Field Notes on Healthcare Strategy: Stop Asking People to Work Harder
Pablo Castañeda, MD
Most struggling healthcare systems are not short on effort. They are drowning in it. People arrive early, stay late, answer messages they should not have to, fix scheduling problems with favors, and cover gaps with goodwill. They keep the clinic moving because patients are in front of them and saying no feels impossible. Then leadership looks at the mess and says the system needs more productivity. That is usually the wrong diagnosis.
The problem is often not that people are lazy. It is that the system has been built in a way that forces good people to compensate for bad structure. That is expensive and corrosive. Over time, it erodes trust. I have seen this pattern in different forms: busy clinics, full operating schedules, long waitlists, talented physicians, good staff, and a mission people still believe in. On the surface, the institution looks active. Underneath, no one can answer the basic questions. How much capacity do we really have? Who owns the patient? What counts as productive work? Which cases are complex? Which patients are waiting too long? Where are outcomes tracked? What work is invisible? Who is actually building the program?
That is usually where the real work begins.
The first mistake is confusing activity with capacity. A hospital counts rooms and assumes it understands what it can do. It does not. Rooms are not capacity. Rooms are walls. An operating room is useful only if it has staff, equipment, anesthesia coverage, recovery space, implants, nursing support, medical backup, and a data system to support the work safely. The same is true for clinics. A clinic room without the right physician, nurse, imaging access, casting support, scheduling logic, and a follow-up plan is not capacity. It is space with furniture.
This should be obvious, but it is missed all the time. Hospitals like physical denominators because they are easy to count. Four rooms. Ten rooms. Thirty rooms. Eight clinic templates. Five operating days. These numbers look clean on a slide, but real capacity is messier. It depends on staffed minutes, case mix, patient complexity, turnover, cancellations, recovery, late starts, support services, follow-up, quality signals, and human fatigue. The denominator that matters is safe, staffed, supported, measurable throughput. Not theoretical throughput. Real throughput.
If leaders do not define that denominator, the next move is usually bad. They set a target, push volume, extend hours, add pressure, and ask physicians to “do more.” But more what? More simple cases? More complex cases? More clinic visits? More decisions? More complications? More undocumented work? More late-day risk? Before asking for more volume, the system has to define true capacity.
Case count creates a similar problem. It feels objective, but it is often crude. A 20-minute case and a six-hour case are both “one case.” A simple follow-up and a complex new patient visit are both “one visit.” A quick procedure and a high-risk reconstruction can sit next to each other in a spreadsheet as if they mean the same thing. They do not. This is how bad metrics punish the wrong people. The clinician who takes the hardest cases may look less productive. The surgeon who manages complications, counsels families, teaches trainees, and thinks carefully may look slow. The person doing easy volume may look efficient. The spreadsheet smiles. The system gets dumber.
If a system wants fair productivity, it needs to measure work in ways that respect clinical reality. What was done? How long did it take? How complex was it? What risk did it carry? What resources did it use? Was teaching involved? Was coordination involved? What outcome followed? Did the patient complete the pathway? That is a different conversation. It is also a better one. Volume matters. Access matters. Throughput matters. Patients should not wait forever because doctors dislike measurement. But volume without context is not performance. It is just counting.
Another touchy issue is presence. Healthcare organizations often drift toward presence-based control when trust starts to fall. More sign-ins, more attendance rules, more monitoring, more reports, more proof that people were physically there. I understand why it happens. Leaders need accountability. Some physicians abuse flexibility. Some systems are too loose. Some people hide behind autonomy, while others carry the work. But a blunt tool can make the culture worse.
A physician’s value is not measured only by time in the building. It is measured by judgment, clinical output, quality, access, teaching, leadership, problem-solving, and ownership of patient outcomes. Presence is easy to track. Contribution is harder. That does not mean we should avoid measuring contribution. It means we should do the harder work. A real contribution model should include clinical work, procedural work, complexity, quality, teaching, research, leadership, supervision, program building, care coordination, and institutional citizenship. Some of that can be counted. Some of it needs judgment. That is fine. Healthcare is full of judgment. The lazy answer is to monitor time and call it accountability. The better answer is to define the work that actually matters.
Quality has to come before productivity. This should not be controversial, but it often is. When a system is under pressure, quality becomes the paragraph after productivity. It should be the first line. If volume rises and complications rise with it, the system did not improve. If access improves but follow-up collapses, the system did not improve. If more patients move through the clinic but no one owns the plan, the system did not improve. If surgery expands into hours where the support system is weaker, the system may be creating risk and calling it efficiency.
Volume is only valuable within a quality boundary, and that boundary must be measured. Complications, readmissions, reoperations, cancellations, delays, adverse events, return visits, follow-up completion, patient experience, and service-specific outcomes all matter. Not everything needs to be perfect on day one, but the system needs to start. A quality dashboard is not a punishment tool. At least it should not be. It is a mirror. In many hospitals, the mirror is missing. People tell stories instead. “Our outcomes are good.” “We are efficient.” “Patients are happy.” “The team is strong.” Maybe. Show me. Not because I distrust the people, but because good people still need feedback. Surgeons need to know their outcomes. Clinicians need to see patterns. Leaders need to know when the system is drifting. You cannot improve what you do not see.
Continuity is another place where systems quietly fail. A patient is seen by one person, scheduled by another, treated by another, and followed by whoever is available. Then a complication appears, and the system cannot clearly trace the loop. Who owns this? No one and everyone. That is bad design. Team-based care is necessary. Trainees matter. Advanced practice providers matter. Cross-coverage matters. No one person can do everything. But responsibility cannot become so diluted that learning disappears.
The clinician who makes the decision should remain connected to the result. The person who performs the procedure should know the follow-up. The team should know when the plan failed. The system should know where the handoff broke. Continuity is how professionals learn. Without it, complications become isolated events. Follow-up becomes clerical. The system loses memory. Good care needs teams. Great care needs ownership.
Healthcare also spends too much energy on what happens after the visit starts and not enough on what happens before. The front door determines everything downstream. How does the patient enter the system? Who decides where they go? What information is gathered first? Is imaging needed? Is the problem urgent? Is the patient in the right clinic? Could the issue be handled differently? Is this a specialist problem at all? A weak front door creates waste. Patients go to the wrong place. Specialists see problems that should have been triaged earlier. Urgent cases hide inside routine volume. Families wait. Staff improvise. Clinicians spend time sorting chaos instead of using judgment.
This is one of the places where healthcare still behaves as if demand should simply arrive and be absorbed. It should not. Demand has to be shaped. Structured intake matters. Pre-visit review matters. Triage matters. Clear referral rules matter. Remote review matters. Eventually, AI will matter here too. Not as a magic doctor, but as a sorting layer. A good AI-supported front door could collect history, identify red flags, organize documents, suggest routing, reduce out-of-scope visits, and prepare the clinician to use time well. That is not science fiction. It is workflow hygiene. The front door is not administrative. It is clinical.
Most healthcare systems have data, but that does not mean they know anything. They have records, dashboards, scheduling exports, billing fields, quality reports, spreadsheets, committee minutes, and monthly summaries. Then someone asks one practical question, and everyone pauses. How many staffed OR minutes did we actually use? Which service has the longest wait? Which cases are delayed by missing implants? Which patients are being seen by the wrong pathway? Which physician is doing the most complex work? Which outcomes are worsening? Which clinic rooms are actually available? Which support service is limiting throughput? Which work is unpaid, unseen, or uncredited?
Often, no one knows. Or five people know five different versions. That is not a data problem. That is a definition problem. Data only helps when it is defined, trusted, timely, clinically meaningful, and visible to the people doing the work. A dashboard that clinicians distrust is wallpaper. A metric that ignores complexity is noise. A report that arrives three months late is history, not management. Healthcare needs less decorative data and more usable truth.
Incentives always win. People talk about culture as if it floats above the organization. It does not. Culture is shaped by what the system rewards, ignores, punishes, and tolerates. Reward presence, and people optimize for presence. Reward raw volume, and people chase raw volume. Ignore complexity, and complex work becomes a tax. Ignore teaching, and teaching becomes charity. Ignore leadership, and leadership becomes unpaid emotional labor. Ignore quality, and quality becomes a slogan. Underpay commitment, and people commit elsewhere.
This is not a moral flaw. It is predictable. If a healthcare system wants full commitment, it has to build a model that recognizes full contribution. That does not always mean paying more for everything. It does mean being honest about what the institution expects and what it rewards. Mission cannot carry the whole load. At some point, structure has to match the mission.
The hardest part is sequence. Healthcare systems rarely have one problem. They have stacked problems: access, morale, productivity, quality, compensation, data, governance, recruitment, scheduling, communication, follow-up, and technology. All real. All connected. But not all first. This is where many transformation efforts fail. They try to move everything at once. Or they pick the most visible issue rather than the first structural one. Or they install a tool before defining the workflow. Or they change compensation before defining contribution. Or they demand quality without building measurement.
Sequence matters. First, define the current state. Then define the true denominator. Then build trusted metrics. Then clarify ownership. Then redesign the operating model. Then align incentives. Then pilot. Then scale. Boring? Maybe. But it works better than announcing transformation and hoping the slide deck becomes reality.
Here is the lesson that may irritate people. Healthcare systems often protect themselves from the truth by praising the mission. The mission may be real. The people may be good. The patients may be grateful. The history may matter. None of that proves the operating model works. A noble mission can still sit on top of a weak structure. Good people can still work inside a bad system. A busy hospital can still be poorly designed. A beloved program can still be underdeveloped. A high-volume service can still lack real accountability.
Saying this is not an attack. It is the beginning of repair. You cannot fix what you are too polite to name.
Good healthcare strategy is not abstract. It answers practical questions. What are we trying to build? What is the true capacity? Which work matters? Who owns the patient? What should we measure? Where is the bottleneck? What should stop? What should start? Who decides? Who is accountable? What changes in 30 days? What changes in 90 days? What will we measure to know if it worked?
That is the difference between a review and a transformation plan. A review describes. A transformation plan assigns work: owners, timelines, metrics, decisions. Without that, the report is just a document.
Healthcare does not need more speeches about working harder. Most people are tired already. It needs a better structure. Better front doors. Better denominators. Better measures. Better incentives. Better dashboards. Better handoffs. Better ownership. Better alignment between what leaders say matters and what the system actually rewards.
This is the work. Not glamorous. Not easy. Often uncomfortable. But necessary.
A good healthcare system does not ask committed people to keep compensating for poor design. It builds a model worthy of their effort.