“Every system is perfectly designed to get the results it
gets.” — W. Edwards Deming (quality systems pioneer)
Most people will see the Empire State Building stunt and
think: “security failure.”
That’s the wrong lesson.
The real lesson is more uncomfortable:
The system didn’t fail. It behaved exactly as
designed—just not for the outcome everyone assumed.
Two climbers reach over 1,400 feet, scale a globally
recognized landmark, and unfurl a banner in full public view.
Security existed. Protocols existed. Surveillance existed.
And yet—someone still made it to the top.
Not because there was no system.
But because the system was optimized for routine threats,
not edge-case behavior.
Now translate that into healthcare.
The Uncomfortable Parallel Physicians Don’t Want to Admit
Most independent clinics assume:
- “Our
billing is handled.”
- “Our
RCM vendor is managing it.”
- “Denials
are just part of the game.”
- “This
is just how healthcare works.”
But that mindset is exactly like standing at the base of the
building saying:
“Security is present, so nothing can go wrong.”
Meanwhile, the real leakage is happening somewhere between
floors 10 and 102.
Quiet. Distributed. Normalized.
The Real Stunt Wasn’t on the Roof
The stunt wasn’t climbing the Empire State Building.
The stunt was how easily complexity disguised itself as
safety.
Because what looked like “controlled systems” was actually:
- layered
responsibility
- fragmented
accountability
- delayed
detection
- and
assumptions that someone else is watching the critical point
That is also modern medical billing.
Just replace:
- rooftop
access → claim submission
- security
guards → coding teams
- building
surveillance → clearinghouse edits
- police
response → denial management
And the pattern becomes uncomfortably familiar.
Healthcare Billing Isn’t Broken
It’s stable.
And that’s the problem.
Because it is stable in the same way an old bridge is
stable:
- It
holds under normal conditions
- It
passes inspections
- It
appears “good enough”
- Until
load patterns change slightly
Then the weak joints reveal themselves.
In healthcare, those “load changes” are:
- payer
rule updates
- documentation
variability
- staff
turnover
- EHR
templating drift
- coding
interpretation gaps
And suddenly:
15–30% revenue leakage becomes “normal variance.”
The Hidden Truth About Middlemen
Every layer added to “improve billing” does two things at
once:
- It
reduces local workload
- It
increases system distance from truth
So clinics end up with:
- clinicians
documenting one reality
- coders
translating another
- billing
teams submitting a third
- payers
adjudicating a fourth
By the time money moves, no one is looking at the same
system anymore.
That’s not efficiency.
That’s distributed misunderstanding at scale.
Why Physicians Feel Like Things Are Getting Worse (Even
When Revenue Is “Stable”)
This is the paradox:
Revenue cycle reports often show stability.
But physicians feel instability.
Why?
Because stability is being maintained through:
- more
rework
- more
appeals
- more
staffing
- more
back-and-forth corrections
So the system doesn’t collapse.
It absorbs friction.
Silently.
Expensively.
Continuously.
What the Empire State Incident Actually Reveals
The climbers didn’t break physics.
They exploited blind spots between enforcement layers.
Not one failure.
A chain of acceptable tolerances.
That’s the same structure inside most clinic billing
systems:
- Each
step is “acceptable”
- Each
vendor is “doing their job”
- Each
denial is “normal”
- Each
correction is “handled downstream”
Until you zoom out and realize:
No one owns the full outcome.
The Real Question Physicians Should Be Asking
Not:
- “Why
are we getting denials?”
But:
“Why does our system require interpretation at every step
before we get paid?”
Because interpretation is where revenue dies.
Not in coding.
Not in billing.
In translation.
Between:
clinical intent → structured data → payer logic
Every translation step introduces variance.
And variance is where revenue leakage hides.
A More Dangerous Insight
Most clinics are not underperforming.
They are over-mediated.
Meaning:
They don’t have a performance problem.
They have a distance-to-truth problem.
What High-Performing Systems Actually Do Differently
Whether in aviation, finance, or logistics, high-performance
systems share one principle:
Reduce the number of human interpretations between action
and outcome.
Healthcare did the opposite for decades.
We added interpreters:
- coders
- auditors
- billing
vendors
- clearinghouses
- prior
auth intermediaries
Each one necessary in isolation.
But collectively:
they create latency where accuracy should live.
The Real Fix Is Not “Better Billing”
This is where most solutions go wrong.
They say:
- improve
coding accuracy
- improve
denial management
- improve
RCM workflows
But that is like adding more cameras after someone already
reached the rooftop.
You don’t need more observation.
You need fewer ambiguous transitions.
Expert Perspectives on System Failure in Healthcare
To understand why these “silent failures” persist in
healthcare billing, it helps to look at how leading voices in medicine and
health systems think about complexity.
1. Dr. Atul Gawande — Complexity vs. Reliability
A consistent theme in Dr. Atul Gawande’s work is that modern
healthcare does not fail because of lack of knowledge, but because of lack
of reliable systems.
His core idea is simple:
High performance in medicine comes from reducing unnecessary
variation, not increasing effort.
In the context of billing systems, this translates directly:
When every clinic, coder, and payer interprets the same
event differently, the system becomes unpredictable—even if each actor is
“doing their job.”
2. Dr. Donald Berwick — Systems Over Blame
Dr. Donald Berwick, former CMS administrator and founder of
the Institute for Healthcare Improvement, has long emphasized that healthcare
outcomes are determined more by system design than individual performance.
His central principle:
“Every system is perfectly designed to get the results it
gets.”
Applied to revenue cycle management:
If denials, delays, and leakage are common, it is not a
staffing issue.
It is a design outcome.
Not a failure of people—
a reflection of architecture.
3. Dr. Ezekiel Emanuel — Administrative Burden as
Structural Cost
Health policy expert Dr. Ezekiel Emanuel has repeatedly
highlighted that administrative complexity is one of the largest hidden cost
drivers in U.S. healthcare.
His perspective reinforces a key insight:
Administrative layers do not just manage care—they
reshape it.
In billing systems, each added intermediary:
- increases
transaction cost
- slows
feedback loops
- and
distances clinicians from financial truth
Over time, this creates a system where compliance
replaces clarity.
Synthesis: What These Perspectives Converge On
Across all three viewpoints, one pattern emerges:
Healthcare does not suffer from a lack of effort.
It suffers from excess interpretation layers between
intent and outcome.
That is exactly where modern revenue cycle systems break:
- not
at execution
- but
at translation
- not
at performance
- but
at handoffs
And this is why clinics can feel “stable on paper” while
financially leaking in practice.
The OnnX Perspective (What This Actually Means)
This is the problem OnnX was built around:
Not to “optimize billing.”
But to reduce the number of moments where:
clinical reality must be reinterpreted before it becomes
revenue
Because every reinterpretation step introduces:
- delay
- error
- dependency
- and
leakage
The goal is not faster billing.
The goal is fewer chances for billing to become
guesswork.
Myth That Needs to Die
“More RCM sophistication improves revenue.”
In reality:
More sophistication often means:
- more
layers
- more
dashboards
- more
exceptions
- more
specialists interpreting other specialists
Sophistication feels like control.
But often it is just structured confusion with better
reporting.
What Clinics Should Start Paying Attention To
Not just:
- collections
- A/R
days
- denial
rates
But:
- where
interpretation is introduced
- where
handoffs occur
- where
documentation becomes subjective
- where
decisions are delayed for validation
Because those are the real revenue inflection points.
Not the billing department.
The interfaces between departments.
Final Insight
The Empire State Building wasn’t “breached.”
It was navigated.
Step by step.
Layer by layer.
Within acceptable assumptions.
That is exactly how revenue leakage works in healthcare.
Not as a failure.
But as a sequence of acceptable decisions that no one
re-examines end-to-end.
Until someone finally asks:
“Why does this system need so many people to explain what
already happened?”
Closing Thought
If your billing system requires constant interpretation to
function, it is not a system.
It is a conversation between disconnected parts.
And conversations are expensive when they determine revenue.
Call to Action
Where do you see the most unnecessary interpretation in your
revenue cycle?
Comment your experience.
Because the real problem is not disagreement.
It’s distance.
Share this if you think healthcare doesn’t have a billing
problem—but a systems design problem.
And if you’re building or running a clinic, start asking a
harder question:
What would break if we removed one layer of interpretation?
About the Author
Dr. Daniel Cham is a physician and healthcare founder
focused on rebuilding revenue cycle systems from the ground up through clinical
data design and AI-native workflows. His work centers on reducing structural
friction in independent medical practice operations.
Connect with Dr. Cham on LinkedIn to
learn more.
Continue the Conversation
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Knowledge drives progress — start your journey today.
1. CMS
– National Health Expenditure Data
A foundational source showing how administrative complexity
and system design contribute to rising healthcare costs in the U.S., including
billing and overhead burdens.
2. American
Medical Association (AMA) – Administrative Burden in Healthcare
This report highlights how excessive administrative work,
including billing and prior authorization processes, contributes to physician
burnout and inefficiency in care delivery.
3. HFMA
(Healthcare Financial Management Association) – Revenue Cycle Insights
HFMA provides ongoing analysis of revenue cycle
inefficiencies, denial management, and structural leakage in provider
reimbursement systems.
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#ClinicalOperations #AIinHealthcare #HealthcareEfficiency #PracticeManagement
#HealthcareSystems #ValueBasedCare #PhysicianBurnout #HealthcareStrategy
#StartupHealthcare #OnnX
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