The Missing Screw: why healthcare gets rebuilt every 5 years while patients age over 50.

As a dietitian working across oncology, lifestyle medicine, and executive health, something plays out daily that is impossible to unsee. Healthcare is being designed by people who will never feel the consequences of their designs.

Complex diseases like cancer, metabolic syndrome, and cardiovascular disease unfold over decades. They demand longitudinal, interdisciplinary care. Yet the decisions shaping that care are increasingly made by executives whose incentives reward the opposite: short-term ROI, cost-center consolidation, the quiet elimination of services that don't generate immediate revenue.

Nutrition intervention is often that service.

The Two Clocks

Imagine a machine built to run for fifty years. Somewhere inside is a small screw. Cheap. Unremarkable. Its function is distributed. It doesn't do one specific thing. It holds tension across the whole assembly. Remove it, and nothing breaks immediately. The machine keeps running for months. Maybe years.

Then everything begins to wear asymmetrically. Bearings that were never designed to carry that load start failing. Components that used to last a decade last two. By the time anyone connects the failures back to the missing screw, it is no longer manufactured. The knowledge of what it did is gone.

The chart below shows the same asymmetry in healthcare. The top rows are the clock the decision-maker runs on. The bottom rows are the clock the patient runs on. They never intersect.

The average hospital CEO leaves the organization after approximately 5 years. The average hospital CFO leaves after about 3. The annual bonus cycle is one year. Meanwhile, Type 2 diabetes progresses from pre-diabetes to diagnosis over 3-5 years, from diagnosis to a first major cardiovascular event over ~10 years, and obesity-driven cardiometabolic multi-morbidity unfolds across 15-20 years. The decision clock ends before the clinical clock becomes relevant. This isn't a failure of intelligence. It is a structural mismatch between the timeline on which damage is compensated and the timeline on which damage appears.

The Load-Bearing Wage Gap

"Load-bearing" isn't a metaphor. The dietitian, the social worker, the chaplain — these are the roles that quietly reconcile a treatment plan with a patient's actual life at home. Take one out and the others absorb the gap until they burn out and leave. Then the gap absorbs the patient instead.

Here is what the people doing that reconciliation work earn, on a log-scale axis so every bar is visible next to proxy-statement compensation for the executives whose signatures approve the cuts.

Every figure above is from a public document. BLS Occupational Employment Statistics for the clinical roles. Lown Institute 2023 hospital-exec review for the nonprofit CEO median. HCA Healthcare and UnitedHealth Group 2024 DEF 14A proxy statements for the named-CEO figures. The point is not that any specific executive is personally responsible for any specific cut. The point is that the gap between the people holding the system together and the people making the optimization decisions is three orders of magnitude. That gap is not neutral. It is a statement of institutional priority.

The Hollowing

One rebuttal to this critique is that administrative growth reflects real regulatory, IT, and compliance demand. That's partially true. HIPAA, EHR implementation, quality reporting, and payer documentation all require people. But the growth far outpaces what regulation alone can explain.

From 1975 to 2024, the US population grew about 60%. Staffed hospital beds actually declined. Practicing physicians grew about 2.5×. Registered Dietitians grew about 4× — from approximately 28,000 to 114,209 credentialed RDNs as of March 2026. And administrators — the people who work at a hospital but never touch a patient — grew by roughly 15×.

But the RDN headline number hides the real trajectory. Growth has flatlined at about 1% per year since 2020. The dietetic internship match rate fell from 70% in 2019 to 38% in 2023 before being discontinued. The first-time RDN exam pass rate dropped from 87% in 2016 to 62% in the first half of 2024 — a collapse unique to dietetics among health professions. The January 2024 graduate-degree mandate added cost, debt, and time to an already squeezed pipeline. And per the 2024 Academy Compensation and Benefits Survey, approximately 30-35% of the current RDN workforce is age 55 or older — a retirement cliff arriving in the next 5-10 years.

The conservative interpretation of the Woolhandler & Himmelstein analyses puts administrator growth at 15×. The higher-end figure cited in some advocacy literature approaches 30×. Either number describes the same pattern: the clinical workforce didn't just shrink relative to admin. It's about to contract absolutely, while the administrative layer continues to grow. When clinical nutrition gets cut in a budget meeting, it is almost never a dietitian voting yes. Soon there will be fewer of them to send into the meeting at all.

The Missing ROI

Here is the part that makes the whole story almost comic, if you don't have patients. The services being optimized away generate a positive return on investment. The math is documented. In the case of Medical Nutrition Therapy, we have multiple peer-reviewed estimates.

The independent lower bound — $2.25 returned per $1 invested — comes from Sriram et al. 2017 in JPEN, a nutrition-focused quality improvement program without industry funding. The upper bound — $4.00 returned per $1 invested — comes from Philipson et al. 2013 in the American Journal of Managed Care, funded by Abbott (which sells enteral nutrition products). We lead with the independent number and disclose the funding on the other. Even at the low end, this is an intervention the system should be expanding. It is being cut. US annual cost burden of disease-associated malnutrition was estimated at $156.7 billion in 2014 (Snider JPEN), or roughly $207B in 2023 dollars. Approximately one in three patients are malnourished at hospital admission. Most are never told.

Tenure vs. Disease Arc

One last way of looking at it, because the mismatch is the entire argument and the argument keeps being made in different dialects.

The average hospital CEO stays in the job about 5 years. The average time from a Type 2 diabetes diagnosis to a first major cardiovascular event is about 10 years. The latency from sustained dietary risk exposure to colorectal cancer diagnosis is 15 to 20 years. An executive can complete an entire tenure at an institution before the patient population whose outcomes they 'optimized' enters the phase where the optimization becomes visible. By then, the executive is running a different system, or sitting on a board, promoted on margins that reflect the cut more than they reflect the patient.

What it would take to fix this

You don't reconstitute a decade of clinical nutrition practice by reopening a job req. That knowledge lived in people and relationships that were never documented because they were never fully seen. You cannot run a fifty-year machine on a two-year incentive cycle and expect it to hold.

We need leadership that reads a balance sheet and a ten-year outcomes curve. We need compensation structures that extend past executive tenure, so the person who removes the screw is the same one who answers for the machine when it fails. We need finance teams that understand that clinical value is not always clinical revenue — and that the services hardest to put on a line item are often the ones holding the line.

The screw matters. Put it back.