Will Business Management Save US Health Care?

Summing Up: Problems confronting the US health care system are much larger and broader than those that can be solved by management in the absence of other remedies, readers tell Jim Heskett.
by Jim Heskett

Summing Up

What Role Will Management Play in Saving US Health Care?

The verdict is in, according to respondents of this month's column: Problems confronting health care in the US are much larger and broader than those that can be solved by management in the absence of other remedies.

As David Wittenberg put it, "… management will never fix the health care system… (it) can promote standardization and mass production … (but) the actions of individual managers will have no effect on the overall system," one that as Barry Shere pointed out, "attempts to override the laws of supply and demand." John Van Slyke commented that "business people have the leadership skills and command over the kind of technology that is needed, (but) … the record of business, particularly the financiers, has been to distort health care organizations." Phil Clark said, "Unfortunately, health care is about life, quality of life, and death. Start trying to manage, control and put a dollar figure on that and you will instantly run into … walls at all levels of society."

On the other hand, David Giammittorio described how the introduction of good management practices in his for-profit health care organization led to better patient outcomes at the same time that "provider engagement and feeling of satisfaction have increased, our costs have fallen and our net profit has increased."

One of the basic problems confronting management is a lack of alignment of needs and goals. For example, as Joanna pointed out, "… we have a 'disease management' system, (not) a 'health care' system… Insurers profit from healthy individuals, but they do not actually contribute to our health." Another problem is a lack of definition of just what the system should accomplish. In this regard, Donald Shaw commented that "We are nowhere close to concerning ourselves with controlling healthcare when we have not defined adequately what it should accomplish and can accomplish for those who are asked to pay for it."

In proposing remedies, Walter Blass emphasized the need to achieve "a cooperative effort on the part of physicians, hospitals, and yes, even patients." Milton Recht provided a list of responses: "Increase competition, allow medical business failures, remove guaranteed sources of revenue, relax government regulatory and licensing of doctors and hospitals to remove the cartel and guild aspects of medicine and put more of the purse strings directly into the consumers' hands …" Addressing incentives, Tom Dolembo suggested that "We should pay doctors well who cure patients, award hospitals who are empty, and stop evaluating our system as if sickness is a necessity."

There was little enthusiasm for requiring joint degrees in medicine and management. Kapil Kumar Sopory said that "… some important aspects of good business management … need to be practiced. These can be emphasized during the medical professional training." Doug Garr proposed that "Medical schools should require a month of 'learning' where students become patients and actually get checked into hospitals." As Cheri Thomas put it, "… I do not see the cost-benefit of having … managers also be MDs… Docs are going to have to get over themselves and learn to respect non-docs who are competent managers."

If management cannot lead the charge in saving the US health care system, from where will the leadership come? What role will management play? What do you think?

Original Article

Judging from the recent writing of physicians like Atul Gawande, US health care may be in the process of discovering management. Of course, hospital administration has been with us as long as hospitals. But the administrator has always been a second class citizen in the workplace, a facilitator of both the best and worst practices of those actually providing health care. There are signs that this is changing.

Gawande, in a recent article in The New Yorker, describes what health care can learn from The Cheescake Factory, a chain of 160 full-serve restaurants. Almost in a tone of amazement, he marvels at the way standards are enforced, new techniques and menu items introduced, and practitioners learn from each other across the chain.

Gawande conveys the impression that the biggest single obstacle to the adoption of these practices may be the practitioners themselves∼those unwilling to listen, adopt new techniques, and communicate with others, and unwilling to think of themselves as members of teams rather than the stars and specialists they were taught to be. Twenty years ago, when I was invited to address a group of doctors, I was nearly laughed out of the room when I suggested that the best service providers in a variety of industries hire for attitude and train for skills. Regardless of whether it worked elsewhere, they were sure that it didn't apply to health care, where people want the best in skills whether as providers, recipients, or hospital administrators who have to pay for mistakes. (I wish I had known then of research by Harvard colleagues claiming that the majority of malpractice lawsuits result primarily from poor attitude and failed personal relationships rather than medical mistakes.)

Perhaps hiring for attitude and then training for skills is too simplistic. But there is reason to believe that the era of a medical star system is about over. Outstanding medical institutions like Mayo Clinic and Cleveland Clinic have long avoided it. They opt instead for hiring practitioners as employees who are paid incentives for providing better care at lower cost. Practitioners work in teams that believe that the patient, not the practitioner, comes first. In these organizations, management is not a dirty word. In fact, managers and doctors are recognized for exhibiting mutual respect and aiding the transfer and adoption of good ideas across a network. They may foster some stars, but that is not the primary objective.

Forces are at work that make it possible to see a day when better care is delivered at a fraction of current costs in the US, regardless of regulatory approach. Insurance companies now are instituting incentives for quality care at lower cost that will require better management of hospitals. Hospitals are responding by consolidating and signing up doctors as employees rather than entrepreneurs with their own businesses. Companies, on behalf of their employees, are contracting with hospitals to deliver care along with wellness programs designed to avoid hospital treatment, especially for emergencies. A byproduct will also be the transfer of best practice among larger groups of practitioners working in teams. These forces may elevate the role of management.

This sounds good. Do you agree with it? Whether or not you agree, a number of other questions are raised. From where will the necessary management skills come? Medical schools? Business schools? Will joint degrees in medicine and business be necessary? If so, just how many students will be willing to engage in a long and arduous course of training to qualify for a job that in many hospitals is still relegated to the background? How will change be achieved? What could go wrong? Will management save US health care? What do you think?

To Read More:

Atul Gawande, Big Med, The New Yorker, August 13 & 20, 2012, pp. 52-63.

Paul C. Weiler, Howard W. Hiatt, Joseph P. Newhouse, William G. Johnson, Toryen A. Brennan, and Lucien L. Leape, A Measure of Malpractice (Cambridge, MA: Harvard University Press, 1993)

Post A Comment

In order to be published, comments must be on-topic and civil in tone, with no name calling or personal attacks. Your comment may be edited for clarity and length.
    • David Wittenberg
    • CEO, The Innovation Workgroup
    Management can do a lot to make an individual organization more effective and profitable, but management will never fix the health care system.

    The problem with the American health care system is too much interference with supply, demand and efficient delivery through cartelization of medical education, intermediation by employers and insurers, and the imposition of regulatory burdens and restrictions by governments.

    To deal with such gross inefficiencies, management can promote standardization and mass production (as with Aravind Eye Care), new practice management models, cost control, and other measures. However, the actions of individual managers will have no effect on the overall system, which will require repeal of most current laws to achieve better results.
    • Barry Shere
    I agree with David Wittenberg. The best management cannot fix a fundamentally flawed process. The current system attempts to override the laws of supply and demand, redefines the meaning of "insurance," and enriches lawyers and (other) thieves. Trying to manage one's way out of political demogoguery is futile and nonsensical. Perhaps we should deal with the fundamental flaws before we manage them.
    • Doug Garr
    • Writer, self-employed
    I read Gawande's article with great interest when it was published, and though along with Dr. Jerome Groopman, his colleague at The New Yorker, I usually concur with their often very astute views. In this case, I disagreed, perhaps because he was trying to equate managed care on a macro level with the highly successful Cheesecake Factory restaurant chain. What is wrong with medicine today begins with patient contact. The bureaucracy of care has ruined doctor-patient relationships. You're in voice mail. The huge office placards that tell you you must pay your co-pay at the "time of service." You rarely can get a doctor to call you back. Nothing will ever change the impersonal nature of health care as we now know it. Medical schools should require a month of "learning" where students become patients and actually get checked into hospitals. Then, maybe, just maybe, we can see real change in the deterioratin
    g care.
    • Michael leahy
    • President and CEO, Health Metrics Solutions
    Thanks again for your thoughtful insights about the need for basic and pervasive change in improving health and health care. The case studies, framing the most important questions, and deeply thinking through alternative courses of action taught at HBS and Harvard Public Health Program for Health Systems Management have been enormously useful to those of us who have been trying to lead and manage health organizations.
    To build upon your question "Will Business Management Save US Health Care?", my sense is that health care needs to do much more than discover management. Decades ago we were encouraged to focus primarily on the business aspects of running health care organizations while being very cautious of not interfering in the practice of medicine. Many of us have come to understand that today the most promising health care systems are those that deeply understand how to plan and implement the US Health Triple Aim objectives (provide best overall value by controlling over cost, measuably improving quality outcomes, and encouraging access for all without disparities). Hence, informed and courageous leadership, systems oriented management, genuine partnerships between administrators and medical and nursing professionals, and aligned system financial incentives that encourage the use of good real time information at the point of care, and evidence based practices are all necess
    ary ingredients in 21st Century health care in the US and in the developed world. Thanks, Mike HBS '74
    • Phil Clark
    • Clark & Associates
    If health care was easy to fix...it would be done. If management was all that was needed...that too could likely be done. Unfortunately, health care is about life, quality of life, and death. Start trying to manage , control and put a dollar figure on that and you will instantly run into multitude of walls at all levels of society. Healthcare is something everyone will face. No one opts out. I dare say that modern health care must maintain the flexibility to deal with life to be successful. It does not mean everyone is treated the same way...but everyone must be treated. Those left out of health care may carry disease that infects all, drag down the health of a city or nation, or created a population that cannot keep a society going because of poor health.

    Sadly modern discussion focuses on the have and have nots. The cost, the method, etc. Bottom line ...a nation's health will be determined by the lowest common denominator of health care treatment. A friend of mine from Austrailia provided a unique insight. He said, "I thought American was the richest nation in the world until I saw for myself how everyone's health care wasn't looked after."

    Our founding fathers knew that. The earliest hospitals were charity hospitals supported by prominant business men and churches in the community. Ben Franklin was one who supported a hostpital. They realized that poor health impact everone. We worry to much of making health care a profit business when it should be designed to break even.
    • John Van Slyke Jr.
    • President, Morgan Hall Institute
    There is no question that business people have the leadership skills and command over the kind of technology that is needed.

    Unfortunately, Wall Street has corrupted so many good concepts. If there is a revenue stream, amoral and expedient slimes on the street will find a way to capitalize the cash flow, turn it into a security, and ultimately flog it to the public. The examples abound, particularly in private equity.

    The result is leadership that becomes myopic in its focus on earnings growth and that places personal economic interests ahead of patient care.

    Nothing surprising here. We humans are less than 10,000 years away from our ancestors in the trees and only 6,000 years or so away from the first civilizations in Mesopotamia and Egypt. Human brains still have all of the brain programming of back then. Among these are greed. In modern business greed dominates people's sense of the public good.

    So, on the one hand business represents a social resource that could make a decisive difference. On the other hand, the record of business, particularly the financiers, has been to distort health care organizations. This begs a number of questions in my mind.

    Ultimately, I think the health care system of a nation is what economists call a public good. The one in Canada works that way, and it works well.

    Given the inevitable distortions caused by the profit motive, I do not think business can operate in health care without constraints and regulation. The abuses of health insurance companies over the past 20 years provide excellent examples of what happens when the profit motive dominates.
    • Gerald Nanninga
    • Consultant, Planninga from Nanninga
    Better management practices can make incremental improvements to the status quo, but that is not enough. We need a wholly different strategic approach. Options could be:

    a) Focusing on promoting health instead of curing disease;
    b) Empowering consumers to take on many of the tasks that are currently outsourced to some health care practitioner; or
    c) Changing the definition of acceptible health.

    In the end, the only way to take huge chunks of money out of the health care network is to institute major change that will dramatically hurt the size or profitability of key health care sectors. Those hurt will fight back. So we are stuck with merely improving the status quo incrementally.
    • David Bley
    • Forked End Down, Not Very Good
    It is my opinion that the healthcare industry is fundamentally broken and no amount of painting will fix a house that has a sinking foundation.

    The healthcare industry is GREAT at intervening in acute situations, but virtually all of its attempts in chronic care are palliative, expensive, complicated, and do not treat the underlying condition. When medicine is unable to effectively treat a condition, it becomes the patients fault.

    The other BIG problem with the health care industry, as a whole, is now that profits are shrinking in other industries, corporations have discovered that there are large profits to be had in medicine.
    • Milton Recht
    Management is a response to competition and economic decision making with uncertainty. Medicine has neither competition nor uncertainty as to its demand or revenue stream. There is no single correct management for businesses. Management type depends on the needs created by the business environment.

    Medicine's current organizational state is a successful and logical response to its business environment. Like all businesses with little economic business risk and high regulatory involvement, medicine is unconcerned with costs and much more concern with process than outcome.

    How many physician practices go out of business or into bankruptcy! How many people have to choose between spending money on a doctor visit or spending it for something else when 3rd party employer or government insurance will pay the medical bills?

    Increase competition, allow medical business failures, remove guaranteed sources of revenue, relax government regulatory and licensing of doctors and hospitals to remove the cartel and guild aspects of medicine and put more of the purse strings directly into the consumers hands and US medicine will transform into a better managed, more efficient, lower cost, higher quality service with more focus on outcomes and less on process.

    In a competitive environment, medicine will also differentiate the market place of consumers to satisfy lower income and higher income patients through number of available physicians, wait times, plushness of the offices, location, convenience of hours, etc.
    • Anonymous
    What if you were told to dine at the Cheesecake Factory by your place of business because they have a preferred contract? What if your order had been placed by a nutritionist ahead of time that was in your employer's network? What if when your bill arrived you are only responsible for a predetermined tip because the price of the meal had been negotiated by your employer before you arrived? Would your dining experience be as pleasurable? Would management really make a difference?
    • Hugh Quick
    • home, None
    I think American medicine has achieved remarkable beneficial advances for people in general but does not look after its citizens health very well.
    • Walter P. Blass
    • President, Strategic Plans UnLtd
    Prof. Heskett: In my experience it is not the admninistrator who is going to be the change agent. The skills set required is seldom what administrators learn. What Gowande is asking for in the latest article, as well as earlier ones where he proposed checklists for each procedure is a cooperative effort on the part of physicians, hospitals, and yes, even patients. In Europe, the very expensive use of high tech equipment to prolong life ( eg. cardiac catheterization) is avoided by using far less intrusive but still reliable devices like Doppler echoography. Like the magician's wand, the cardiologist can see on the screen just about all (s)he needs to determine the state of the heart. We in the U.S. are demanding royal treatment even when the prospects are dim indeed( think pancreatic cancer.) Until we can arrive at a consensus that agrees to minimize procedures that extend life by a matter of a few months, we will continue to spend
    17-18-19% of GDP on healkh care; until we fashion either a single payer system, or its equivalent ( say like driving infractions which get you fined, regardlkess in which state it took place) the admin costs will still play an outsize role in health care. Likewise, what you reported in your intro, that doctors be paid as employees who deliver care, rather than piece work slaves that are pressured into doing "more" whether that results in healthier or more satisfiued patients, we will not fix things.

    What is needed is a systems approach ( a la Jay Forrester of MIT ) that permits all the participants to work out a (social) contract who gets what , at what cost, when. Failing that, I doubt that we can arrive at a satisfactory resolution of this delicate issue. If a Nurse Practitioner can do the job of compiling patient history/lab work/physical exam, why have the M.D. do that work? As Americans we have done what we do best, throw money at a problem rather than think it through strategically and come up with a satisfactory, socially agreed to system. That's how Medicare was conceived of with Congressional passage.
    Nothing short of that at a national level will accomplish those changes. Not the administrator's role, I am afraid.
    • Kapil Kumar Sopory
    • Company Secretary, SMEC(India) Private Limited
    At the outset, it needs to be clarified that medical profession is not a business in the sense that manufacturing or selling, etc. are. No doubt there is a profit motive behind setting up a nursing home or a hospital, at individual level each doctor has a missionary job - to provide health care to the needy without considerations of position, status, etc. He has an oath of applying his knowledge, expertise and skills sincerely to healing the sufferers.
    That being so, some important aspects of good business management - ethics, transparency, truthfulness, etc.- need to be practised. These can be emphasised during the medical professional training they receive. These will do good to wipe out their often criticised working style leading to a bad image. We do witness doctors with haughty temperament with scant regard for human values. Good governance principles can attempt to teach them the futilityof such behavioral patterns which take them to courts quite often.
    Knowledge of better management practices could also broadbase vision of the doctors to understang the external
    environment and business scenario around them.
    I believe a generation of MD, MBA's can use management and medical knowledge to manage hospitals. This has already been proven. Of course, there is managerial talent involved also. They will have a hard time telling doctors "no you can't do that," but I think it can be solved. Physicians respect other physicians.

    I think doctors have to shift to thinking about managing patients instead of treating patients.
    • Executive Director, IQ Business
    Health must be package as a service in order to be managed systemically. Like in any service, the customer is king, and in this case any citizen seeking assistance in any form from a healthcare provider must be the ultimate focus of all role players in a hospital from administrators to clinical practitioners. Customers learn quickly and can destroy you if the service they receive is sub-optimal. In the case of healthcare services, the consequences are dire - the fatal the consequence of inadequate care the more pointed is the reputational risk. Regarding the latter, privately owned healthcare providers especially cannot ignore this critical risk given it can significantly dent the bottom line. If administrators in this instance ruthlessly chase bottom line without recognizing they need to preserve the dimensions of quality clinical care, they are worst fired by their board, or at best realize they need to partner clinicians and agr
    ee with them to aim predominantly at the needs of patients/citizens. It is satisfied patients that are your best ambassadors.
    • Hugh Quick
    • home, none
    In my opinion the USA makes brilliant advances in medical science which benefits many but is not very good at looking after the health of its citizens. I don't think 'management' has anything to contribute, it depends on the attitude of health care professionals. Do they make a call that they don't want make because they are paid or because they want to help?
    • Prof. Subrata Chakraborty
    • Retired Professor, IIM, Lucknow, India
    I believe health care delivery system can be improved through better management. However, everybody associated with the system needs to understand what value (s)he is generating individually and, more importantly, what is their collective contribution in value creation for the patients. I have often found (in Indian health care delivery systems) that the collective contribution is much less in comparison to the potential each individual possessed.
    What came out of deeper investigation is, there is a great divide between the doctors and the paramedics because of lack of clarity on how their works can be purposefully integrated to create a more effective whole. I, therefore, feel that research is required in this area to better understand how to create proper goal congruence in order to deliver better results for the clients of the healthcare delivery system. It is important to understand that being a good doctor or a good nurse etc. in itself may not be very useful to the patients as such. What matters much more is the effectiveness of combined output.
    Before closing, I must confess that all my experiences are in the Indian context; therefore, may be far removed from the American reality.
    • Ravindra Edirisooriya
    • Accountant 09/14/12, Midwestern Small Business
    I must respectfully say that Professor Heskett's assertion "... (hospital) administrator has always been a second class citizen in the workplace, a facilitator of both the best and worst practices of those actually providing health care." is incomplete without his assumptions and inaccurate from a (quality) management perspective. Are the best and worst practices from the patient's perspective, healthcare providers' perspective or both (highly unlikely in an unregulated free market healthcare system because naturally economics/greed comes before patients)? An administrator may be a "figurehead" who really may not have to do an honest day's hard (and smart) work nevertheless getting paid a handsome salary but never "a second class citizen", which the underclass (and some minority/marginalized citizens) may take great offense. Physicians are paying more attention to (quality) management because something
    changed in the US healthcare universe and not because suddenly they discovered The Cheescake Factory, which has been in business for a while. Ask any member of ASQ (which I am) and they will tell you all about the Healthcare Division and its objectives. The change is the affordable care act. Before the change, healthcare management and actual healthcare providers (physicians) had conflicting objectives. For instance, management wants physicians to reduce the patient contact and processing time and physicians wished to take a reasonable (longer) time to make a "good" diagnosis. Also, some physicians are not interested in selling additional healthcare services whereas healthcare management wanted to sell additional fee based healthcare services to patients who are already in the door, irrespective of patients' need or affordability oftentimes leading to patient bankruptcies. After the change, (http://www.healthcare.gov/law/timeline/) "At least 85% of every heal
    th insurance dollar must be spent on health care & improving quality (effective January 1, 2011)" for large employer plans and at least 80% for individual and small employers. Also, it encourages Integrated Health Systems (effective January 1, 2012): " ... provides incentives for physicians to join together to form Accountable Care Organizations" and "provide high quality care and reduce costs to the health care system, they can keep some of the money that they have helped save." I know some small business employers get health care rebate checks and they are not complaining. Also, they are optimistic that the cost curve can be bent in the long-term, which may not be seen as a cost saving in the face of increased short-term premiums.

    It is time we humans (especially us Americans) think beyond the next election cycle or two when electing our politicians who (aspire to be statesmen or stateswomen) can compromise on their political/party/agent/special interest/personal agendas for the good of the country/economy/debt ceiling/... and the world.
    • Cheri Thomas
    • Managing Director, Capital Group, Newmark Grubb
    Here in Tennessee (the capital of the for-profit healthcare industry) I see literally hundreds of listings for healthcare provider managers. There seems to be a huge shortage of trained managers, and most healthcare companies either have to train their own, without a very coherent program to do so, or poach from other companies. I believe that there could be a productive partnership between educators and healthcare providers to train managers, but I do not see the cost-benefit of having those managers also be MDs. Management is a full-time job. Docs are going to have to get over themselves and learn to respect non-docs who are competent managers.
    • Tom Dolembo
    • Founder, New North Institute
    Hire for attitude, train for skills? A number of eye surgeons I have spoken to are appalled at the fact that the new docs have terrible eye hand coordination. Medical schools produce smart people, but, clumsiness and smart seem to follow hand in hand so to speak. Most have said they could take a highly coordinated person with a good attitude, teach them what they needed to know and have them do their work under their supervision. Eye surgery, to their mind, is a skill first, a medical profession second. Ham handed brilliance is a waste of medical school. For their purpose, training the best video gamers with a will would yield a better surgeon.

    We feed our children into sickness, deliver them into an adulthood of sickness and drug dependency, and have a medical system prepared to offer symptomatic relief at great expense. The sickness industry, of which hospitals are a part, effectively sustains illness, is mesaured by its sickness flow, not the health of a community. We should pay doctors well who cure patients, award hospitals who are empty, and stop evaluating our system as if sickness is a necessity.
    This is like delivering bad parts, building a bad car, and guaranteeing lifetime repairs. We accept diabetes, cancer, heart disease and dementia as the price of doing business in a troubled environment. Every week, in my tiny church in Michigan, I hear the litany of prayer requests for cancer victims. I listen to the DNR explain that our pristine lakes are laden with dioxins, mercury and pesticides (we are downwind...). The local chemotherapy center runs day and night. My friends die anyway. New people move in. It all works, really well, in a satanic way to offer up an invisible and endless supply. Nothing will change until we just ask why we're sick and expect an answer?
    • Dr. Kaustubh Lahiri
    • HOD, Deptt. of Geography, S.N. College for Women, Kolkata, India
    In consonance to news available via media to India, it is evident that President Obama is doing a remarlable job by ensuring health care facilities to common U.S. citizen. Unfortunately in India we dont have any such compassionate visionary. In stead we are bonded to hypocrats who talks about socialism in public but promote private health care facilities only for the affluents
    by clandestine and deliberate destruction of state health care sysytem.
    • David Giammittorio, MD
    • CEO, The Physician and idwife Collaborative Practice
    We began the transition from the star based system to the team based approach 6 years ago.
    It took starting from the beginning....who did we serve and why? Were we correctly internally and externally aligned? Answer....don't know and no and no.

    We began anew....realigned provider pay and work schedules. Rationalized office hours.
    Installed an EHR to service our four locations.
    Hired nursing and support staff for attitude and trained for skills needed.
    We relentlessly sought process that would produce
    "Convenient, Compassionate Care"
    Our medical out comes have improved. Provider engagement and feeling of satisfaction have increased, our costs have fallen and our net profit has increased.
    In short, I believe that recognizing that medicine is a business and will respond to management excellence is critical to improving medical care.
    • Donald Shaw
    • President, Donald E. Shaw, P.E.
    Better management will do nothing to help healthcare because unlike the restaurant business, there is no agreement of the buyer as to what healthcare is. Everyone knows what it means to them but that does not mean there is anything approaching an agreement. And a statistical survey or a political process will not help unless we are prepared to accept the fact that we will wind up with a large percentage of the people wanting nothing to do with it. Before extolling the virtues of managing a restaurant chain, no matter how successfully, it should be asked what if The Cheesecake Factory were the only restaurant available--it had to please everyone. How good would it be doing?

    One major difference between a healthcare system and a restaurant is that the healthcare system involves a million times the agent interactions than a restaurant. And each agent interaction changes the context for other agents doing other tasks. Any healthcare system that purports to serve all will be a complex adaptive system operating far from equilibrium. And one aspect of anything operating far from equilibrium is that it takes a lot of energy (read money) to keep it operating there.

    Our current structuring of healthcare is based on the factory model--something which demonstrated its own set of problems when customer demands went from Henry Ford's model T which the buyer could have in any color he wanted as long as it was black to today's gazillion models, features, colors, etc. that customers demand. One size fits all no longer works.

    Health is personal. So healthcare has to recognize that fact from the outset. Healthcare is context dependent--the needs of an 18 year old are drastically different from an 80 year old. The environment we live in and/or work in, the food that we eat, the air that we breathe all have potential for leading to different outcomes in terms of health. Our genetic makeup also contributes to our health. How we use our bodies relative to exercise and stress also affect our health.

    An interesting observation may be that it seems that none of these issues seem important to someone 18. They become important when a Cancer diagnosis appears. That may be why the definition of healthcare is so context dependent.

    The current preventative medicine strategy seems to be modeled after preventative maintenance programs for machines. Fortunately the machines do not care how intrusive a program may be. Neither do they care if a diagnosis with all of the stress it can produce is wrong.

    It also interesting that research seems to be finding one thing after another that is a cause of poor health---usually cancer. But none of that research seems to include the effects of the multitude of factors that definitely leads to the result. So we operate with highly incomplete knowledge at best. Listen to the warnings that accompany today's advertisements for designer drugs. Drug testing and food testing is for extremely short durations which in no way approximate the time some diseases like some cancers take to evolve. Yet to test a drug for say 30 years of more before it can be marketed would result in no drugs being marketed.

    The most significant cause-effect relationship that has been established yet is between smoking and cancer. We have outlawed smoking nearly everywhere. In many cases we have forced the smokers to congregate in their own social network that meets outside the building where they all work. So smoking continues.

    A very important question is whether people have responsibility for their own health at least to the degree they can control important aspects of their life. It is not clear if the causes that will someday lead them to a cancer diagnosis are a part of their everyday environment that do not get changed.

    Back to the beginning. What is healthcare? It can probably be summed up in the human wish to remain alive as long as possible and at any cost if someone else is paying. That definition might get a consensus but even then who determines what is possible and at what cost.

    In the DMAIC process of Six Sigma, the beginning is Define the project. Without that, Measurement, Analysis, and Improvement are impossible. Relative to healthcare we have yet to perform that step successfully and it is ludicrous to then talk about the last step, C-Control the resulting improved process. We are nowhere close to concerning ourselves with controlling healthcare when we have not defined adequately what it should accomplish and can accomplish for those who are asked to pay for it.
    • Joanna
    • Analyst
    I would like to suggest that we really do not have a "health care" system here in the US; we have a "disease management" system. Although I have a strong bias towards repeatable processes, and checklists are helpful in many circumstances, I am not sure the assembly line analogy is applicable when it comes to healthcare.

    While society as a whole benefits from high functioning healthy individuals, our medical system does not profit. Insurers profit from healthy individuals, but they do not actually contribute to our health.

    I don't see how "management" could make a difference.
    • Ajay Kumar Gupta
    • Erasmus Mundus Fellow, University of Milan, PhD Scholar, TISS, Faculty, TAPMI, T A Pai Management Institute
    There emerge two issues here- managing hospitals and managing doctors. Managing hospitals is more related to cost reduction, relationship building, and tie up with insurance providers, proving wellness awareness, creating better environment for doctors etc. Managing doctors is more related to treatment of patient with human touch, create a feeling of comfort and trust among patients, and unbiased treatment irrespective of class, status or gender etc. Now to manage health care industry both the doctors and administrators should realize that they are complementary to each others. Providing administrative or business management skills to doctors might not solve the issue. Since this is attitudinal and perceptual issue which comes from our within. This can be dealt with providing joint exercises of administrators and doctors from time to time in workshops and making them feel that both are important. This could be a part of usual exerc
    ise by the hospitals.
    Here the Surface Issues like cost management, patient care, time management, and better services flows from the lack of collaboration between doctors, administrators and insurance providers. And these are generally perceptual, behavioral and attitudinal issues. I think such issues could be better dealt with inculcating, teaching and encouraging emotional intelligence.
    Doctors can maximize their returns by running their private clinics but the major question they need to ask themselves is "Are they doing justice to their profession". They should take moral responsibility with their profession and avoid temptation of making money. Instead, they should instil the temptation to treat maximum number of patients with humility and respect.
    Alternatively hospitals should create opportunity for doctors to engage in innovation and research. Incentive for faster turnaround time, quality patient care, and lesser repeated patients should be encouraged and rewarded.
    At this moment, can we say that Business management is not solution to all issues? Had it been true, no institutional collapse or failure would have been taken place. It means there has to be something bigger than business management. I think what is missing in patient care is - "Emotional empathy".
    Unless doctor realize that their role is bigger than themselves, it is almost impossible to revive the healthcare industry. Medical education can play role by imparting education that can inculcate feelings and sensitivity towards their role. Doctors should win heart of patient. It is possible when they do more than treatment. Doctors should create a feel of "Human Respect" for patients.
    • Atul Guglani
    • Director, Mantex Technologies
    Doctors Never Make Good Managers : Simple, because the way, the education of medical system is designed. It does not address cures, but only disease management. And any management can only be successful, if the principles of the same are well applied. These can be only applied, if one is well trained in the management practices.

    Around 90% of human diseases are lifelong and incurable starting from Hypertension to Diabetes to Heart Diseases and one can go on and on.

    Therefore the system is not about curing the disease, but it is about managing the disease throughout the life of a person. Practically the patient doctor relationship starts with the onset of the disease and ends with the end of life.

    This life long relationship is not something which is taught in medical science. It is part of the social management system.

    Each time, I have gone for a check of my BP, I have told the Doctor, that one basic difference between you doctors and we engineers and managers is that we are solution oriented. We are designers, technologist and there is nothing which is sub optimal solution sticking to our system for life time. If Hypertension was engineering problem, we would have long back solved it . But the way, the medical system works. Doctors go through a learning cycle which is much longer then all the other professionals , yet the material deliverables are the lowest against all the professionals. A small disease like hypertension , still neither the causes are known, nor the cure is known. Will any manager ever accept this as part of his job ?

    The key reason being that health management is more in the hands of the pharma companies, then in the hands of the medical professionals. No pharma company will give away a target customer, who is life time dependent on its supplies. At best, the medical specialist works around these dozen global pharma company offerings and rarely ever does a Doctor himself come out with a drug. The Health Care and Health Management will remain a hugely challenging issue for all nations, till disease management is the deliverable of the medical system and not Disease Elimination.

    Thanks to alternate medical systems now emerging via stem cells, tissue engineering, regenerative medicines , biosciences, nature, yoga, TPM, etc that the monopoly of pharma companies is getting challenged and medical science within in the next one decade will take a totally different shape.

    Another issue with medical professionals is the low level of IT skills. I am linked to Google alert for any new development on hypertension and instantly I get to know the same. But, when I visit my doctor, he still has no clue of it.

    Overall the big gap between medical professionals and managers is that, the education system restrains the professionals to take risk and management is about risk taking. The net result is that , while technology has changed the world face since the industrial revolution in the last 200 years, however, on health, the system still stands in time , with hundred of diseases unresolved and only being managed with life time supporting medications.

    The solution is giving management education along with the attitude of engineers and technologist to the medical professional . So that he starts believing that chronic Diabetes etc is not a life time disease and he will not wait for the pharma industry to find a solution, but he would use his experience and education and expertise to eliminate Diabetes from the face of the earth.

    • Bruno J Poitier
    • President, ID-Bahamas
    As I sit here browsing and continuing my research into assisting the Government of the Bahamas in introducing technology of identification firstly.
    Through identification, a patients records can be linked to the file and made portable through the use of a PDF.

    I am in agreement with the fact that Physicians and Practioners are not willing to listen and search out new initiatives that not only drive the profits of the Medical Institution, but also maintain a personal service oriented system, where a doctor can actually follwo up with all records available.
    It is imperative that as the years go on an new diseases and illlness appear, the health care system will be forever burdened, however the proper and correct receipt , use and storage of patients health care data remains priority one.
    • Tammam Farhat, MD, MBA
    • Tufts Medical Center, Boston, MA
    Healthcare is a complex system - so there are no quick & painless solutions. Healthcare is a basic need in the 21st century USA, based on experience, one cannot entrust financiers only with such a need. In business, generally speaking, profit is the top priority, in healthcare quality of the service, ought to be the highest goal as well as cost. Good leadership and good strategy remains in short supply in healthcare, as well as well-thought rational experiments with system changes. Physicians are generally smart and many of the younger generation are acquiring business education. This younger generation of business oriented physicians, if operating with high ethical standards and human values, in collaboration with high quality management academicians and experts, may have good insight and understanding of the system problems and its fixes on the long run.