This issue should be of interest to many different readers. It offers articles on nursing homes as well as hospitals, and on topics that range from strategy to quality and compensation. The issue also contains a FORUM on Stakeholder Management with three wide-ranging papers. Myron Fottler and John Blair served as guest editors, and we extend our thanks to them for their splendid efforts. They will review the FORUM papers in a separate Introduction to the FORUM.
Three papers precede the FORUM; two of them address nursing home management. The article by Castle and Fogel makes an interesting link between administrators' membership in a professional association and the quality of care in nursing homes. The authors call membership in a professional association a signal of the individual's commitment to the field and a factor in building identity as a manager. On a practical level, such membership offers access to knowledge and help in solving problems. In this study nursing homes whose administrator was active in a professional association had fewer patient care problems. This is a significant link. As the authors point out, the study could not address the direction of causality, but the findings provide impetus for the pursuit of an interesting research question: Do changes in quality occur when an administrator who is not active in a professional association is replaced with one who is.
Academic training and continuing education for managers have held an important place in health care for a very long time. From the start of the hospital movement at the beginning of the last century it was recognized that running health care organizations should draw on special expertise, a recognition that was subsequently applied to newer organizations such as nursing homes. As Duncan Neuhauser recorded with such care in his history of the American College of Healthcare Executives, it took enormous dedication and work to develop the institutional infrastructure that would create and transmit such expertise to practitioners.
The article by Singh studies compensation levels for nursing home administrators. It makes two interesting findings: first, there is a significant difference between the salaries of female and male administrators. Second, the difference is explained by differences in nursing home characteristics and by differences in administrators' education, experience, and tenure. The author makes an important point when he cautions against drawing conclusions from differences in mean salaries without taking into account explanatory factors such as the ones used here.
The findings of this study are consistent with human capital theory, which places heavy emphasis on factors such as education, experience, and number of hours worked. While human capital theory is a popular approach to the study of payment differentials, it has limitations. For example, it focuses on experiences and skills that are acquired on the job or are stereotypically assumed to be job related. Thus it does not attend to other factors that may contribute to a manager's value, and that may be of particular salience in health care organizations. Examples would be nurturing and caring skills or facilitative skills. These have begun to receive attention as important management skills only recently, and it is to be hoped that eventually they will be considered valuable enough to be termed a form of human capital as well and to be compensated accordingly. For women at least, their actual or assumed caring responsibilities in the family have traditionally been seen as diminishing their human capital and as a rational explanation for lower compensation. Singh speaks to this when he draws attention to the finding in his study that being married was associated with higher income levels for male administrators but not for female administrators.
The article by Olden, Roggenkamp, and Luke provides a compelling analysis of the strategic orientation of hospital alliances. Using Kotler's five market orientations, the authors argue that during the 1990s hospital alliances focused mostly on making themselves attractive to managed care organizations and other institutional buyers. In the process they emphasized cost control, utilization management, and selling to these buyers, at the expense of a focus on patient satisfaction. Olden et al. argue that current trends indicate a renewed focus on patients who will be increasingly powerful, because they are becoming more knowledgeable and assertive and because they are supported in this by more legislative control over managed care organizations and providers. The argument has significant management implications because-as the authors point out-organizations that want to shift from a production to a marketing orientation will have to undergo major structural and behavioral shifts.
In the popular press the empowered patient often becomes the normative patient who not only has a right but an obligation to be an active participant in selecting providers and treatments. That makes it appropriate to raise questions about who this empowered consumer of health care is. When one tries to imagine the assertive individual who researches diseases on line, shops around for providers, and engages with physicians in matters of treatment, a picture emerges of someone who has health insurance that permits provider choice; who has enough education to make good use of all the information that is available; who has enough status in the eyes of providers that they will respectfully listen to the patient's suggestion; and who is independent enough and has sufficient time to pursue all of the responsibilities of an empowered consumer. That picture leaves out many. People who have no health insurance at all or are woefully underinsured will not have many options to shop around for a provider of their choice; neither will people whose employer offers only one health plan or people who depend on family members and friends for much of their care. People who are in the throes of a sudden acute illness may not be in a position mentally or emotionally to engage in much independent research as a counterweight to their physician's expertise; neither will frail elderly with chronic conditions who live in nursing homes and who don't even have physical access to information. All of them-and at one time or another that will likely be any one of us-still have to rely on the good will, expertise, and commitment of our health care institutions, physicians, nurses, and other caretakers. Assumptions that health care institutions are just like any other business and that patients must protect their own interest could become a self-fulfilling prophecy, eroding the trust that is essential when we have to turn ourselves over to our health care providers because we have become temporarily or permanently unable to be empowered, knowledgeable, and independent consumers of health care.
We thank the authors for their wonderful work and hope that you, the reader, will find the articles in this issue of Health Care Management Review as stimulating as we did. It gives us great pleasure to present them to you.
-Margarete Arndt, D.B.A.
Coeditor
-Barbara Bigelow, Ph.D.
Coeditor