As I write this editorial in early July, national health care reform seems likely by the end of the year. Negotiations, compromises, economy, and politics will shape the final legislation. Over my 30 years as part of the health care system, I have come to view changes in health care as ongoing social experiments, but with barely time to reflect on the past successes and failures. I am not a historian, but my experiences, picking up roughly where Starr (1982) ended, have shaped my view of what the future may hold.
The first health care system change I experienced was the decline of general practitioners due to untenable fees for malpractice insurance. At the time, I saw that as a great loss. The general practitioners delivered generations of babies, comforted the dying, and were part of a community held together by the Hippocratic oath. They were replaced by family practice, which has become a marginalized and low-paid medical specialty. Then came patient activism, first around giving birth and then around HIV and AIDS. These movements were the roots of the customer focus and valet parking services that we now expect. This was followed by the broad uptake of the evidence-based health maintenance organization (Newhouse, 1993) as managed care. The managed care mania focused on managing costs by managing care and has resulted in managed care essentially becoming a four-letter word. Meanwhile, nursing, pharmacy, and the other allied health professions have increased the educational requirements for entry into practice and expanded the scope of practice into realms once reserved for medicine. More recently, the ubiquitous advertising of pharmaceuticals, individual and group medical practices, national ratings, and latest research findings have fostered a sense of health care as a product rather than a private, personalized service. This brief contemporary history of the U.S. health care system is by no means complete but does convey the dynamism of the system. More to the point, it reflects the reality that our health care system may be shaped less by health policy than by evolving social values, complexities of professionalism, and so much more.
So, where does health care management fit in this brief history? My experiences began when Humana seemed to rule the health care world. Of the many chief executive officers (CEOs) that Humana sent to my small rural hospital, one stood out; he was the only CEO who visited the night shift staff. While he was there, the hospital was successful. Later, as part of collecting data for my dissertation, I interviewed two hospital CEOs. Their most memorable quotes were that for hospitals 3 years is a long term for strategic planning and that throwing more resources into personnel rarely solves a problem. My dissertation focused on understanding organizational uncertainty. Managing health care organizations today almost seems too complex for even a charismatic CEO to succeed, and the environment beyond hyperturbulent (McCann & Selvsky, 1984).
From this historical perspective, the experiment continues. Hopefully, our collective wisdom, intelligence, and curiosity will yield interesting and informative research for subsequent reforms/experiments.
L. Michele Issel, PhD, RN
Editor-in-Chief
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