Wednesday, March 9, 2011

The Organizational -Medical- Governmental Complex

Every single social task of major impact . . . is increasingly entrusted to institutions which are organized for perpetuity and which are managed by professionals, whether they are called ‘managers,’ ‘administrators,’ or ‘executives.'

Peter Drucker (1909-2005), The Age of Discontinuity, 1969

Individual physicians are relatively powerless against large organizations, be they run by health care executives or government officials. For good reasons. It takes a large organization to get big things down- to deal with the bureaucracy, to afford the technological infrastructure required, to mobilize a team of professionals, to make one’s market presence known, to have an impact, to exert leadership.

Yet, when it comes to seeing a doctor, most of us want doctors who look after our personal interests, not the interests of the organizations. Doctors, who cherish their autonomy, are not good in forming effective organizational counterweights.

We often resist the impact of large organizations on our practices by complaining about astronomical salaries of executives, excessive power of government officials, unneeded burdensome bureaucracies, unfair reimbursement policies, and the loss of freedom of doctors and patients. Doctors say misplaced organizational power leads to unneeded regulations, to punitive laws, to outside interference, and to diminished innovation.

To sample the reality of what I am saying, viz., that independent doctors feel helpless in the face of organizational juggernauts, look at the activities of these large organizations.

• The World Health Care Congress
– This huge organization holds a series of “Congresses” each year, culminating in a Summit Congress, in Washington, D.C. in April. Its motto is “Driving Strategy in an Era of Government and Market-Driven Care.” Its meetings feature organizational movers and shakers from all realms of government and the health care industry. In these meeting rarely do you hear the voice of independent physicians.

AARP - With over 40 million members, retirees, near retirees, and the elderly, AARP is the largest private organization in the United States next to the Catholic Church. Its biggest source of revenue may be Medigap policies, administered by United Healthcare, which proudly complains it has 78,000 employees providing benefits for 78 million Americans. Robert J. Samuelson, Washington Post columnist, says of AARP, “ AARP is in charge. Power is the ability to get what you want. It suggests that you control events. By these standards, the AARP runs government budgetary policy, not presidents or congressional leaders.”

• Health Affairs
This is America’s premier health policy journal. It is very much an Inside-the-Beltway publication and generally reflects the views and hopes of government-directed health care while bashing consumer-directed or physician-directed care. To be sure, its tone is always high-minded and fair, but its drift is palpable. An example is its March issue on innovation. It features 15 organization innovations presented at a December conference. The organizations included: Commonwealth Care Alliance in Boston, Geriatric Resources for Assessment and Care of Elders. Aurora Health Care in Wisconsin, The American Academy of Pediatrics’ Asthma Pilot Project. Cambridge Health Alliance in Massachusetts, Clinica Family Health Services in Colorado, HealthCare Partners Medical Group, Mercy Health System in Pennsylvania. ThedaCare in Wisconsin, The Vermont Blueprint for Health. Martin’s Point Health Care in Portland, Maine, Bellin Health in Green Bay, Wisconsin, Capital District Physicians’ Health Plan in New York .

I do not mean to demean the work of any of these organizations, but all undertook projects to demonstrate the effectiveness of strategies espoused by Medicare and Medicaid Innovation Centers. It may take an organization to exercise social responsibilities for care, but it takes a physician to deliver the care, which may conflict with organizational goals.

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