Friday, March 25, 2005

Survival of AHCs: Why Do They?

In a series of interviews conducted last year (2004), Drs. Hamilton Moses and Samuel Thier, along with David Matheson, Esq., asked 23 leaders in 15 academic institutions to address this ingenious and properly-ingenuous question. (Why do they survive? That is, of what use are they, these days?) Essentially, another SWOT analysis. This is one of the best articles in this genre that I've seen in quite a while.

Answers were revealing, beyond the round-up-usual-suspects identification of lesions such as reimbursement issues, problems with community outreach, and perversities in both the internal and external environments.

Of note, unless I missed something staring me in the face, Moses et al. chose to keep their informants--and their institutions--anonymous. OTOH such anonymity no doubt did promote candor. One of the nifty things about blogs is that we don't need to take the classic review-panel high-science approach and take them so much to task in demanding such detail from a JAMA "Special Communication" piece.

The article nicely combines elements of the diagnostic and the prescriptive. What's wrong? What's right? And how to fix what's wrong? It is also a welcome call to arms, when the authors (at least implicitly) revert to their own voices.

The authors say their informants came "from all walks of life," to paraphrase; translate: more than just the ivory tower.

But we may legitimately ask: how many came from institutions that had failed, or were about to fail? I see an interesting defect here, by no means fatal for their arguments and recommendations, but still a potential skew-factor.

Namely, tellingly, included amongst their informants, did they include anyone from AHCs that were, or are, nearing the unlovely status of non-survivorship? There's a thread woven through the piece suggesting that AHCs survive in part because they do a lot of things right, and by contrast other sorts of organizations (industry, CBOs, CROs, etc.) don't always do much any righter!

Thus do the AHCs limp along. ("The Paradox: Survival Against the Odds.")

Yet we might add: not always. The first tier institutions have more money, more lucrative clinical specialty cadres, and bigger research portfolios--they have, that is, a lot of ballast and momentum. But not all of them have been surviving. Witness the recent demise of what was once the Medical College of Pennsylvania (the hospital and most of the faculty are gone, and a vestige lives on on the stationery of Drexel Med). It's not quite cricket for those doing better, for now, to assume that any part of their business-as-usual will guarantee future survival. Seems a bit circular.

With this caveat, I suspect that many of this group of authors' conclusions can be considered to be well taken and useful to ponder. (Though, true, they often verge on bromides.) "Do, don't just preach." "Position yourself as honest information brokers." "Get leaders with experience outside the AHC."

Finally, Moses and his colleagues advocate two "fundamental changes." They are (1) enhance ties with the community and (2) simplify the "organizational labyrinth."

These are interesting, if not wholly new. Below the elite tier, one might point out, such ties, paradoxically and perhaps only because of economic and organizational necessity, are already in place. (That's another minor glitch in the argument, but one that's ultimately unexceptionable.)

The biggest issue, then, is how AHCs are themselves governed--here I think again of Pogo, "we have met the enemy...."

Ultimately, institutions, like families, ultimately fall victim to their own contradictions. The perversities of AHC organization, even in best-of-breed AHCs, are nicely laid out in this article, and paramount among them is probably the huge array of disincentives for true collaboration at all levels.

Ultimately, a question and an opportunity stand out. The opportunity: with outpatient medicine becoming more and more important, as the authors note, AHCs have a great chance, if they find ways to seize it, to take over from the hospital as the traditional framework for improved links with the community. Bingo! Eureka! Touché!

The question: who will give the New Leaders, the cadre of community-, market-, and business-savvy deans and chairs and directors that Moses et al. call for here, the Archimedean lever with which to effect all the changes they call for?

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