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Editor's notes

Health Care Is Not Walmart

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The parts of health care are not "connected" by an overall design. Institutions are where they are more as a by-product of personal and community history than via a grand plan to achieve a goal and, for the most part, they are self-governed and self-organized.

That may not be a very surprising declaration, but perhaps not for the reasons that first come to mind.

For many years now, practically everyone in health care has sternly repeated that the "system is broken." And it is. In its current incarnation, it is not working for the folks who provide the care, and it's not working for the growing millions of people who cannot afford to buy insurance, or for those who were locked out of the system by the circumstance of a preexisting condition. And that's not counting who knows how many more people who fall somewhere in the shadowy, shifting borders of inadequate insurance or changing public-policy mandates that push and pull people in different directions, such as in "now you have health care," "now you have less health care," or "now you have nothing." Altogether, not a very happy bunch. Such is the "system."

Then, if by magic, we zoom way out into the conceptual stratosphere, some would say, "Hey, what system? Health care isn't a system that stopped working; it wasn't a system in the first place." Some of our brethren in the engineering community have argued this point for many a moon. They say health care is what is termed a complex adaptive system, requiring leadership and incentives rather than power and control, and we should recognize that and get on with life.

System traditionalists ask such questions as: Who is in charge? How is the system controlled? How are the parts connected and how do the different parts serve and support each other? What are the uniform system rules and outcomes?

How would you answer those questions?

No one person or entity is in charge of the "system." Certainly, government programs such as Medicare and Medicaid exert more than considerable influence but, in the end, there is no single top-down control mechanism. No single authority exists.

The parts of health care are not "connected" by an overall design. Institutions are where they are more as a by-product of personal and community history than via a grand plan to achieve a goal and, for the most part, they are self-governed and self-organized. As far as how the different parts serve and support each other? I'm sure you can tell many a good story to illustrate that answer. That's because, well, there are no hard-and-fast rules. Health care supports more serve-at-will-type relationships. Even as hospitals pour sweat, time and money into physician-alignment efforts, realizing how bedrock important it is for the future, words like authority and control—even, to some extent, management—are never uttered. We want partnerships with physician leaders for mutually beneficial arrangements marked by personal commitments by both parties. Our culture prefers that we fight with kid gloves on.

No, we are not Walmart or any other highly defined "system" and probably never will be. There's nothing wrong with this as long as we know ourselves and know how to lead in a way that our lack of traditional systemness becomes our greatest strength.

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The opinions expressed by authors do not necessarily reflect the policy of Health Forum Inc. or the American Hospital Association