The meaning of strategy is obscured by its wide variety of definitions. It is often easier to see it in action than it is to define. In the early 1980s, three different health systems embraced equally different strategies.
In a small conference room at St. Luke's Hospital in Milwaukee, Wis, a strategy emerged that would fuel St. Luke's transformation into Aurora Health Care and plant its signature teal-colored rooftops all over eastern Wisconsin. St. Luke's had carved out the strongest preference levels of any hospital in the state, largely on the reputation of its heart program. When health plans began to push hospitals in southeastern Wisconsin for significant discounts, St. Luke's CEO, Mark Ambrosius, pushed back. He knew no health plan could offer a competitive product that didn't include St. Luke's. Leveraging that knowledge into a strategy of premium pricing generated the margins that propelled the growth of Aurora.
Ninety miles to the south, Northwestern Memorial, faced with a growing chorus of experts who suggested that hospitals were an endangered species destined to languish at the bottom of the food chain, doubled down on the continuing importance of hospitals. When the Chicago system's CEO, Gary Mecklenburg, looked at providers arrayed across the nation, he saw no world-class academic medical center serving America's third-largest metropolitan population. He rejected the advice of those pointing to the managed care-dominated California market as the harbinger for the rest of the country and spent billions on new facilities and technology consistent with Northwestern's aspiration to fill that open world-class position. Meanwhile, many California hospitals went on to demonstrate that the quickest way to become a commodity is to believe that you are one.
In Cleveland, the CEO of the Cleveland Clinic, Floyd (Fred) Loop, M.D., recognized early in his tenure that the institution would not long survive if it sat unchanging in the then decaying neighborhoods surrounding its main campus on Euclid Avenue. So the Cleveland Clinic built anchor outpatient facilities in the Cleveland suburbs and then, trading on the value of its powerful brand, acquired community hospitals at below market prices. Those suburban investments secured the utilization that would catalyze the rejuvenation not only of the clinic's downtown campus, but also of Cleveland.
Advice from an Enduring Sage
When executives ask how to build their strategic capabilities, one of my first recommendations is always "read Porter." For more than three decades, Harvard professor Michael Porter has ruled the strategy roost. Other pundits emerge, grab attention, then fade away. But Porter endures.
Porter's contributions have been cumulative — a string of big ideas which, when considered together, constitute a comprehensive recipe for competitive success. For anyone who seeks to lead an organization in a complex competitive environment, understanding Porter is not only useful, it's obligatory. He provides the foundational ideas without which organizations remain strategically illiterate.
While Porter's work has accumulated over time, it has also clarified. He cut his teeth as an economist — a field properly characterized as being particularly dense. His first book, Competitive Strategy, was more than 400 pages and his second, Competitive Advantage, more than 500 pages. Few of those pages could be described as light reading. But out of them, compelling ideas emerged and took hold.
Porter's scope of concern has been broad. He applies his thinking not only to firms, but to industries, geographic clusters and nations. In doing so, he reinforces the notion that there are principles of strategy that are universal. Recently, Porter has turned his attention to health care, coauthoring a book, Redefining Health Care, with Elizabeth Teisberg, as well as contributing high-profile articles in Harvard Business Review, the New England Journal of Medicine and the Journal of the American Medical Association.
Porter's principles are interrelated and interdependent, better viewed as a Venn diagram than a list. They are held together by consistency of their underlying logic and synergy. Here, then, are some principles key to thinking like Porter:
Strategies explain how an organization will create unique value. There are various answers to the question, "What is a strategy?" Porter's answer is straightforward. Strategy is how an organization faced with competitors intends to achieve superior performance by delivering greater value. Competitors generate uncertainty and resistance. Absent uncertainty and resistance, you don't need a strategy. Value represents the difference between price of a product or service and the cost of the inputs needed to produce or deliver that product or service.
A strategy is not a goal. In fact, the notion of a "strategic goal" is an oxymoron. A strategy is about action. It ought to have a verb in it. It is how you achieve a goal. Strategy is the pathway to some desired outcome. A goal is an endpoint. Some goals are measurable. Some aren't. A vision is a broad overarching goal. Strategies describe what an organization does to achieve its vision. Calling a goal "strategic" is intellectually sloppy. It is a sloppiness that matters because it reveals a fundamental misunderstanding of what leadership should be about — initiating and shepherding action that generates unique value.
The central role value creation must play in health care was described in an article Porter co-authored with physician Thomas Lee in the April 2015, issue of the New England Journal of Medicine: "Value is defined as the health outcomes achieved for patients relative to the costs of achieving them. It is the only goal that can guide strategy in health care, the only ‘true north' that can resolve the difficult choices organizations will need to make. Providers that organize themselves to improve outcomes and become more efficient in doing so will be rewarded with patients, professional satisfaction and financial success … . Those that fail to focus on value lack the essential foundation for strategy. Whatever their reputation is today, they will become increasingly nonviable and irrelevant."
Market structure determines profitability and shapes strategies. Industries are characterized by varying degrees of uncertainty and resistance. Porter addressed this reality and its connection to profitability within a framework referred to as the Five Forces. He emphasizes that the object of competition is not to beat rivals; it is to earn profits. Your ability to earn a profit is determined in part by your performance, but the level of potential profit available is determined by market structure, which includes, according to Porter, the degree of rivalry between existing competitors, the bargaining power of customers and suppliers, the availability of substitutes for existing products and services, and the extent to which new entrants are poised to enter the market. Each of the Five Forces holds the potential to drive down prices and drive up the cost of competing.
Porter's Five Forces can be applied not just to industries, but to discrete markets as well. For example, one metro area may be more profitable than another because it has fewer hospitals or has insurers with limited leverage. The Five Forces framework brings discipline to the challenge of understanding market dynamics and defining strategies within an informed context. It is a superior substitute for SWOT (strengths, weaknesses, opportunities and threats) assessment which is, in my experience, a weak and overused tool.
Successful organizations compete to be different, not to be the best. Leaders frequently exhort their organizations to "be the best." Such encouragement is often inspiring. But, according to Porter, it's also wrong-headed. By definition, there can be only one "best." Competing to be the best results in a zero sum game. The focus should be on generating differentiated value for chosen customers. There is a distinction between good competitors and bad competitors. Good competitors compete to increase value while bad competitors compete to diminish their rivals.
Competing to be the best results in convergence toward undifferentiated homogeneity and price competition. The airline industry reflects this kind of convergence. That's why the airline industry as a whole has never enjoyed sustained profitability. Competition to be the best has driven out meaningful differences, so the airlines today compete as commodities almost exclusively based on price and the quasi-monopolies they operate at hub airports. Only one airline, the one that competed to be different — Southwest Airlines — has prospered.
An alternative to competing to be the best is competing to be the biggest. The presumption, of course, is that size delivers economies of scale. Porter suggests there is no systematic evidence that size correlates with profitability or any other measure of success. In 2010, the CEO of General Motors, which had just gone public after a mammoth government bailout, issued a challenge, "May the best car win!" In so doing, he delivered the beleaguered company with its second curse. The first had been a flawed view that size and dominance were pathways to sustained success. The chunks Toyota and other foreign manufacturers took out of GM's market share proved otherwise. It's a lesson seemingly lost on health pundits and leaders who continue to pound the "big is better" drum.
The essence of strategy is choosing what not to do. Choosing what not to do requires first determining an organization's fundamental purpose. This involves more than articulation of a mission statement. It requires saying, "We will focus here and forgo the rest." At its core, purpose for a hospital must involve delivering high-value outcomes for patients. But there are different ways to deliver value, and defining a way that is unique is the essence of strategic leadership.
Being different requires trade-offs. Trade-offs are conscious decisions to do some things and not do other things. Differentiation on value requires trade-offs, because being different requires doing different. And doing different requires doing some things to the exclusion of others. In truth, you can't take Yogi Berra's advice when confronted with a fork in the road. Trying to be all things to all people accelerates convergence toward homogeneity, price competition and commoditization.
Aurora decided not to play the price game with insurers. Northwestern decided not to embrace managed care as an inevitability, and the Cleveland Clinic decided not to rely on a single downtown location.
Porter sees health care organizations as portfolios of businesses that treat specific clinical conditions or care for particular segments of patients. Deciding which clinical conditions and patient segments to emphasize requires making trade-offs — deciding what not to emphasize and what not to do.
Being different requires doing different. A unique value proposition sits at the heart of differentiation and determines the kind of value that will be created to serve chosen customers. It defines what customers and what needs will be served at what relative price. Offering a unique value proposition requires that an organization do things differently from rivals. Underpinning unique value is what Porter calls a "value chain." Specifically, it is the set of discrete activities performed to create, produce, market and deliver unique products and services. Every product or service that delivers unique value must have a unique value chain that is tailored to its value proposition.
Walmart's move into groceries, a low-margin business, was not the result of a desire to be all things to all people. It came out of a desire to fortify the retailer's core business and profits. Regular Walmart customers tended to visit a Walmart store about once a month. But most shoppers visit the grocery store once a week or more. By positioning groceries with its existing retail business, Walmart increased the frequency with which customers purchased products from its more profitable retail operation and made it less likely they would turn to a competitor. In entering the grocery business, it brought to bear the power of its unique value chain including warehousing, distribution and information technology. A similar strategic logic drives Walmart's movement into health care services. Such moves deepen Walmart's value proposition while synergistically extending the application of its value chain.
There are generic strategies that have broad, universal application. Porter identifies three broad generic strategies that he says can be applied to achieve strategic success. "Focus" refers to the breadth or narrowness of markets that will be targeted: the customers and needs that will be served. "Differentiation" describes the extent to which a product or service embodies features that allow it to command a premium price. And "cost leadership" involves achieving a sustainable cost structure that allows the organization to compete by offering a low relative price.
Children's hospitals demonstrate focus. So do heart hospitals and orthopedic hospitals. By default, academic medical centers, because of the breadth and depth of their subspecialty capabilities, enjoy differentiation that supports premium pricing. To this point, there are few health care organizations competing on cost leadership, although physician-owned surgery centers and some hospitals that do high volumes in a particular location (and thus achieve proximity-based economies of scale) may be accomplishing this. Organizations need not pursue one generic strategy to the exclusion of the others but, instead, can differentiate themselves by the emphasis they give to each. That generic strategies haven't received more attention in health care probably reflects the extent to which the industry has not operated under true market pressure. Porter warns that this is changing.
Strategic success requires fit and continuity. "Fit" amplifies unique value. Fit, according to Porter, describes the extent to which the activities constituting the value chain relate to one another in a way that makes the contribution of those activities greater. For example, IKEA packages its furniture in flat packs. This reduces the cost of shipping and warehousing. Flat packs also allow IKEA to maintain higher levels of inventory, which means greater choices available to customers and less waiting for the furniture they want. It also allows price to the customer to be further reduced through self-assembly and in-store pickup.
Organizations are constantly encouraged to transform themselves. And transformation, of course, implies a wholesale remaking of what the organization does, presumably including changes to its value proposition and the chain of activities that generate unique value. But success also requires resolve, an unshakable commitment to persist in the face of a dynamic environment. Adjustments are necessary to meet change but overreacting can be as destructive as underreacting. Porter uses "continuity" to describe stability in an organization's value proposition. It takes time to develop and deepen competitive advantage including tailoring the discrete activities that constitute the value chain, making trade-offs and achieving fit. Many health care organizations abandoned employment of physicians in the 1990s when the costs of the strategy seemed too onerous. But some organizations didn't blink and kept building group-practice experience and infrastructure. The same pattern was repeated when hospitals entered, then abandoned, the insurance business. Today, the organizations that persisted may end up with a decade-long lead over many of their rivals.
Clusters can support competitive advantage. A "cluster" describes a geographic concentration of companies, suppliers, researchers, intellectual property and financiers who, because of proximity and incentive, develop a network of self-reinforcing relationships that generate a synergistic environment for organizations in the same or related business. The best example is Silicon Valley, where William Shockley, a co-inventor of the transistor, encamped when he was offered a good deal on office space near Stanford University. Shockley then proceeded to alienate his partners and employees, who subsequently left to form their own technology companies — 65 of them over the course of the subsequent 20 years. These 65 companies then formed the nexus of what would become Silicon Valley. Similar clusters exist including the optics cluster that grew up around Kodak in Rochester, N.Y., and the entertainment cluster proximate to Hollywood. In health care, clusters arguably exist in Boston (related to the Harvard teaching hospitals), Houston (related to Texas Medical Center) and the corridor leading to and around Rochester, (related to Mayo Clinic) Minn. Nashville, Tenn., has a cluster for investor-owned heath care companies.
The formation of a cluster like Silicon Valley is usually accidental. Leveraging cluster power is not. It requires intentionality. A cluster effect can be seen when consumers and referring physicians demonstrate a preference for providers concentrated in a particular geography. This is typically because that area has a relatively high degree of subspecialization (often because of the presence of one or more academic medical centers). Thus, consumers in suburban and rural areas may express a desire to "go to the city" for specialized care. In health care, such clusters represent unexploited opportunities because the providers in them generally fail to recognize, jointly develop and promote them. Cluster dynamics can generate the rising tide that lifts all ships in a discrete geography, although admittedly at the expense of other locations.
Porter Principles at Cleveland Clinic
Perhaps no health care organization demonstrates sustained application of Porter's principles better than the Cleveland Clinic. Current CEO Toby Cosgrove, M.D., captures the extent to which the clinic has adhered to those principles in a September 2013 article in the Harvard Business Review, "Value Based Health Care Is Inevitable and That's Good."
On value as the heartbeat of strategy. Cosgrove points to value as a game changer: "Vaccines. Anesthesia. Penicillin. Bypass surgery. Decoding the human genome. Unquestionably, all are life-saving medical breakthroughs. But one breakthrough that will change the face of medicine is being slowed by criticism, misunderstanding and a reluctance to do things differently. That breakthrough is value-based care, the goal of which is to lower health care costs and improve quality outcomes."
On industry and market structure. Cosgrove describes the significant shifts in industry structure: "Whether providers like it or not, health care is evolving from a proficiency-based art to a data-driven science, from freelance physicians to hospital-employed physicians, from one-size-fits-all community hospitals to vast hospital networks organized around centers of excellence." Cleveland is a highly consolidated market with two increasingly dominant health systems that have reached a state of relative competitive equilibrium. This has allowed them to begin to expend less on competing with one another and to invest more in value creation.
On competing to be different. According to Cosgrove, "What makes Cleveland Clinic different stretches back to our founding 92 years ago as a physician-led group practice that runs a hospital — not a hospital that employs doctors."
On value proposition and value chain. Cosgrove identifies one of those discrete activities that helps to make its value chain unique: "As a leader in electronic medical records, we have a wealth of data that can tell us what's working and what's not." Accumulating and distributing that wealth of data fortifies and leverages a value proposition built around a multispecialty group of physicians who are connected and coordinated by shared purpose and integrated systems of care.
On choosing what not to do. Cosgrove, when reflecting on the deep legacy of the clinic's reputation in heart care, has emphasized the importance of "dancing with the girl who brought you to the prom." By this, he meant the clinic was willing to forgo other opportunities to build strength related to heart disease. It then selectively and systematically extended the aura of its distinction in heart disease to diseases of the eye and the neurological system as well as to cancer. The clinic chose not to overinvest scarce capital in acquisitions. Instead, it traded the reputational value of its world-class brand for ownership and partnerships regionally, nationally and internationally. Recognizing that economies of scale are derived from geographical concentration of volume rather than from sheer size, it decided not to become a multihospital conglomerate and opted instead to market bundled products to draw patients to Cleveland where it can deliver economies of scale that are real.
On fit and continuity. At the Cleveland Clinic, fit can be seen in the rapid adoption and use of information technology by physicians employed in its multispecialty group practice. And the clinic's long-standing commitment to ambulatory care facilities on its main campus and in the suburbs generates fit by making care available in the most convenient, affordable and clinically appropriate setting. The fit among the clinic's multispecialty group practice model, its advanced information technology and its ambulatory capacity allows it to offer patients and referring physicians next-day appointments.
Cosgrove and his predecessors have been dogged in reinforcing the legacy of the clinic's uniqueness. For decades, the clinic has honored and leveraged continuity by publishing its history in a hardbound book entitled To Act as a Unit, a phrase attributed to founder George Crile, M.D., that captures the essence of the organization's differentiation. The book is updated regularly and helps to ensure that the clinic's values, accomplishments and uniqueness continuously roll forward.
On leveraging a cluster. The intense rivalry between the clinic and neighboring University Hospitals of Cleveland is the stuff of legend. Yet, through the movement of talent and ideas between the two organizations and other kinds of inevitable transference that result from proximity, they have lifted rather than diminished one another. The clinic and University Hospitals now share an academic relationship with Case Western University. Both organizations have invested heavily in rejuvenating downtown Cleveland. And while local officials bankrolled the marginal contributions of the Rock & Roll Hall of Fame, the clinic and University Hospitals turned health care into an economic juggernaut fueling the growth of high-paying jobs in northeastern Ohio.
In addition to being an effective executive and world-renowned cardiothoracic surgeon, Cosgrove is an inventor widely recognized for his innovations in medical devices, some of which, in entrepreneurial fashion, he developed in his garage. Among his lasting contributions will be his efforts to expand that garage to the benefit of Cleveland by spearheading development of the city's Global Center for Health Innovation. Already, Cleveland-area health care startups lead the Midwest in attracting investment. Taken together, all of this yields a cluster advantage by which the center of gravity for reputation, innovation and value in health care has shifted decidedly north in Ohio.
Understanding the strategies underpinning the success of organizations like the Cleveland Clinic will benefit leaders throughout health care. And one of the best ways to understand those strategies is to understand Porter.
According to Porter, "The time has come for health care organizations to rethink the meaning of strategy. Strategy is about making the choices necessary to distinguish an organization in meeting customers' needs … . Strategy demands leaders willing to make these choices, drive their execution, and bring the organization along. Leadership in health care organizations has tended to be more about stewardship than choices … . But future success depends on the ability of organizations to create value for patients. Leaders must ensure that all activities are aligned around this goal. In the emerging competitive marketplace, only organizations that truly understand strategy will thrive."
Author's note: No one has done a better job of pulling Porter's ideas together than Joan Magretta in her book Understanding Michael Porter. She is a brilliant writer and synthesizer.
Dan Beckham is the president of The Beckham Co., a strategic consulting firm based in Bluffton, S.C. He is also a regular contributor to H&HN Daily.