Addressing Social and Economic Responsibilities through Governance

Abstract

Loosening the Gordian Knot of Governance in Integrated Health Care Delivery Systems provides a very complete analysis of the issues and components of integrated system governance. Pointer, Alexander, and Zuckerman leave the reader with a framework on which the governance of an integrated health care delivery system (IHCDS) can be conceptualized. For those of us who are entering the new world of system integration, this article provides a checklist of items to consider as we formulate new governance structures. For those of us who are already within an integrated system, the article gives us better definition and understanding of the problems we face in governing a larger entity with diverse constituencies. After paying tribute to this helpful system of taxonomy, we are left thoughtfully nodding in appreciation and agreement but without the answer to the most difficult questions facing many community hospitals contemplating merging into an integrated system. Can a governance structure created to address economic issues accommodate social mission? Community hospitals were created and governed by local citizens to provide health care to towns and cities all across this country. people they served were never described as but as the citizens of neighborhoods and parishes. elements of community transcend the bounds of a term like population and speak to a human consideration with roots based on the very reason that our local hospitals were founded and by which they enjoy philanthropic support. Despite the authors' assertion that IHCDSs must be held responsible for improving the health status of the population, health care institutions and physicians most often seek to merge or integrate, as Russell Coile (1994b) has said, to share a capitated premium in the new world of managed care. This shift in mission from one of service to one of economic survival is the prime angst of those who must justify new governance structures that often relegate important social responsibilities to decentralized advisory boards. authors have drawn on their participation in focus group discussions held among CEOs of integrated systems. Perhaps, as we listen to the voices of individuals already swept into the maelstrom of multi-institutional systems, we should realize that these leaders are irrevocably committed to trying to bolster the governance structure of systems whose most important mission is the survival of the system as an economic force. In reviewing some of the same material generated from the AHA conferences on the governance of integrated systems, I was struck by the rhetoric used to justify such things as the reimbursement of board members or the centralization of decision making. References to the practices of multicompany corporations with centralized authority and focused corporate mission were made with the clear implication the industry provides the governance model that we should emulate in structuring a large IHCDS. Admittedly, it is certainly easier to make crisp business decisions if you can reduce the influence of local community boards whose interests reflect long-standing social missions. Thus, it is the agenda behind the IHCDS rather than the governance structure itself that may be the most important determinant of the appropriate governance model. Integrated system governance, as the authors have outlined, can range from very decentralized systems with a fair amount of local autonomy and representation to highly centralized ones with almost no influence in governance. But is there a governance structure that can accommodate local social concern as well as economic survival? New Concept of Virtual Integration Jeff Goldsmith's (19941 recent article, The Illusive Logic of Integration, reviews the past decade of integrated system formation and finds, like others, that as yet it is hard to document that there is added value to the communities or defined populations they serve. …