Rationale, principles, and educational approaches of organizational transformation.

Abstract

Weaving through the drama we call managed care are three distinct plots that are playing out against a backdrop of escalating health care costs, uneven access to care, and a delivery system that frequently aggravates its users. The first plot concerns money and ownership: What will be the respective roles of the for-profit and not-for-profit sectors in providing the capital needed to rebuild the health care system? Who will own the system? What form of ownership leads to the best system performance? The second plot concerns the control of medical management: Will it be payers or providers who make the ultimate decisions about what care is given, how, and by whom? Although these two plots are of great importance, and certainly receive most of the public's attention, they cannot be adequately addressed without a thorough understanding of the third plot: the reorganization of health care delivery into integrated systems. It is this third plot that is the most revolutionary and the most fundamental; it is also the most obscure. Many, perhaps even most implementations of managed care fail to attend adequately to the restructuring of health care delivery. Rather, they superimpose new financial arrangements and external control mechanisms on the traditional, nonintegrated structures of fee-for-service medicine. In short, they manage costs, not care. Not only are such internally inconsistent efforts doomed to fail, but the stress and frustration they create for both patients and clinicians poison the waters for more sincere, creditable implementations. For precisely this reason, it is vital that we understand the organizational transformation that is at the heart of managed care, that we know how to distinguish the real thing from inadequate or even disingenuous implementations, that we not lose the baby with the bath water. Equipped with such understanding, we can help steer the changes in health care in a favorable direction, toward the emergence of new and more capable approaches to health care delivery that make it easier for clinicians to provide higher-quality, more efficient care. In this article, we describe the rationale and mechanisms for the creation of integrated health care systems. We also present ideas for educators about how to prepare future physicians for their roles in integrated systems. Finally, we reconsider the themes of money and control, and find that they are but subplots of the theme of reorganization. New forms of financial and medical management will be judged by their contribution to the performance of integrated systems and, ultimately, to improvements in the health of the community.