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Abandoning our utopian fantasy

June 1, 2007
by Edward R. Jones, PhD
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Field professionals must come to grips with the realities of the business world

My career has taken many twists and turns. I have worked on my own in private practice and have jointly owned a multidisciplinary group practice. I have been an employee within nonprofit and for-profit corporations, and I have worked in companies with fewer than 50 employees and more than 8,000. Today I am the executive director of a small, private-pay, residential treatment program for chemically dependent adults, and last year I was a senior executive for a large managed behavioral healthcare organization. Many colleagues suspect I might have whiplash from such a move, while others are convinced that I lost any moral compass when choosing to spend more than eight years in the managed care industry.

In my mind I am the same professional who received a license as a psychologist more than two decades ago, and I simply have been choosing different business environments to ply my professional skills. My sense is that many professionals want businesses to conform to their professional view of the world (i.e., “give me autonomy, high pay, and blissful ignorance of business realities”). I, instead, always have accepted that I had to figure out how to promote the highest quality care (my passion as a professional) in whatever business environment I entered. In other words, I love my profession, but I have a deep respect for the world of business. I believe that wherever you decide to use your professional skills, you should understand your business environment in depth and be able to “follow the money.”

For example, in the 1990s I owned a group practice that contracted with numerous managed care companies, and I came to understand that insurance benefits were contracts with explicit limitations. My contract with each managed care company stipulated that my treatment providers would provide only clinically necessary services. I often had to train practitioners who worked for me to understand these concepts, and during my years as a managed care executive I heard this basic dialogue between care managers and clinicians every day.

My sense is that most professionals would prefer to work in a private-pay environment, viewing the less complicated reimbursement and the autonomy as being more consistent with the professional role. This is fine if you can attract enough high-income people to use your services, but too many people confuse the high-flying professional with high quality. I have discussed “quality assurance” with many professionals through the years, and there is a prevalent view that can best be summarized as “just trust me, I am a licensed professional.” In fact, autonomy and high compensation may be wonderful job qualities, but they are no guarantee a professional can deliver quality services. Rather, they are part of a professional utopian fantasy.

We have many reasons to be frustrated with the state of U.S. healthcare, but the bitterness spawned by not having this professional utopian fantasy is one current of discontent for which I have no sympathy. While many consumers seem to believe they are getting a higher quality product or service when they pay more for it, this should not be misunderstood by providers to be any verification of quality. Consumers are desperately searching for any mark of quality and should be forgiven for believing that cost is the best measure.

The best antidote to the professional utopian view is the competitive business view. While many professionals seem to believe they have earned the right to a good living, most business people understand they simply have rights to compete in the marketplace. Competition has certainly led to some unsavory business practices, but this is generally due to the nature of the competition. When competition is focused solely on becoming the biggest or most profitable entity in an industry, quality is likely to be compromised.

What, then, constitutes healthy competition?

Michael E. Porter and Elizabeth Olmsted Teisberg answer this question in their book Redefining Health Care in a way that satisfies my longstanding desire to be both a competent professional and a successful business person. They start by acknowledging that competition in healthcare today is failing to deliver care that is continuously increasing in quality and decreasing in cost, and they identify the nature of the competition as being the cause. Their core argument is as follows:

The way to transform health care is to realign competition with value for patients. Value in health care is the health outcome per dollar of cost expended. If all system participants have to compete on value, value will improve dramatically.1

As a treatment professional I have evolved in my thoughts about health outcomes. I now have an absolute belief that we must provide empirical evidence that clients are benefiting from the services we deliver. This belief has many sources, but one is my exposure to the realities of business.

A business always is evaluating its performance in a variety of ways, and this should be a routine practice for professionals, as well. We are all healthcare consumers, and as a consumer, which would you prefer: a healthcare system that demonstrates the quality of its services with hard statistical measures, or one dominated by professional associations that monitor themselves with the assumption that quality can't really be measured?