Does anyone else feel like we've been here before?
Back in the early 1980s, those of us who thought a holding company was a shortened version of Janis Joplin's backup band began to get the feeling that if we didn't have one at our organization, we might soon meet a fate similar to Janis'.
So we traveled to our attorneys' offices (not the local ones-only big-city lawyers would do) to meet with them in their beautiful offices overlooking majestic urban vistas. We felt important; we were making things happen.
We felt even better when the investment bankers appeared; they valued us for our true worth and gave us the respect that was so elusive and fleeting from the physicians and even our own trustees. Now, they were our colleagues.
We were proud, in a somewhat macho sense, of our new corporate organizations. The bigger the better, and they were very complex. It took a while to explain the intricacies of our strategy, so we spent a lot of time doing just that, using flip charts and slides to enlighten our medical staff, employees and trustees. We told them, "This is for the good of our mission, our community and our patients." We mystified many audiences, impressed others and left some shaking their heads in disbelief.
These wonderful structures allowed us to maximize reimbursement, avoid "inappropriate taxes" and expand our revenue base. To counter the naysayers, we proved the worth of our strategy with beautiful new edifices. We spent millions on our new programs, and our architects made sure our facilities reflected our success.
Unfortunately, some disturbing trends developed in our communities that didn't fit so neatly into our organizational charts. AIDS appeared and grabbed the headlines. With less fanfare, tuberculosis arose once more, and we had to scrounge around to find a place to treat this unforeseen patient segment. Childhood diseases long thought eradicated reappeared, turning the gaps in our immunization system into gaping holes.
As we studied our organizations and optimized our payments, our cities fell apart. Rodney King and Reginald Denny ushered in the 1990s as Los Angeles' most famous emergency department cases, symbolizing a fractious, troubled and still-racist society. With the prevalence of handguns and associated violence, urban children began to preface comments about their future with the words, "If I grow up*.*.*.*"
As the tax burden grew to deal with these social issues, those in our communities wondered why the healthcare organizations-the ones with the fancy corporate charts and stylish facades-shouldn't help with the burden. So, we got out a new set of slides and explained just how much we already were doing and spoke about our limitations-it wasn't our fault that children weren't immunized, that pregnant women wouldn't attend prenatal classes at our facilities or that housing and nutrition were substandard.
But a few executives began to wonder if they were on the right track. "Just what is our institution's true role?" these few started asking. "If the health status of a community isn't our responsibility, then whose is it?"
In time, the rest of us began to consider the possibility that even though we provided lots of charity care, that wasn't enough; we needed to connect to our community in a more fundamental way.
And then, just when the phrase "community benefit" became part of our routine vocabulary, some said, "We should do even better. The issue facing us is basic to our very role in society and doesn't lend itself to a checklist or a financial computation. Our communities need to feel our worth, not be convinced of it. Nothing less than our committed leadership in addressing lackluster immunization programs, too-high infant mortality rates and the other ravages of poverty will do."
Finally, we began to see progress.
But now, as our field is gripped by fear over what healthcare reform may or may not be, this progress may slow. The headlines in our journals and newspapers indicate that a new form of organization-chart fever is appearing. These are very big, very complex charts that put several hospitals, physicians and insurance products and all kinds of organizations on one piece of paper.
In some cases, these organizations are good. But in many cases, they represent little more than temporary institutional defenses against inexorable demographic and economic trends. They are the holding companies of the 1990s.
Moreover, if we give to their creation the same single-minded devotion we gave to their predecessors', and don't focus on the results that these organizations are supposed to achieve for their communities, they again will serve to separate us from our communities.
You may recall the movie "The Natural," starring Robert Redford, which was based on a book by Bernard Malamud. Mr. Redford plays a Ruth-like ballplayer, Roy Hobbs, whose talent is exceeded only by his desire for the fast life. After losing most of what he held dear to his hedonistic lifestyle, he redeems himself in the movie's climax by hitting the kind of home run that only Hollywood can produce, saving the day for his team. We all left the theater feeling very, very good.
The primary difference between the book and the movie is the ending scene. In the book, at his team's critical moment, Roy Hobbs strikes out. Mr. Malamud's sobering theme is that mankind is doomed to make the same mistakes over and over again.
As we organize to face reform, let's be careful this time. I can almost hear those opening chords for "Kosmic Blues."