Health Professional Leadership
Normal is getting narrower and narrower.
—Personal observation by an experienced nurse practitioner
Health professionals can be important participants in health policy processes. They bring their experiences, their knowledge of both science and art, their ability to distinguish between the two, and their commitment to the patient. Typically, they also bring a commitment to lifelong learning. The power of the professions, especially physicians, has been waning of late, but that has a lot to do with the height of their dominance in the past. In an open, market-driven, information-rich society, the old monopoly power described by Starr (1982) is not sustainable. Health professionals now need to undertake new leadership roles or else their status will be further undermined by those actively seeking a greater share of the pie. Those new roles will have to focus more on collaboration and coordination of care.
Much of the diminished respect for health professionals stems from the public’s perception of reduced disinterestedness. Current fashion in economics seems to deny the concept of disinterestedness—the concept of lack of bias and freedom from special interests, the ability to set aside one’s own interests and to seek the best possible outcome for others. The opposite is the oft-repeated phrase, “All they care about is money.” Money is harder to come by in most parts of the health care system because of utilization controls and deep discounts to health care plans, and thus the increased concern is understandable; however, that is not reassuring to the public. Much of the literature on the rising costs of care blames the current fee-for-service system for making it in the providers’ interest to promote overutilization. Schlesinger (2002) argued that this loss of faith seemed to intensify with the advent of Medicare and Medicaid, and that that has led to a loss of political power as well. One parameter of successful professional leadership will be the ability to engender faith that the professional and the profession have the interests of other constituencies in mind.
15.2 INFORMATIONAL CREDIBILITY
Disintermediation in general and direct-to-consumer advertising in particular have affected the informational monopoly of the health professions. This is not a one-way street. The claims and counterclaims of the various interested parties can be hard to sort out. One leadership role for the health professional is to guide the general public through that welter of information. This is not just a physician’s task. It involves all health professionals. An article in BusinessWeek asked, “How Good Is Your Online Nurse?” and compared the online patient portals of the three largest health insurers: WellPoint, United Health Group, and Aetna (Weintraub, 2006). The trends reported in the article included greater integration with patient records, more add-on purchased counseling, and more personalized responses. It concluded, “A bit like Big Brother? Sure. But as health care gets more complex, it’s comforting to have a virtual coach” (p. 89). Despite the word “nurse” in the title, the article compared the companies’ automated systems that tailored the information. One insurer did offer written and telephone nutritional consultations for a fee, but the professional component was largely invisible in the process. Maintaining the power of the professions in the future will require efforts to maintain acceptance as a unique and relevant information domain. There is relatively little art in computerized communications, and the public might well want more in the way of art, if it is offered. Procedural control alone is a slender reed upon which to stake the future of a profession. Conceding the informational domain to others is risky. The countertrend is the rise of boutique medical services, which offer more access and attention for an annual fee.
15.3 TO INFLUENCE GLOBALLY, START LOCALLY
The health professional’s power to participate effectively in the political process is earned through leadership in one’s profession, in one’s institution, and in one’s community. Although some leaders and spokespersons appear to have burst onto the national scene directly—Dr. Donald Berwick in government and health quality improvement, for example; Dr. Atul Gawande with his New Yorker articles and his books; and Dr. Paul Farmer in international health—most rise slowly through the ranks of their profession as team players. The routes to leadership positions are varied. Health professionals are in leadership roles in medical centers, community hospitals, government agencies, and insurance companies. Each presumably came by his or her position by training, intelligence, hard work, and usually trustworthiness. They were able to convince others to work beside them and for them because they could be trusted to take the interests of others into account.
Leadership career paths often overlooked in the health policy arena include those in corporations and in entrepreneurial ventures. A number of very influential health professionals have stopped delivering care directly and have moved into the management of health institutions, insurance companies, occupational health, medical device and supply companies, pharmaceutical companies, and government agencies. They represent those institutions, and many seem able to do so without negating the trust of health care decision makers. Their leadership roles may have been thrust upon them, or they may have sought them. In either case, they took a prepared mind and a sense of what they wanted to accomplish in an arena of health care policy.
The press seems to emphasize the importance of careers in publicly held companies, as considerable wealth can be created by developing a company and taking it public. After the company goes public, however, it is beholden primarily, if not solely, to one set of stakeholders, the stockholders; therefore, there is still a major role in health care for the nonprofit organization that does not have stockholders and can balance a number of competing interests. A deeper knowledge of nonprofit organizations and their behaviors is necessary for determining their role in setting and implementing health policy. This is especially true of entrepreneurial nonprofit organizations that can participate in the marketplace as fully as a stock corporation. Leaders must understand the similarities and differences in how these types of organizations function. The term governance is often applied to the roles of management, staff, and boards of both for-profit and nonprofit organizations. The professional leader must be able to function effectively and help govern effectively in one or the other or both.
15.4 PROCESS INNOVATION
There seems to be a consensus developing that there is great potential in the area of process innovation. This goes well beyond improving current processes and moves into major changes that meet the criteria outlined by the Institute of Medicine’s (IOM) Learning Health System initiative and its Innovation Collaborative (IOM, 2012a, 2012b). Those criteria included:
• A participatory, team-based transparent culture
• Patient-anchored and patient-tested processes
• Fully active and engaged patients and the public
• Informed, facilitated, shared, and coordinated decisions