Managerialism, in my humble opinion, is one of the major reasons why the US health care system is so dysfunctional. We have long discussed how people whom we first called "generic managers" have taken over health care. Increasingly, health care organizations, including hospitals, pharmaceutical companies, health insurance companies, government agencies, etc are now led by people with management training, but not necessarily with any training or background in medicine, biomedical research, epidemiology, public health, or health care policy. We began noting how such generic managers often prioritize short-term revenue over all other concerns, presumably based on the shareholder value dogma taught in business schools (look here). Worse, generic managers may be ignorant of, misunderstand, or be frankly hostile to the core values of health care professionals. (See our posts on mission-hostile management.)
More recently, we found that our observations could be better described as aspects of "managerialism." We noted an important article that in the June, 2015 issue of the Medical Journal of Australia(1) that made these points about managerialism:
- businesses of all types are now largely run by generic managers, trained in management but not necessarily knowledgeable about the details of the particular firm's business
- this change was motivated by neoliberalism (also known as economism or market fundamentalism)
- managerialism now affects all kinds of organizations, including health care, educational and scientific organizations
- managerialism makes short-term revenue the first priority of all organizations
- managerialism undermines the health care mission and the values of health care professionals
Many health care professionals mutter under their breath about the behaviors of their managerialist leaders, but there has been little open discussion of managerialism, and no organized movement against it.
Last week, I found an excellent example of how managerialism has become the norm in health care.
A UPS Executive Becomes a Hospital Executive
An article in the Buffalo News on May 26 recounted how one Mr Martin Boryzak ascended to the the position of CEO of Sisters Hospital and its St Joseph Campus.
His Highest Degree was an MBA
Per his Linked In page, from St Bonaventure University.
He Ascended to Hospital Management without Any Medical or Health Care Background
Per the Buffalo News,
The Buffalo native was working for the package delivery company in Philadelphia in 2009 when Catholic Health recruited him after his mother, a nurse in the hospital system, slipped his resume to management unbeknownst to Boryszak.
He joined 290-bed Sisters that year as director of finance and was also named vice president of operations at 123-bed St. Joseph Campus in 2012. In 2014, he rose to chief operating officer at Sisters.
He Believes He Has No Need for Health Care Background, Because It is All About the Revenue
Per the Buffalo News, first
Martin Boryszak, the new president and chief executive officer of Sisters Hospital and its St. Joseph Campus in Cheektowaga, came to health care from what seems like an unusual route – UPS.
The differences in the businesses are not as great as you might think. As Boryszak sees it, they both adhere to basic business principles.
Q: Does it matter whether you have an academic background in health care?
A: It depends on the person. The most complicated piece of health care is the revenue. And, in that respect, it's not unlike any other service industry. The best way to maneuver through that is not that unique. When half your revenue comes from the government and the other half is influenced by what the government does, it's a difficult thing to navigate. Once you figure that piece out all other business principles are applicable.
Q: What keeps a hospital CEO up at night?According to Mr Boryszak, hospitals are just another business. Keep the money coming in, and everything will be fine.
A: Where is your revenue coming from....
What About the Hospital Mission, the Care of Patients, the Values of Health Care Professionals?
The closest Mr Boryszak got to any of these issues was in his reflections, if that is the word, about his career at UPS.
I liked what I did, but wanted a balance with some type of calling. I wanted to feel that I was making a difference. It wasn't a function of UPS because it has great people and is a great company. I enjoyed every minute there but felt as though there was something more. I was recruited and never really thought about health care, but what better industry to drive change.
He said not a word about what hospitals actually do. He could not even define the "sort of calling," the sort of "difference" he might make, the kind of change that should be driven.
There you have it in a nutshell. Here is an MBA running a hospital that feels not the slightest need for training or experience in medicine, biomedical research, epidemiology, public health, or health policy. He wanted to do something involving a "calling," and would "drive change," but expressed precisely nothing about the nature of the calling in the hospital setting, or the sort of change to be driven. He thinks the most complicated issue in health care is "revenue." Presumably he feels revenue is more complicated than determining a difficult diagnosis, managing an acutely ill patient, counseling a patient with chronic illness, or consoling a patient who is dying, if he even understands that those are some of the things that go on in a hospital. Furthermore, he seems to feel entirely comfortable issuing orders to health care professionals who need to take on such tasks, and more.
Thus has managerialism been normalized, or maybe I should say thus has deviancy been defined down.
As an aside, the reporter interviewing Mr Boryszak also seemed entirely comfortable with the notion of an MBA without health care experience or training, and apparently without understanding of health care professionals' values running hospitals, and entirely comfortable with the notion that the most complicated thing about health care is generating revenue. The reporter never even slightly challenged any of this.
Thus has managerialism been normalized.
So as we have said endlessly,...
We need far more light shined on who runs the health care system, using what practices, to what ends, for the benefits of whom.
True health care reform would enable transparent, honest, accountable governance and leadership that puts patients' and the public's health over ideology, self-interest, and self-enrichment.
Can that happen in a world in which the business CEO is viewed as the highest form of life?
1. Komesaroff PA, Kerridge IH, Isaacs D, Brooks PM. The scourge of managerialism and the Royal Australasian College of Physicians. Med J Aust 2015; 202: 519- 521. Link here.