Investor-owned chains and teaching hospitals. The implications of acquisition

Against customer service

This essay examines the nature of service in medicine and the relationship between service and profit. "Customer service medicine" is identified with the interrelated views that 1) profit is or ought to be healthcare's fundamental concern and 2) the quality of medical service corresponds to the degree to which it produces a feeling of approval in patients. This position is contrasted with the more traditional "beneficence model," which holds that 1) service ought to be healthcare's fundamental concern and 2) the proper criterion of quality medical service is the alleviation, mitigation, or prevention of the human suffering that occasions illness. Five shortcomings in the customer service model are identified: 1) customer service advocates often appeal to an unsound "efficiency argument"; 2) the prioritization of profit over service will vitiate patients' legitimate trust in healthcare; 3) the prioritization of profit converts medicine from a "practice" into an "instrumental activity"; 4) the prioritization of profit countervails the values of continuity and thoroughness; and 5) the notion of service as customer satisfaction derives more from the exigencies of turning a profit than from an analysis of sick persons' needs.

Corporately managed health care and the new role of physicians

The roles described are not all-inclusive, since a small proportion of physicians, as in times past, will continue to pursue diverse careers outside of an tangential to health care. Neither are the roles mutually exclusive, as physician-managers are also organizational employees, as independently contracting professionals may also be partly fee for service, as physician entrepreneurs may be fee for service practitioners or contracting professionals, and so forth. The point is, that as the delivery of health care becomes a more complex and formalized process, and as large organizations delivering and insuring health care become more predominant, the various roles of physicians are becoming more distinctly obvious. What are the implications of this trend toward greater internal segmentation of the medical profession? At this juncture, they are not entirely clear. It could mean that some groups of physicians will achieve higher status and more rewards than other groups, which might result in greater conflicts within the medical profession. Undoubtedly, the emergence of corporately managed health care and the development of new (and possibly divergent) roles for physicians confronts the medical profession and its members with the gnawing questions of who they really are and what do they really want to be? Ultimately, the greatest challenge may be in finding a common set of commitments and values which transcend our many different roles, and which provide physicians with a clear and continuing sense of ourselves as medical professionals.

Proprietary hospital chains and academic medical centers

This article examines the reasons why proprietary hospital chains have become interested in buying or managing academic health center hospitals. Among the explanations that are discussed are such factors as vertical integration of health care, chain legitimation, integration of finance and delivery systems, and short-term profit potential. These factors are further examined through the use of a structured analysis of the interpenetration of proprietary chain hospitals and academic medical centers. We also discuss the consequences of these linkages in terms of such issues as continued educational mission, types of sponsored research programs, degree of indigent care provision, and changes in the nature of physician and other health worker training. The larger social implications of the movement of proprietary chains into tertiary medical care are evaluated.