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Yves here. As if MBAs haven’t already done enough damage to the medical industry and hospitals in particular by putting profit (or in not-for-profits, greatly increasing administrator pay packages) over patients, the post below presents another ugly tale, of trying to fit hospitals into managerial Procrustean beds. This would be funny if it weren’t serious.
By Roy Poses, MD, Clinical Associate Professor of Medicine at Brown University, and the President of FIRM – the Foundation for Integrity and Responsibility in Medicine. Originally published at Health Care Renewal
Once, a long time ago, in a galaxy far away, doctors and hospitals did no marketing, and pharmaceutical marketing was restricted to health care professional audiences. Now, in the US, we have often seen the negative effects of exuberant marketing, often deceptive, on the health care system.
A Marketer Pushes More Marketing Influence on Hospital Management
Yet, in a post in the Marketing Insider section of MediaPost, a writer lamented that marketing does not have enough influence within hospitals.
About 10% of hospital budgets are designated for marketing. It’s been that way for years, with stagnant year-on-year growth.
That is in contrast to … Amazon, of course:
Amazon reported record profits in 2018, earning $10.1 billion in net income compared with just $3 billion the prior year. Amazon ranked as the nation’s fourth-largest advertiser in 2017, spending an estimated $3.4 billion in U.S. advertising and promotions.
It goes beyond Amazon, though:
Amazon is not the only company appropriately valuing marketing. Many modern consumer-focused enterprises are moving from seeking maximum ROI to actually transforming the marketing value chain.
IMHO, this shows how managers who run, or at least pontificate about running hospitals do not seem to have an idea what hospitals actually do. How does a hospital, the locus for providing care to sick and injured people, care provided by highly trained health care professionals sworn to put patients’ values ahead of all other concerns, compare to a web-based retailer, or to most “consumer-focused enterprises?”
Furthermore, the post pushes the value of marketing beyond just raising awareness of or promoting a product,
Part of the reason hospital systems are starting to spend more on marketing is that the function is broadening. Marketing teams are being asked to take on more strategic tasks, from managing the hospital’s brand and reputation to operationalizing patient engagement.
Traditionally, patient experience falls under the purview of quality or safety. But in the last decade, health systems have seen the marketing department’s impact on the patent experience, even going so far as to have marketing report to the chief patient experience officer.
One might think that the typical patient who comes to a hospital wants to experience an improvement in their condition, their symptoms, their function, reduction of their pain, or sometimes the remission or even cure of their problem. I do not see how any rational person seeking a fun experience would choose to go to a hospital. What marketing has to do with health care quality or safety completely escapes me.
The Rationale: a Misinterpretation of the Social Determinants of Health
The rationalization for involving marketers in patients’ experiences was:
Leaders are seeing that the care they provide accounts for just 20% of patients’ optimal outcomes. The rest is attributable to factors like social determinants of health. Today, if hospital systems want to keep patients healthy, they have to influence experiences patients have outside the hospital walls.
The notion that marketing by a hospital would be an optimal way to positively influence social determinants of health is bizarre, to use a polite term. To quote an article entitled “Beyond Health Care: The Role of Social Determinants in Promoting Health and Health Equity” published by the Kaiser Family Foundation,
Social determinants of health include factors like socioeconomic status, education, neighborhood and physical environment, employment, and social support networks, as well as access to health care. Addressing social determinants of health is important for improving health and reducing longstanding disparities in health and health care.
What could hospital marketing do to affect such factors? Instead, the writer explained:
Hospitals and health systems are moving beyond simple outreach and using the principles of marketing — such as segmentation, personalization and meeting consumers where they are — to engage patients in changing behavior and getting them invested in their own well-being.
Health systems must ensure that every time a patient interacts with their brand, that interaction keeps patients engaged and satisfied and delivers on the fundamental promise that they make to their patients: making and keeping them well.
Again, what has that to do with socioeconomic status, education, neighborhood and physical environment, employment, and social support networks? Rather than talking about social factors, the writer appears to be talking about some efforts to change individual patients’ behavior.
However, the KFF article made a clear distinction between social determinants of health and individual health behaviors, while asserting that social determinants of health may influence individual behaviors, but not necessarily the other way around:
While there is currently no consensus in the research on the magnitude of the relative contributions of each of these factors to health, studies suggest that health behaviors, such as smoking, diet, and exercise, and social and economic factors are the primary drivers of health outcomes, and social and economic factors can shape individuals’ health behaviors. For example, children born to parents who have not completed high school are more likely to live in an environment that poses barriers to health such as lack of safety, exposed garbage, and substandard housing. They also are less likely to have access to sidewalks, parks or playgrounds, recreation centers, or a library.4 Further, evidence shows that stress negatively affects health across the lifespan5 and that environmental factors may have multi-generational impacts.
Thus, to argue that hospital marketing could influence individual patient behaviors and thus positively affect social determinants of health makes no sense.
Summary: Managerialism, Again
I applaud the writer’s implication that
hospital systems want to keep patients healthy
(As an aside though, hospitals cannot want anything, but the people who work in them can.)
But however well intended, or at least rationalized, marketers pushing their greater involvement in patient experience, even if it is not self-serving, seems like just another push for the managerialism that already haunts health care.
Managerialism is the belief that trained managers are better leaders of health care, and every other sort of organization, than are than people familiar with the particulars of the organizations’ work. Managerialism has become an ascendant value in health care over the last 30 years. The majority of hospital CEOs are now management trained, but lacking in experience and training inmedicine, direct health care, biomedical science, or public health. And managerialism is now ascendant in the US government. Our president, and many of his top-level appointees, are former business managers without political experience or government experience.
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
Managerialism may be a major cause of mission-hostile management. In non-profit hospitals, mission-hostile management threatens care of vulnerable patients, particularly by prioritizing hospital revenues, and the financial self-interest of management over patient care. Note that the rise of the manager-leader occurred at a time when management schools increasingly preached the dogma that maximizing shareholder value, usually equivalent to maximizing short-term revenue, should be the first, if not the only goal of all managers (look here). For example, an article on the miseducation of Sheryl Sandberg, Facebook’s chief operating officer, asserted that
Harvard Business School, like much of the M.B.A. universe in which Sandberg was reared, has always cared less about moral leadership than career advancement and financial performance.
Managerialists may be convinced that they are working for the greater good. However, I am convinced that our health care system would be a lot less dysfunctional if it were led by people who actually know something about biomedical science, health care, and public health, and who understand and uphold the values of health care and public health professionals – even if that would cost a lot of very well paid managerialists their jobs.
Reference
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.
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Shakespeare’s quote in King Henry the Sixth act4 sc2 “First we will kill all the lawyers.” will in the not too distant future be updated to ” First we will kill all the MBAs”. As to the method, to quote my Irish mother’s phrase applied to the British army “Shootin wud be too gud for dem feckers slow hangin wud be more appropriate.”
A common misconception. Context is everything. Whether you agree or disagree. [Emphasis mine.]
[Note link does not appear in preview, so I”m repeating.]
https://www.howardnations.com/wp-content/uploads/2013/08/Shakespeare.pdf
I have a 15 year old son. We were watching TV. A commercial came on. A pharma, slow motion, all smiles. He looks at me and said, ‘Marketing is fraud’. I think I’ll get a t-shirt printed……
utter hypocrisy.
they assert that their marketing will lead to improved ” socioeconomic status, education, neighborhood and physical environment, employment, and social support networks”…when treating health as a business helps do exactly the opposite.
I’m a Human, not a “consumer”…that’s the fundamental ontological disconnect.
and the weasel words that follow are atrocious! “Patient Experience”?
lol.
our “experience” has largely consisted of fear, uncertainty and doubt.
Patient outcome (survival rates, readmission rates, etc.) would be marketly improved if they would just thoroughly and systematically sanitize the phones in the patient’s rooms.
One expects that the prevalence of managerialism is in part responsible for the financialization of many businesses. Professional managers may not know much about any particular business, but cooking the books, manipulating share prices, and looting a company can work in may different fields.
Brilliant! I laughed until it hurt! I’m soooooo stealing this!
I still get marketing material in the mail from the hospitals that my parents dealt with while they were dying over 10 years ago. No amount of calling or writing has stopped it.
Hmmmm, that’s marketing mail I’ve been missing. Nothing from the hospital — yet.
My nurse manager definitely fits the definition of a “generic” manager, despite the fact that she has a master’s in nursing. After having a few brief conversations with her on some work-related matters, there is little doubt in my mind she knows next-to-nothing about the specialty area that she manages, which is nephrology and dialysis. Even though she was hired without any nephrology or dialysis experience, the hospital has sent her to enough nephrology and dialysis classes and has flown her to enough nephrology and dialysis conferences that her knowledge level of both nephrology and dialysis should be at least above average. But it is not. It is nowhere close to above average.
So why is this so? And perhaps more importantly, why does the hospital allow such form of incompetence to happen, especially given that all previous nurse managers in nephrology and dialysis were the most knowledgeable nurses in the hospital when it comes to these two medical specialities? Some would argue that she is just plain dumb or that she was simply not paying attention in class. But my theory is that she really has no need to know anything about nephrology or dialysis from either a nursing or medical angle. That’s because she has four assistant nurse managers working below her that do have a good working knowledge of both nephrology and dialysis and are readily available to help her out whenever she doesn’t have a clue as to how to handle any nursing-related issue or problem on the unit that comes her way.
This has resulted in a strange working relationship whereby the assistant nurse managers protect the manager from not knowing much at all in exchange for the assistant managers getting away with doing little to no work. The assistant managers have so much free time at work that many of them over the year have spent most of their time at work doing schoolwork, planning a wedding or doing other such personal business at work. And if any staff nurse complains about this to the manager, the manager just looks the other way. After all, she’s a big beneficiary in this two-way protection racket between herself and the assistant managers. If she don’t protect her assistant nurse managers from doing nothing work related at work, they won’t protect her from knowing nothing work related at work.
Unfortunately, two-way protection rackets of this kind are probably occurring throughout the entire management track at the hospital, from top to bottom. And if there weren’t so many generic managers throughout the hospital, there wouldn’t be as many two-way protection rackets between clueless managers and lazy, self-centered assistant managers. I see this as the leading cause of managerial bloat in the hospital. Needless to say, if managers had a good working knowledge of the particular specialty area they are managing in the hospital, there would be no need to employ assistant managers. This would reduce managerial bloat, sending more money and resources back to the bedside, back before generic managers ever existed. Then finally, as a result, hospital care would improve and hospital costs would go down.
Reminds me of a young (oddly male) Nurse Manager who Managed at the very well known Women’s Cancer Clinic at the Hospital I go to. He sported being a leader in implementingLean Management™ (which, from everything I’ve read was another horrid, many times deadly, Capitalist Failure – at the very least as regards healthcare) on his resume and refused to respond to telephone calls despite the fact that it’s a teaching hospital which treats a significant amount of patients who have little to no reliable internet access, along with very wealthy patients. Pretty horrifying, especially when a person has cancer.
Worse (though I’m positive it’s likely the norm because I’ve witnessed it in other hospitals which loved ones have been stuck at), the well known hospital’s patient complaint group was hideously managed by a horrid woman whose only pedigree is obscene profiteering in the field of medicine. Interestingly, she has quite the name to match her highly defined predatory instinct.
The whole experience, which followed an even worse experience with a male intern, was petrifyingly abusive, I’ve not recovered from it.
“Lean Management”
But under its regime management is quite fat. Or does it mean “leaning on subordinates?”
Yeah, both of the above. Additionally, it’s likely that the ghastly Hospitalist™ craze – where ones family members, regular physicians and specialists (even when local) are never consulted about a patient’s background or prescription medications when they end up in ER; and those labeled Social Workers™ and Care Coordinators!™, who actually were hired to harass, or dispatch sick people who may run out of money or coverage (even mere minutes after they’ve just been placed on an ER bed) were ushered into healthcare around the same time as Lean Management™ and its horrid kissing cousin Six Sigma™.
A human being is not a Toyota (from whence all the insanity appears to have been birthed) vehicle, just for one thing, but even if one leaves that out of the equation, this from a surgeon:
[Source: Skeptical Scalpel, November 2016 Lean methodology and patient safety]
“Managerialism”? – It’s time consuming and obsequious; such disgraceful PR. It’s a fantasy stuck between money and morality. Any good medical privateer would want to just go straight to the Mengele Model. Forget your conscience altogether. We really should offshore all these guys and bring in honest medical care from just about any other country on the planet. Good bye Miss American Healthcare.
Marketing saves lives!