Politics. It was a big deal then but rarely mentioned today. President Bill Clinton was the first president with no military service on his c.v. Until that point, military service was considered necessary to serve as Commander in Chief.
Certainly, a military background would have been valued by the electorate because running the armed services is in the president’s job description. A pretext of national sovereignty is competent military. Except in Switzerland but they have the gold.
More than that, the structure of the U.S. Military is replicated throughout the federal government. The Post Office is run by the Postmaster General under a set of nearly inflexible rules, like mailboxes are for U.S. Mail only, often punishable with heavy penalties. The highest-ranking public health official is the Surgeon General. He wears a uniform and directs the public health corps.
Until the lawyers got a hold of things in the 1960s, federal government service was an extension of or a replication of the military experience. Men who did not serve in the armed forces at some point were viewed with some suspicion.
Military service also created a shared experience, a point of connection to voters, primarily men. From that shared experience arose consensus about certain basic things, like western civilization has pretty good track record, that were generally beyond debate.
Now that nothing is beyond debate, even those things that oughta be, we are thinking about some institutions differently. Or we should.
Policy. The health care industry can be forgiven for thinking of itself as an extension of the federal government. After all it began its development in wartime. The recently departed HNGR got its start making wooden prosthetics for the Civil War’s amputees.
(Antibiotics were yet to appear with the result that three out of four surgeries performed were amputations during the war. It is said that very few men in Mississippi had all four limbs in the late 19th c.)
Until about 1995 most physicians were veterans, having served in the Korean or Vietnam Wars or World War II before miliary service became optional. The entire structure of the system was designed to function in a command-and-control environment with no regard for patient experience, not to mention workforce satisfaction.
That shadow of a military heritage has persisted the longest at the large Academic Medical Centers where highly credentialed research physicians rule the roost, making life nearly unbearable for nursing staff, as documented in labor disruptions.
The biases of physician leaders at large non-profits have also led to hospital-centric model, that appears unprepared for a competitive landscape. Competition is real, however, and the large non-profits that dominate the American Hospital Association are doing their best to clip its wings.
As Senate Finance reported out a host of health care provisions last week, it chose not to include the modest site-neutral policies favored by the House of Representatives. The AHA knows, as does everyone else, that the longer it can keep its finger in that dyke, the better.
For them, anyway.
Power. Even a cursory review of HCA’s recent Investor Day deck will tell you the AHA is going to need PhaRMA-level lobbying to hold back the tide. The business management describes is a significant departure from both its own legacy and that of the industry.
When Ambulatory Surgery Centers found a spot in the reimbursement regime in the 1980s, HCA founder, Dr. Thomas Frist, Sr. famously declared that surgeries were to be performed only in hospitals.
Dr. Frist – known around Nashville as “old Dr. Frist” or “Tommy, Sr.” - hailed from Meridian, MS (and I can bear witness to his retention of all four limbs) and served in the U.S. Army Medical Corps during World War II.
For a long time, the primacy of the hospital-based model was honored.
The company today consists of a web of interlocking strategies to maximize customer convenience, advance medical science and yes, defend reimbursement aggressively.
Most notably in this new era of labor markets is a dedication to workforce development, something rarely discussed among non-profits.
It is a quite a turn of events, likely accelerated by all the cash that sloshed around health care during the Public Health Emergency, and unlike what we see in the non-profit world.
Have a great rest of your weekend.
Emily Evans
Managing Director – Health Policy
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