The White Labyrinth: Guide to the Health Care System

This carefully researched assessment presents a reasonably accurate map of the health care system: the white labyrinth, with the organizational mechanisms that underlie its operations and strategies and approaches to change.

Category: Healthcare

This title is part of the Healthcare Administration list.

Of Interest:

Building a Health Care Organization: A Challenge for Physicians and Managers

Competitive Strategy for Health Care Organization

Evaluation and Decision Making for Health Services

Falling Through the Safety Net: Insurance Status and Access to Health Care

Fundamentals of HMOs

Harvest Moon: Portrait of a Nursing Home

Hospitals, Health and People

Long-Term Care in Transition: The Regulation of Nursing Homes

Management of Hospitals and Health Services: Strategic Issues and Performance

Managing Doctors

Partners: Forming Strategic Alliances in Health Care

Written for a variety of readers--whether interested citizens, students, or practicing health professionals--the book provides a systematic understanding of how health care is provided in the United States. It is a readable, candid, and thoughtful dissection of the problems confronted by both individuals and institutions within the health sector. Focus is on a detailed analysis of external environmental issues, financial as well as regulatory, affecting providers, as well as on the structural shifts in health care delivery, with both intended and unintended consequences.

The co-authors, both professors in the health-care field, start their lucid critique of the health-care system with their belief that one has to have a clear understanding of the present system in order to "escape" from it to a better system offering health care to all segments of the public for affordable costs. A choice quote from the top business consultant and author Peter Drucker concisely gives the reason why knowledge of the present dysfunctional health system is crucial to dealing effectively with it: "Young people today will have to learn organization the way their forefathers learned farming." Another way of saying this in keeping with the authors' perspective toward today's health-care system might be, "Know your enemy." And after reading their critique, no one would argue that the present system is not more of an adversary with respect to the health needs and concerns of the majority of the public than it is a benefactor. Not only has the current system demonstrated a chronic inability to control costs and address basic health needs of a large proportion of the public, but it shows every indication of becoming ever more irrelevant to the supposed fundamental purposes of any health system.

Without a thorough and accurate comprehension of the nature and workings of the current system, there is the likelihood that elements of it responsible for the general dysfunction will be included in any new system, leading to the same unwanted results. Over 80 years old (when the book was first published in 1986), the U. S. health-care system has become "a maze of budget overruns, professionals' self-interest, and regulations [in which] seasoned professionals sometimes lose their way." In this system, policymakers, whom one would suppose have both a normal humane desire for effective health care, instead inexplicably "are preoccupied with strategies for erecting more effective barriers to the utilization of services rather than tearing them down." Doctors, who should be at the center of the system, are instead but one group within the vast, complex system; and a group whose position and activities are all-too-often controlled by other groups such as administrators or HMO executives. About 1900, doctors accounted for 90 percent of all health-care workers. In today's system, doctors make up only seven percent, with only about 10 percent of this percentage identifying themselves as general practitioners rather than specialists.

Some attention is given to the history of the U. S. health-care system formed in the early 1900s. The passage of Medicare legislation in 1965 from a combination of economic trends in the health-care field, realities which had already set into it, and public pressures on politicians is cited as a crucial turning point leading to today's brobdingnagian, bureaucratized system. In this watershed moment, "[t]he definition of health care as an economic good rather than a social relationship or professional service gained ascendancy." At the time of the debates and legislation on Medicare, individuals in the fields of investment and finance recognized the changes being brought to the health-care field, making health care the "hottest investment area in the stock market."
But all the problems of the health system cannot be traced to the passage of Medicare in the 1960s. Medicare was intended to solve major problems which had developed in the health-care system in the decades leading up to the 1960s. But unfortunately for much of the population, Medicare brought its own basket of problems. These were made all the more worrisome and difficult to deal with because of the strong support for the new system among politicians and the host of lobbyists and government bureaucracies which had quickly sprung up in connection with it.

In their analysis and critique, Smith and Kaluzny also point to basic American cultural factors which work against a beneficial health-care system. As they note, the origins of American culture are found in the early settlers' desire to "get away from community pressures such as religion, military service, and taxation." Whereas a system such as Sweden's works because local medical-care boards in touch with their communities are the primary organizations, American health care suffers from the weak bonds of community resulting from the high value placed on individuality, social mobility, and similar cultural factors.

After going through the origins and structure of the health-care system in general, the authors turn to organizations within the system and individuals in these organizations. They see the sprawling health-care system in general as the environment to which the organizations within it and the individuals working in these have to adapt to survive. It is this adaptation that makes for the layers of bureaucratic mindset leaving the system so resistant to change for the better.

In the final section, "Escaping the Labyrinth," out of their clear-eyed critique, the authors specify a number of recommendations for making the health-care system more responsive and relevant. But more important than their recommendations, as pertinent and beneficial as these are, is the authors' formulation of four principles to guide any new practices or decisions in overhauling the system. These four guiding principles are decentralization, miniaturization, desegregation, and reappropriation. Desegregation for the health system means that services should be provided in the "least restrictive and least specialized settings consistent with good medical practices." This would limit the disproportionate place of specialists and routine use of costly technologies in health care. Reappropriation means that health services should be owned by those who use them, not corporate owners who operate them as profit centers fitting into a corporate structure.

"The White Labyrinth" is different from any other critique of the U. S. health-care system. After reading it, one realizes that the criticism of the system one constantly hears in the media, often accompanied by a particular heart-wrenching vignettte of some unfortunate person neglected or harmed by it, is a dialogue about symptoms of the system, not ways to replace it or even improve it. Such criticisms are like punching a punching bag hanging from a beam--one can punch as hard as one wants as long as one wants, but the next day the bag will still be hanging there ready to absorb another round of punches with nary any effect on it. What Smith and Kaluzny accomplish in their "The White Labyrinth" is the inestimably valuable task of making the invisible visible. With this book, policymakers, officials, health-care workers, citizens, etc., can at least see the daunting task ahead of them in instituting a respectable health-care system in this country. As the authors say when uncovering the cultural factors making for a deeply-flawed health system, "They are invisible. We are only aware of them when we bump into them..."; when it is too late to do anything about them, like holes in the earth one falls into. Knowing the political, bureaucratic, and economic forces lined up against devising a better health-care system, one is not optimistic even with Smith and Kaluzny's outstanding analysis and counsel. But one is thankful that the book has been done as one voice sounding clearly for commonsense, reason, and humaneness.

David B. Smith is a Professor of Healthcare Management at Temple University. Arnold D. Kaluzny is a Professor of Health Policy and Administration at the University of North Carolina-Chapel Hill. Both have written other books on health care.

Dr. Kaluzny is Professor of Health Policy and Administration in the UNC School of Public Health and a Senior Fellow in the Cecil G. Sheps Center for Health Services Research. He has been the recipient of numerous awards including the NCI Year 2000 Award, the Edward G. McGavran Award for Excellence in Teaching and Bernard G. Greenberg Alumni Endowment Award. Dr. Kaluzny is a nationally recognized expert in cancer prevention and control, health services research and evaluation, and organizational theory and behavior. He has served on numerous national committees including Chairman of the Board of Scientific Counselors for the NCI Division of Cancer Prevention and Control, was a member of the NCI Special Review Group on Cancer Control, and presently serves as an Associate Editor of the Journal of the National Cancer Institute. He is the author of numerous articles and has co-authored several books, including Managing a Health Care Alliance: Improving Community Cancer Care, with Richard Warnecke, and Partners for the Dance: Forming Strategic Alliances in Health Care, with Howard Zuckerman and Thomas Ricketts.

Professor Smith received his Ph.D. at the University of Michigan in Medical Care Organization and has previously held faculty positions at the Graduate School of Management at Cornell University and the Department of Community Medicine at the University of Rochester. He has also served as an IPA Fellow in the Office of Research and Policy of the Health Care Financing Administration. Currently, he is a Professor and Chairman of the Department of Health Services Administration in the School of Business and Management at Temple University.

He received a 1995 Robert Wood Johnson Health Policy Research Investigator Award for research on the history and legacy of the racial segregation of health care. He is the author or co-author of four books on the organization of health services and numerous articles in peer reviewed journals.