1. Issel, L. Michele PhD, RN

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Health Care Management Review was launched 40 years ago. The RAND Health Insurance Experiment was only 3 years into family recruitment and data collect. This study stimulated conversations for decades about the influence of payment mechanisms on health-care-seeking behaviors. The Health Maintenance Organization Act of 1972 was still news. This legislation and subsequent legislation regarding managed care organizations opened the doors for insurance companies and entrepreneurs to create the alphabet soup of PPOs, IPAs, and Health Maintenance Organizations. We still referred to our physician as the one providing care; we did not yet have the new terminology of PCP, NP, APRN or just plain provider, irrespective of background and training. We did not yet have AIDS/HIV, SARS, or multidrug-resistant TB as ongoing public health treats, nor did we have preparedness or the obesity epidemic. We did not yet have widespread use of MRIs, CT scans, lithotripters, or sonograms and the pantheon of technicians who come with these technologies. Single hospitals dominated; the hospital mergers and conversions had not yet created the vast health care systems of today, with physicians as employees and vertical integration of services. The discipline of health services research did not yet have a professional association; the Association for Health Services Research (forerunner to AcademyHealth) was established in 1981. It goes almost without saying that we did not have bedside computers, pagers, or electronic medical records.

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These and the multitude of other changes to the financing of health care services, to the organizational structures for delivering health care, and to the diversity and characteristics of the workforce cumulatively constitute an evolving context in which health care managers and administrators function. In reflecting on these changes, I wondered what have been the accompanying or subsequent managerial and administrative changes and advances. Employees are still people, with the same cognitive processing capabilities. Work groups and team processes still carryout much of the work required to provide health care services. Organizational processes still entail steering and having a direction. We have an ever-expanding body of evidence and best practices to guide clinical care and management practices. However, what has changed, really?


Top management teams have grown in complexity and diversity to better match the complexity and diversity within the health care organization and its environment. Approaches to management, perhaps reinforced by the quality improvement ethos, have become more participatory and systems focused. Much more data are available for use in the decision-making processes. Research methods and analytic approaches used to study health care management topics, issues, and interventions have greatly improved. Unfortunately, none of the internal or external changes have made us a healthier nation.


Looking forward to the next 40 years would be wildly presumptuous of me. What I do see or wish for is greater attention to utilization in daily practice of what is known about how to improve our health care systems. Many factors keep the United States from being in the top five healthiest nations in the world; some of those factors relate to how human capital in health care organizations is not optimized. We have added and added layers of bureaucracy and workers. Perhaps, it is time to simplify, subtract some layers, and get back to the basic service of human interactions that promote health and well-being. Find a way to get the best of the "old country doctor" into the technological mix that health care has become. Whatever is the way forward, Health Care Management Review will be there disseminating the best ideas and research.


L. Michele Issel, PhD, RN