Subjectt:
Spring 2020 – InfoTech in a Global Economy (ITS-832-43) – Full Term
Please give the research topics by today or tomorrow morning and I will get it approved and then u can start the abstract.
Quick clarification about the research topic selection proposals and the abstract creation.
Ok, the final research paper is an individual deliverable, and not a group deliverable. So, I expect ALL the students to follow the following steps:
- select your own topic that you want to complete your final research about,
- send it to me via e-mail to review and approve
- receive approval from me,
- after you receive approval, then create your abstract.
- submit your completed abstract via SafeAssign to me for a grade,
- This will be the abstract that will guide your final research paper. Remember, per APA 6E guide, abstracts are between 150 – 250 words long.
- Part 1: Topic selection and approval will be (2% equivalent)
- Part 2: Abstract Formulation, and completion: Your research topic related work will be completed submitted via SafeAssign in iLearn. Your research topic must be selected carefully by researching through the UoC academic Library from peer-reviewed prior research work that is closely related to your topic to complete this section. This is an exercise that must be completed with care because, your research topic must be independently formulated by you, and not similar to any other previously researched titles (authentic)
School of Computer & Information Sciences
COURSE SYLLABUS
Course Name:
Professor:
Contact Information:
Online Support (IT)
and I-Learn Policy:
Course Website:
Course Description:
Course and Instructor Information
ITS832 – Information Technology in a Global Economy
Section – 43
Spring 2020 – MAIN term – Hybrid Course with Required Residency
Course Start Date: 01/06/2020 – 04/23/2020
Residency Session Date: 03/26/20 – 03/29/20:
Start Times: Friday 5pm – 10pm; Saturday 8am – 7:30pm; Sunday 8am-1pm
Residency Session Course Site: UC @NOVA College, 5000 Dawes Ave., Alexandria, VA 22311
Dr. John Bosire, PhD, MBA, PMP, LSS MBB
E-mail: john.bosire@ucumberlands.edu
Office Location: Remote
Office Hours: By appointment
All members of the University of the Cumberlands’ community who use the University’s computing,
information or communication resources must act responsibly.
http://www.ucumberlands.edu/it/downloads/terms.pdf
Access to the course website is required via the iLearn portal on the University of the Cumberlands
website: http://www.ucumberlands.edu/ilearn/
ITS 832 – Information Technology in a Global Economy: This course covers theory, development, and
impacts of national and international policy on IT. It explores how frequent shifts in public policy require
IT businesses to adjust rapidly to adhere to regulations. Students will develop sophisticated strategies to
be able to adapt to the changing environment including new technologies, global transfer, and analysis.
Upon completion of the course, students will be able to (Outcomes):
• Develop an understanding of public policy and how it impacts IT from a business and development
standpoint.
• Demonstrate the ability to perform analyses related to trade policy, standards, domestic and
international regulatory policy, and the impacts of changes in policy on the IT structure of a business.
• Describe an example of: (1) a public policy that had a positive and negative impact on IT
• Discuss the current trends in the global IT arena ranging from technology, hardware, policy, software,
and available services including out-sourcing.
• Define the activities and tools required to develop a sophisticated national and international strategy
for IT.
• List and describe available tools to assist business organizations in the development of a competitive
strategy.
• Understand how international and developing markets play an ever-changing role in IT; and integrate
that understanding into an existing strategy to develop reasonable estimates of the effect of new
products, services, and vendors.
• Describe an example of the effect of an emerging market on global IT competition.
1
Alignment Matrix
Course Objectives/Learner Outcomes:
Upon completion of this course, the student will:
• Summarize and demonstrate an understanding of eParticipation in policy-making in
the currently changing landscape due to trends in the freedom of information, the
wisdom of the crowds, open collaborations and the need for interdisciplinary
research
• Demonstrate and differentiate a basic working knowledge of the three major theories of
structuration, instructional and actor-networks and their use
• Explain the basic knowledge and the significance of eParticipation in bridging the digital
divide in developing countries
• Summarize and discuss an understanding of the core competencies and capacities
needed by public managers and policy analysts to be able to lead the next
generation of policy informatics integration
• Demonstrate good understanding that digital divide remains formidable in scaling
information and communication technology (ICT)-enabled opportunities for effective
leadership and development in countries lagging behind
• Differentiate the scope of the evolving environment of policy-making, eParticipation, and
the impact of the digital divide in the developing countries
• Produce graduate-level research papers and practice presentation methods as needed.
• Demonstrate an understanding and proper application of APA as it is applied to
professional writing
• Demonstrate skills in the use of common graduate program technologies – PowerPoint,
Internet Research (None Wikipedia resources), Library Resources, iLearn, Connections, and
SafeAssign.
Prerequisites:
Books and
Resources:
There are no prerequisites for this course.
Policy Practice and Digital Science – Integrating Complex Systems, Social Simulation
and Public Administration in Policy Research
• Author: Marijn Janssen, Maria A. Wimmer, and Ameneh Deljoo
• Publisher: Springer
• Edition: Please Use Most Recent Edition
Course Activities and
Experiences:
Course Deliverables
Other articles and readings may be assigned by the course professor.
Course Expectations
Students are expected to:
• Review any assigned reading material and prepare responses to the homework assigned.
• Actively participate in activities, assignments, and discussions.
• Evaluate and react to each other’s work in a supportive, and constructive manner.
• Complete specific assignments and exams when specified and in a professional manner.
• Utilize learned technologies for class assignments.
• Connect content knowledge from core courses to practical training placement and activities.
• Examinations – Mid-Term Exam (28 March 2020) = 15%
• Final Exam (15 April 2020) = 15% of final grade
• Final Research Paper: Written Paper (15 April 2020; 16 pp/double spaced; APA format) =
15% of final grade
• Quiz #1 – 12 January 2020 – Must be complete to fulfill UoC new student registration policy (2.5%)
2
•
Academic Integrity/
Plagiarism:
Quizzes #2 – “Practical Connection Assignment” (28 March 2020) – Provide a reflection of at least 500
words (or 2 pages double spaced) of how the knowledge, skills, or theories of this course have been
applied, or could be applied, in a practical manner to your current work environment. If you are not
currently working, share times when you have or could observe these theories and knowledge could
be applied to an employment opportunity in your field of study (10%) and
• Quiz#3 – 4 April 2020 – (2.5%) of the final grade
At a Christian liberal arts university committed to the pursuit of truth and understanding, any act of
academic dishonesty is especially distressing and cannot be tolerated. In general, academic dishonesty
involves the abuse and misuse of information or people to gain an undeserved academic advantage or
evaluation. The common forms of academic dishonesty include:
• Cheating – using deception in the taking of tests or the preparation of written work, using
unauthorized materials, copying another person’s work with or without consent, or assisting another
in such activities.
• Lying – falsifying, fabricating, or forging information in either written, spoken or video presentations.
• Plagiarism—using the published writings, data, interpretations, or ideas of another without proper
documentation
Plagiarism includes copying and pasting material from the internet into assignments without properly
citing the source of the material.
Attendance Policy:
Episodes of academic dishonesty are reported to the Vice President for Academic Affairs. The potential
penalty for academic dishonesty includes a failing grade on a particular assignment, a failing grade for the
entire course, or charges against the student with the appropriate disciplinary body.
When any student has exceeded 20% of the time prescribed for any class, that student will be
automatically dropped from that particular class with the grade of “F.” This grade is placed on the official
transcript of the student and is treated as a failing grade in calculating the grade point average. The
definition of a class absence is a student’s failure to attend the class for any reason. Instructors may count
three times tardy or leaving early to be equal to one class absence. There are no excused absences,
regardless of the reason for the class having been missed. However, faculty will make reasonable
provisions to allow students to make up work if the absence is due to a university-sponsored function or a
medical or family emergency that is documented in a timely manner. Allowance for students to make up
work for other reasons is at each instructor’s discretion. A class absence does not excuse the student
from being responsible for course work missed; the student is responsible for contacting the faculty
member to make up class assignments. The Vice President for Academic Affairs is the authorized agent to
consider any exceptions to the above regulations (Student Catalog).
Residency Attendance: Each student must be in attendance for the entire duration of the required
residency weekend. Late arrivals and/or early departures are not permitted. Punctuality is important as
each student is required to have the documented in-seat time per USCIS regulations. If a student is not
in attendance for the full session, he/she will be counted absent for the entire session and receive an
automatic “F” and will be required to pay the $300.00 make-up fee and attend a residency make-up
session.
Participation Policy
Disability
Accommodations:
Study after study has linked successful academic performance with good class participation. Those who
assume positions of responsibility must “show up” in order to be effective. Therefore, students are
expected to actively participate in intelligent discussion of assigned topics in all areas (Discussion Board
Activities, Synchronous Sessions, Forums, Shared Papers, etc.) to help process course material and/or to
demonstrate understanding of course content. Point adjustments will be taken for non-participation.
The University of the Cumberlands accepts students with certified disabilities and provides reasonable
accommodations for their certified needs in the classroom, in housing, in food service or in other areas.
For accommodations to be awarded, a student must submit a completed Accommodations Application
form and provide documentation of the disability to the Disability Services Coordinator (Mr. Jacob Ratliff,
Boswell Campus Center, Student Services Office Suite, jacob.ratliff@ucumberlands.edu). When all
paperwork is on file, a meeting between the student and the Coordinator will be arranged to discuss
possible accommodations before accommodations are formally approved. Students must then meet with
the Coordinator at the beginning of each semester before any academic accommodations can be certified
for that term. Certifications for other accommodations are normally reviewed annually.
3
Academic Appeal
Student
Responsibilities and
Course Policies:
Course Activities and
Experiences
Both undergraduate and graduate students have the right to challenge a grade. If discussions with the
course instructor and department chair do not lead to a satisfactory conclusion, students may file a
formal written appeal with the Vice President for Academic Affairs, who will forward the appeal to the
chair of the Academic Appeals Committee. This formal written appeal must be filed by the end of the 4th
week of classes in the next regular term following the term in which the course in question was taken.
The Academic Appeals Committee then gathers information from the student, the instructor, and any
other relevant parties. The Committee will deliver its recommendation on the complaint to the Vice
President for Academic Affairs. After reviewing this recommendation and concurring or amending it, the
Vice President for Academic Affairs will inform the student and instructor of the disposition of the
complaint no later than the last day of classes of the term in which the complaint was filed. Records of all
actions regarding academic grade appeals, including their final disposition, are maintained by the Vice
President for Academic Affairs and the Academic Appeals Committee. (Undergraduate Catalog/Graduate
Catalog)
• The only authorized electronic means of academic, administrative, and co-curricular communication
between the University of the Cumberlands and its students is through the UCumberlands email
system (i.e. Webmail). Each student is responsible for monitoring his/her University email account
frequently. This is the primary email account used to correspond with you directly by the University;
imperative program information is sent to this email account specifically from campus and program
office.
• Students should check for e-mail and class announcements using iLearn (primary) and University of
the Cumberlands webmail (secondary).
• Students are expected to find out class assignments for missed classes and make up missed work if
allowed.
• Students are expected to find out if any changes have been made in the class or assignment schedule.
• Written work must be presented in a professional manner. Work that is not
submitted in a professional manner will not be evaluated and will be returned as unacceptable.
o There is a craft to writing. Spelling, grammar, punctuation, and diction (word usage) are
all tools of that craft. Writing at the collegiate level will show careful attention to these
elements of craft. Work that does not exhibit care about these elements will be
considered as inadequate for college writing and graded accordingly.
• Students are expected to login several times per week, even if they have completed the assignment
posted at the beginning of the week, to participate in group forums/blogs/class discussions and to
check for additional assignments and/or schedule changes.
• It is the student’s responsibility to check for changes to the assignment, or for additional assignments.
Students are expected to be self-motivated in an online, asynchronous course and to have enough
mastery of the English language to understand the course assignments (all of which will be posted in
English) and to complete the assignment in the English language.
• Students are expected to take the examinations on the designated dates. If you are unable to take
the exam on the scheduled date and know in advance, you are to make arrangements with your
professor before the designated date. If you miss the exam, you must have a legitimate reason as
determined by your professor.
Recognizing that a large part of professional life is meeting deadlines, it is necessary to develop time
management and organizational skills. Failure to meet the course deadlines may result in penalties. Keep
in mind that all deadlines are set using Eastern Standard Time (EST).
Late assignments will NOT be accepted. Else, if accepted, a 15-point penalty will suffice.
Students are expected to:
• Review any assigned reading material and prepare responses to homework assigned.
• Actively participate in activities, assignments, and discussions.
• Evaluate and react to each other’s work in a supportive, constructive manner.
• Complete specific assignments and exams when specified and in a professional manner.
• Utilize learned technologies for class assignments.
• Connect content knowledge from core courses to practical training placement and activities.
4
Writing
Expectations:
Learning outcomes for candidates’ writing competencies include clarity of thought, discernment in
planning and organization, and integration of evidence and criteria.
• The instructor expects that students will have knowledge of appropriate forms of documentation and
use it where appropriate. APA format is required and style of notation to credit all sources that are
not your own.
• There is a craft to writing. Spelling, grammar, punctuation, and diction (word usage) are all tools of
that craft. Writing at the collegiate level will show careful attention to these elements of craft. Work
that does not exhibit care about these elements will be considered as inadequate for college writing
and graded accordingly.
• All assignments, unless otherwise instructed, should be submitted in APA format.
Academic Appeals:
Both undergraduate and graduate students have the right to challenge a grade. If discussions with the
course instructor and department chair do not lead to a satisfactory conclusion, students may file a
formal written appeal with the Vice President for Academic Affairs, who will forward the appeal to the
chair of the Academic Appeals Committee. This formal written appeal must be filed by the end of the 4th
week of classes in the next regular term following the term in which the course in question was taken.
The Academic Appeals Committee then gathers information from the student, the instructor, and any
other relevant parties. The Committee will deliver its recommendation on the complaint to the Vice
President for Academic Affairs. After reviewing this recommendation and concurring or amending it, the
Vice President for Academic Affairs will inform the student and instructor of the disposition of the
complaint no later than the last day of classes of the term in which the complaint was filed. Records of all
actions regarding academic grade appeals, including their final disposition, are maintained by the Vice
President for Academic Affairs and the Academic Appeals Committee. (Undergraduate Catalog/Graduate
Catalog)
Links to Support:
Orientation to I-Learn: Student training course on I-Learn,
https://ucumberlands.blackboard.com/webapps/portal/frameset.jsp
Book Store:
http://cumber.bncollege.com/webapp/wcs/stores/servlet/BNCBHomePage?storeId=50059&catalogId=10
001&langId=-1
Library: http://www.ucumberlands.edu/library/
Academic Resources & Writing Center: www.ucumberlands.edu/learningcommons
Student Handbook: https://www.ucumberlands.edu/student-handbook
Course Catalog: https://www.ucumberlands.edu/academics/academic-catalog
UC Citation Help: http://ucumberlands.libguides.com/c.php?g=504168
Learning Commons: https://ucumberlands.edu/learningcommons
Course Evaluation:
Course Assignments and Evaluation
Graded work will receive a numeric score reflecting the quality of performance. Relative weights assigned
to graded work are as follows:
5
Course Evaluation
A student will be evaluated/weighted on the following basis:
Examinations:
There are two examinations, a midterm, and a final exam for this course. Exams are 50
questions (100 points/2 points per question). Both are a combination of multiple-choice,
true/false, and fill in the blank. Each exam is worth 15% of the final grade; for a total of 30% of
the final grade for both exams. The Midterm Exam will cover Chapters 1-11, with the Final
Exam covering Chapters 10-19 (both exams = 30%).
Final Research Paper:
The course research paper is a formatted APA paper. It is 16 pages, double spaced, Times New
Roman 12 font size. Paper length requirement is 16 pages of content from Title Page through
References. The Research Paper is worth 15% of the final grade. The Final paper will contain a
title page, TOC, abstract, introduction/topic paragraph, summary/conclusion, and reference
page. Research paper topics are approved by the course instructor and can be on any courserelated topic in the field of Information Technology, e-Participation, Policy-Making in a Complex
World, Organizational Decision-Making, ICT for Policy-Making, Challenges to Policy-Making, etc.
CAUTION: Under no circumstance will students be allowed to submit papers of their own choice
at the last minute. Such submissions receive a grade of Zero (0).
Quizzes: This class has 3 quizzes that must be completed and turned in on time as instructed.
Each quiz assignment will be graded accordingly. Missed quizzes will not be re-taken unless
otherwise with special permission.
Attendance: To receive full credit, each student must attend class regularly, answer weekly instructor
questions in the discussion forum (DF) topic, and then comment on three other students responses to the
DF. There will be a total of 40+ points earned across the sixteen-week online discussions that will equate
to (25%).
Although I am not looking for you to meet a specific word count, I am looking for good throughput and
interesting contributions to the conversations. Simply posting a link to a resource or letting your
classmates know that he/she did a “Great job!” will not result in full participation points. A substantive
post is generally greater than 100 words and introduces a new idea or is a meaningful response to
another person’s post. When responding to another student’s post, please either:
1) expand the thought,
2) add additional insights, or
3) respectfully disagree and explain why.
Learners are highly encouraged to collaborate in the course discussion board to score maximum
points in the class. See below:
Points
0.0
.50
1.0
1.5
Discussion Forum (DF) Scoring Criteria
No activity; did not respond to the forum and/or did not respond by the listed
deadlines
point Provided meaningful feedback to 3 or more classmates but did not craft an
original response to the prompt
points Crafted an original response to the prompt but did not provide meaningful
feedback to 3 or more classmates
points Crafted an original response to the prompt and provided meaningful feedback
to 3 or more classmates
Course Evaluation Survey:
You will have the opportunity to evaluate the course in several different ways throughout the
semester. You will have access to post your feedback to a forum through the iLearn platform. The
forum will remain open throughout the semester, and it will be monitored regularly. Participation in
the survey forum is entirely optional, normally at the last week of the semester. Your experience
and feedback are invaluable to our ability to improve the course for future students.
6
Statements of Understanding:
This class will adhere to a zero-tolerance for using someone else’s work as your own. It will
result in course failure if written or verbal presentations are plagiarized. Any research paper
is subject to comparison with SafeAssign at the discretion of the instructor. Students are
responsible for reading, understanding, obeying, and respecting all UoC academic policies.
Added emphasis will be placed upon academic progress policies appearing in the University
of the Cumberlands Academic Catalog applicable to each student’s curriculum and/or
program of study.
Class participation is a key requirement to succeed in this course. Student participation in
discussions enriches each one’s knowledge and appreciation of the principles of
organizational policy-making, integration of modeling, major theories of structuration,
institutional and actor-network, and eParticipation, and how they can be applied to the work
environment to bridge the digital divide. Opportunities to participate include blackboard
weekly forum thread discussions, Q&A, reading chapter assignments, and timely work turned
in by due date as requested by the instructor. Untimely work will receive a markdown in
points at the instructor’s discretion. The instructor holds the right to adjust this syllabus
and its contents in the best interest of the class and course objectives.
Internet Access: All students are expected to have regular access to the internet. Equipment failure is no
excuse for failure to attend a weekly online session. Students must have a backup plan for submitting
assignments and exam in a timely manner. Students simply cannot miss the exam and then after the exam
has closed out the request a makeup exam on the basis that the student did not have internet access during
the exam. For example, if the student’s network goes down during the exam the student should plan on
having access to a mobile hotspot, or similar device, as a backup.
Portable Device: Each student is expected to have access to a portable computer, whether that be laptop,
tablet, notebook or other, which has internet access. A portable device is required to have access to
Microsoft Word, Microsoft PowerPoint, Adobe Acrobat, and a web browser. A smartphone WILL NOT
suffice. All students are required to bring a laptop computer, tablet or notebook to residency weekend,
capable of connecting to the internet. Tablets are not recommended as the student will do a significant
amount of typing over the weekend. There will be WI-FI at the campus. Students will not be permitted to
share a computer and a smartphone will not be enough. Each student’s computer should be equipped with
WORD, POWERPOINT and ADOBE ACROBAT READER.
Midterm Exam: Taken using a laptop computer in the classroom on Saturday morning (March 28th, 2020).
It is essential that students bring with them to class their own computer that is capable of accessing the
internet and iLearn. Students who don’t bring with them on Saturday morning a device capable of accessing
their midterm exam will not be able to submit the exam for grading.
CAUTION: Students are not permitted to share devices for purposes of completing exams, and OR will the
students be permitted to take this exam OUTSIDE of the classroom – NO EXCEPTIONS.
Grading Scale:
Graded work will receive a numeric score reflecting the quality of performance as given above in
evaluation methods. The overall course grade will be determined according to the following scale:
A = 90 – 100%
B = 80 – 89.9%
C = 70 – 79.9%
F < 69.9% (Below 69%)
7
Syllabus Disclaimer:
This syllabus is intended as a set of guidelines for this course and the professor reserves the right to make modifications in content,
schedule, and requirements as necessary to promote the best education possible within conditions affecting this course. Any
changes to the syllabus will be discussed with the students.
Weekly Unit
1
Jan 06 – Jan 12
2
Jan 13 – Jan 19
Course Schedule
Assignments/Discussion Forum Due Dates
Readings/Topics/Chapter
Introduction to the Course:
Class Welcome Discussion
Chapter 1:
Introduction to Policy-Making in the
Digital Age
Chapter 2:
Educating Public Managers and Policy
Analysts in the Era of Informatics
Quiz#1 – Due 12th January 2020: 11:59 PM EST
*Failing to Participate in Week 1 may result in being
dropped/removed from the course*
• Reading
•
•
•
•
•
Discussion Forum (DF) Questions Due
Presentations as instructed
Reading
Discussions Forum (DF) Questions Due
Presentations as instructed
Chapter 3:
The Quality of Social Simulation: An
Example from Research Policy
Modeling
Chapter 4: Policymaking and
Modeling in a Complex World
3
Jan 20 – Jan 26
Chapter 5:
From building a model to adaptive
robust decision-making using
systems modeling
• Reading
• Discussions Forum (DF) Questions Due
• Presentations as instructed
Chapter 6:
Features and added value of
simulation models using different
modeling approaches supporting
policy-making: A Comparative
analysis
4
Jan 27 – Feb 02
5
Feb 03 – Feb 09
Chapter 7:
Comparative analysis of tools and
technologies for policy-making
Chapter 8:
Value Sensitive Design of
complex product systems
• Reading
• Discussions Forum (DF) Questions Due
• Presentations as instructed
• Reading
• Discussions Forum (DF) Questions Due
• Presentations as instructed
8
Chapter 9:
Stakeholder Engagement in Policy
Development: Observations and
Lessons from International
Experience
6
Feb 10 – Feb 16
Chapter 10:
Values in Computational Models
Revalued
7
Feb 17 – Feb 23
8
Feb 24 – Mar 01
9
Mar 02 – Mar 08
10
Mar 09 – Mar 15
11
Mar 16 – Mar 22
12
Mar 23 – Mar 29
12
Mar 27 – Mar 29
Chapter 11:
The Psychological Drivers of
Bureaucracy: Protecting the Societal
Goals of an Organization
• Reading
• Discussions Forum (DF) Questions Due
• Presentations as instructed
•
•
•
•
•
Practical Connection Assignment due-out:
QUIZ #2 – February 22nd, 2020: 11:59 PM EST
Reading
Discussions Forum (DF) Questions Due
Presentations as instructed
Chapter 12:
Active and Passive Crowdsourcing in
Government
• Reading
• Discussions Forum (DF) Questions Due
• Presentations as instructed
Chapter 13:
Management of Complex Systems:
Toward Agent-based Gaming for
Policy
• Reading
• Discussions Forum (DF) Questions Due
• Presentations as instructed
Chapter 14:
The Role of Microsimulation in the
Development of Public Policy
• Reading
• Discussions Forum (DF) Questions Due
• Presentations as instructed
Chapter 15:
Visual Decision Support for
Policymaking: Advancing Policy
Analysis with Visualization
• Reading
• Discussions Forum (DF) Questions Due
• Presentations as instructed
Chapter 16:
Analysis of Five Policy Cases in the
Field of Energy Policy
• Reading
• Discussions Forum (DF) Questions Due
• Presentations as instructed
REQUIRED RESIDENCY SESSION:
Mar 27th – Mar 29th., 2020.
This residency session will be held at
the UC @ NOVA College, 5000 Dawes
Avenue, Alexandria, Virginia, 22311.
Each day of residency session include assessments related to
course concepts in the real-world app (60% of course grade)
❖ Mid-term Exam = 15%
❖ Case study Group presentation = 15%
❖ Practical Connection Assignment = 10%
❖ Peer-Reviewed Research Summary Assinment = 10%
❖ Final Research Paper (Part 3) = 10%
a. APA 6th edition guide (in-text requirements)
b. References/Citations Organization
c. APA 6E Formatting/Paraphrasing
d. Abstract and Research Topic: revise/polish as
needed/other SafeAssign/score Interpretations
❖ Grammarly use for common errors in writing
9
13
Mar 30 – Apr 05
14
Apr 06 – Apr 12
15
Apr 13 – Apr 19
Chapter 17:
Challenges to policy-making in
developing countries and the roles
of emerging tools, methods and
instruments: Experiences from Saint
Petersburg
•
•
•
•
Reading
Chapter 18:
Sustainable urban development,
governance, and policy: A
comparative overview of EU policies
and projects
•
•
•
•
Reading
Chapter 19:
e-Participation, simulation exercise
and leadership training in Nigeria:
Bridging the digital divide
•
•
•
•
Reading
Discussions Forum (DF) Questions Due
Presentations as instructed
Quiz #3 – April 4th, 2020: 11:59 PM EST
Discussions Forum (DF) Questions Due
Presentations as instructed
Final Research Paper – April 15th., 2020: 11:59 PM EST
Discussions Forum (DF) Questions Due
Presentations as instructed
Final Exam – April 19th, 2020: By 11:59 PM EST
16.
Final Evaluations/Final Grades Due
• Operations Research (OR) and Analytics Benefits in the
Apr 20 – Apr 23
**SHORT WEEK**
All Class Work Must be Completed
by Apr 21st at 5 pm EST.
• Video Review Exercise:
• Feedback Due
Global Economies Video
Notice to Student – (Additional to Statement of Understanding).
• ALL assignments, unless otherwise instructed, must be submitted in APA format.
• ALL weekly initial Discussion Forum responses to the chapter questions MUST be completed by Wednesdays 11:59 PM EST;
with ALL other three (3) substantive feedback from or to other student work due on/by Sunday 11:59 PM EST to receive full
points.
• Assignment submission deadlines must be taken very seriously. It is the student’s responsibility to submit their work on time.
Missed deadlines (assignments, Quizzes, and Exams) are considered a missed grade. NOEXCEPTIONS.
• ALL weekly DF responses MUST be original, authentic, and relevant to the week’s DF questions. Anything else that deviates
from the original chapter case studies will receive a zero grade.
• COPYING and PASTING (Verbatim) responses into the DF from the textbooks and other digital Internet sources is HIGHLY
prohibited. This activity violates the UoC’s academic integrity policy, and if involved, severe punishment will ensure.
• Never send assignments to your instructors via email for grading. ONLY submit work for a grade via SafeAssign accompanied
with a similarity score report.
• DO NOT use your previously graded Course work/other ongoing course project/study from another class to earn a grade for
this course. It’s NOT acceptable! Doing so violates the UoC’s academic integrity and will get you penelized. Don’t be the one.
10
Academic Medical Centers and the
Fallacy of Misplaced Concreteness
Lawrence D. Brown
Columbia University
Abstract Academic medical centers (AMCs) are a familiar target of critics who
charge the US health care system with indifference to the most pressing needs of the
public. AMCs are frequently faulted, for example, for promoting specialization instead
of primary care, for favoring high-tech services rather than the promotion of health and
prevention of illness, and for failing to adequately meet the needs of the disadvantaged.
An organizational perspective, with particular attention to the structure, mission, and
environment of this institutional form, suggests that these critiques may misplace onto
AMCs responsibility for solving problems with deep roots in the larger political economy of health care policy in the United States. By the same token, however, the pressures of that political economy (i.e., environment) on AMCs progressively strain their
structure, mission, and (arguably) their capacity to serve the public interest.
Keywords academic medical centers, health care policy, public health
If you don’t know where you are going, you’ll end up someplace else.
—Yogi Berra
When I joined the faculty of (what is now called) the Mailman School of
Public Health at Columbia University in 1988, David Axelrod, commissioner of New York State’s Department of Health, was pursuing a long
and ambitious agenda that included an initiative (UNI*CARE) to bring
affordable universal coverage to the state, new interventions to combat
AIDS, and, neither first nor last on the list, carrots and sticks that would
at long last induce the academic medical centers (AMCs) of the state
(and especially those in New York City) to change their errant ways. (For an
insightful account of the health policy action in New York State at the time,
Journal of Health Politics, Policy and Law, Vol. 43, No. 5, October 2018
DOI 10.1215/03616878-6951151 Ó 2018 by Duke University Press
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see Beauchamp 1996.) The commissioner was indignant that these powerful institutions persisted in producing an oversupply of specialist physicians despite the state’s need for more primary care; focused heavily on
acute (and technology-intensive) services while showing indifference if
not contempt for the prevention of illness and the promotion of health;
and worked tirelessly to market their services to well-insured patients while
sitting, like castles protected by invisible moats, amid lower-income communities badly in need of health care. Unsurprisingly, the AMCs begged
to differ.
This late 1980s vignette captures a conflict far wider than a local contretemps between one state health commissioner and one set of AMCs.
Scholars, practitioners, and policy makers on the left of the health policy
spectrum have long articulated a critique substantially the same as Axelrod’s, and the defenders in and around AMCs have long offered a riposte to
the effect that, notwithstanding their pioneering efforts to cure disease
(both dread and more mundane), they are undervalued and misunderstood
by pundits, payers, and politicians who insist that they embrace new missions and constituencies while, perversely, constraining their revenues,
thereby driving them into states of crisis and siege that imperil their productivity and perhaps their survival.
The argument of this article is that the familiar critique of AMCs exemplifies what Alfred North Whitehead (1929) called (and which I take some
liberties in recalling) the fallacy of misplaced concreteness. The fallacy, as
construed here, consists of reifying (concretizing) and laying at the doorstep of a particular type of organization problems that are properly ascribed
to large contextual considerations of public policy (and thus to the historical, cultural, and political forces that produce public policy). I argue further that the problem at hand—assessing the validity of the conventional
critique of AMCs—is (to follow Wittgenstein) one less amenable to solving than to dissolving and that organizational analysis supplies an effective,
albeit too little noticed, (dis)solvent.
Organizational analysis (a term I prefer to the rather more grandiose
organization theory) is a pastiche of propositions deriving from (among
others) Max Weber, Herbert Simon, James March, Michel Crozier, Charles
Perrow, Oliver Williamson, and James Q. Wilson, which holds that the
behavior of actors across the public, private, and nonprofit sectors is shaped
importantly by the properties of complex formal organizations — to wit,
their histories, structures, incentive systems, technologies, environments,
and missions. Precisely because these variables are multiple, mushy, and
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overlapping, they are well suited for making sense of the distinctive and
particular complexities of organizations and of organizational types.
The AMC as an Organization
Behold, then, the AMC, a formal organization of a quite extraordinary complexity that begins with its structure. Denotations and connotations of the
term academic medical center differ. At its narrowest, an AMC contains a
medical school and a teaching hospital (usually, though not always,
affiliated with a university). More commonly (and more in keeping with
the moniker academic health center), a center also encompasses an allied
university-based institution such as a school of public health or of nursing. Prominent AMCs tend to embrace a fourth set of components: university departments such as mathematics, biology, chemistry, and physics
(or individual scholars working within them). And some AMCs affiliate
with community hospitals and/or other providers for purposes of teaching
and caregiving.
Since the 1920s, medical schools “were never to stop growing in
bureaucratic complexity” (Ludmerer 1985: 259), a generalization that fits
all the components of the AMC, and each of its bureaucratic ingredients
is complicated in its own right, to the point of resembling an exercise in
herding cats. The organizational interests of medical schools and teaching hospitals may be imperfectly, indeed poorly, aligned, but both seek to
impose order and routine on physicians, whose professional training and
identity famously resist control not only by laypeople but also by peers who
dare to invoke the authority of formal hierarchies (Freidson 1970, 1975;
Starr 1982). Undergraduate medical education and graduate medical education have distinct governance structures, the latter controlled by “allpowerful barons” (Ginzberg 1990: 61) at the head of clinical departments
answerable to specialty societies and fiercely protective of the “separation
of powers” that ensures their “privileges and freedom” (Ebert and Ginzberg
1988: 16). Over time, taxes on faculty practices and a growing corps of
salaried physicians who mainly care for patients but hold academic titles
have strengthened the leverage of deans, but only to a point. Hot competition among AMCs for stellar physician researchers and state-of-the-art
specialists continues to conduce toward considerable insularity and independence of departments and their senior staffs.
University presidents and provosts have agendas of their own, as do professors, who cherish tenure, academic freedom, and (once upon a time)
faculty governance. Medical schools, hospitals, nursing and public health
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schools, and universities are also governed by boards of directors, the
collective preferences of which (and of course the preferences of their
individual members) are important, perhaps essential, to their institutions’
quest for philanthropic resources and political support. Contemporary
AMCs must also cooperate, however uneasily, with managed care organizations (MCOs), a source of pressures—including “the real threat . . . [of]
financial insolvency” (Rogers, Snyderman, and Rogers 1994: 1376)—that
ripple throughout the AMC enterprise.
Intricate as these governance arrangements are, budgetary relations surpass them in complexity. These complications appear in elaborate and
often contested cross-subsidies that may remain substantially opaque even
to those who transact them as they endlessly seek to enlarge, juggle, and
recoup losses in revenues derived from grants, contracts, GME (graduate
medical education) payments, patient revenues, philanthropy, and taxes
on physician practices. The institutional precincts of the AMC are scenes
of Hobbesian struggles for power and money, and the sojourns of their
presidents, CEOs, deans, and chairs can be nasty, brutish, and short.
These centrifugal structural tendencies come accompanied, moreover, by multiple missions. The institutional components of the AMC are
expected to conduct cutting-edge scientific research that generates biomedical breakthroughs (that is, life-prolonging and life-enhancing innovations in diagnoses, drugs, devices, and procedures) to deliver care of the
highest quality to their patients, and to prepare their students to do likewise.
In 1963, Rensis Likert and Robert Kahn averred that “medical center
administrators face one of the most complex administrative tasks we have
ever encountered” (qtd. in Lewis and Sheps 1983: 192). More than a halfcentury of medical and organization evolution and innovation has multiplied those complexities. As Pierre-Gerlier Forest (personal communication, 2017) put it:
AMCs are the most complex organizations in our societies, embodying
as they do: cure and care at the highest level and coordination of both;
plus knowledge creation and management; plus training of multiple
professional groups from MDs to accountants and social workers; plus
financial management, including investment and real estate; plus feeding and hosting thousands of patients and staff; plus interfacing with
their environment, notably city authorities for transit, public safety,
and infrastructure; plus data management. They are also by definition
“open” institutions, which must accommodate the circulation of patients
and visitors; and they deal continuously with life and death issues, which
demand constant decisions with no, or very reduced, margins of error.
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They also labor under a bewildering array of state and federal regulatory
bodies and voluntary assessors and accreditors.
These multiplex and coincident complications of structure and mission pose a puzzle of organizational ontology: How is an entity like the
AMC possible at all? How can such an assemblage of motley institutional elements cohere and work? Yet this organizational type is alive
and—notwithstanding the grousing about crises, sieges, and impending extinction—in reasonably good health, at least as measured by the
production of world-class research, top quality care, and well-trained
graduates.
Mission and Environment
Two considerations explain the coherence and durability of AMCs. The
first is the cohesion of the AMCs’ three components around a core mission.
I have elsewhere called this mission the “medical cultural nexus” (Brown
2008). This nexus contains five semisyllogistical propositions: (1) a good
health care system should rest above all on the latest and most advanced
scientific knowledge; (2) the most desirable (life-saving and -extending)
fruits of that knowledge take the form of new and improved technologies;
(3) medical specialists are crucial both for the generation of such technologies and for their translation into patient care and therefore occupy
pride of place in the medical division of labor; (4) optimal medical education seeks at once to advance and deploy the three above-mentioned
sources of progress; and (5) a high-quality health care system can be
defined as one that honors the four above-listed propositions. One big
reason why AMCs cohere is that concurrence on this core mission has
created a durable framework and focus for their otherwise fragmentary and
free-ranging contributors.
The other explanation is strong support by the AMCs’ environment,
from myriad nonprofit overseers, private payers, and public subsidizers—
payers and regulators that have, on the whole, wished the AMCs well and
have helped them prosper. This environmental support extends back at
least to the Flexner Report (1910), which argued forcefully for reforms
in medical training based on university-based scientific research. It was
powerfully enforced by the growth in number, budget, and scope of the
National Institutes of Health (NIH) during and especially after World War
II (Fox 1987)—a bold adventure along the “endless frontier” of science
(Bush 1945) that, crucially, awarded most of its money not to scientists
who had civil service status, working in government research agencies,
but rather extramurally, to those medical schools, hospitals, and university
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departments that combined successfully to compete for funding, a development that generated, then and since, powerful constituencies for medical
research in almost all states and congressional districts (Strickland 1972;
Fox 1996). By 1960, wrote Rosemary Stevens ([1971] 1998: 360), the nation’s
medical schools had become, in essence, “arms or branches” of the NIH.
In 1965, the creation of Medicare brought to AMCs the “concomitants
of affluence” (Ginzberg 1990: 61)—sizable new revenues flowing into the
coffers of hospitals, generous treatment of the capital costs of hospitals
seeking to expand and upgrade their facilities and services, and, not least,
financial support for graduate medical education. Additional concomitants
include the Centers for Disease Control and Prevention, the Agency for
Healthcare Research and Quality, the Department of Defense, the PatientCentered Outcomes Research Institute, and, of course, firms in a wide, and
widening, range of industries. In short, since the second half of the twentieth century, providers, pundits, politicians, policy makers, and the public
subscribed wholeheartedly to the medical cultural nexus and, in consequence, handsomely subsidized AMCs in their pursuit of the core mission
it implied.
Environmental Change
Over time environmental support for the core mission of the AMCs has
grown increasingly ambivalent, as in, “We greatly value what you do, but
could you perhaps contrive to do it less expensively?” and “Might you not
also devote more resources and attention to other pressing social priorities?” Since 1970, federal policy has tried to slow the growth of Medicare
spending by encouraging beneficiaries to join HMOs/MCOs, by paying
hospitals prospectively instead of retroactively on a fee-for-service basis,
by imposing financial penalties for inadequate performance, by moving
toward value-based and bundled payments to providers, and by trimming
the generosity of GME payments. These measures of course threaten the
finances of AMCs, whose leaders protest that, although their institutions
tend to charge higher prices, they also serve patients with more complex
and challenging conditions and do so with superior quality of care. Purchasers (which include not only Medicare but also the largely for-profit
insurers who now dominate the commercial health insurance market and
Medicaid managed care) have been of two minds on the issue: on the one
hand, excising the highest-cost providers from their networks is an obvious
economizing strategy, but on the other hand, networks lacking providers
widely reputed to be the best can constrain market share.
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Cost, moreover, is not the sole source of skepticism about the contributions of the AMCs’ core mission to the public interest. Since 1970 the
accumulating findings of what may be summarily termed health services
research have suggested that ready access to primary care correlates
strongly with improved health outcomes (e.g., Starfield, Shi, and Macinko
2005); that some, perhaps many, medical procedures (such as back surgery) are overused despite lack of evidence of their efficacy (Wennberg
2010; Patashnik, Gerber, and Dowling 2017); that an intelligent commitment to the elimination of dread diseases should focus beyond the medical
system, and particularly on lifestyle considerations, such as smoking, diet,
exercise, and avoidance of substance abuse, and on toxins permeating the
nation’s air, water, and workplaces (Lalonde 1974); and that the surest
routes to better health may have little to do with the health and medical
care systems per se but rather with a long list of social determinants ranging from income distribution to stress (Marmot 2004, 2015). And of course
these two environmental destabilizers — costs and corrosive research —
interact: as critical findings in health services research call into question
the value of money yielded by a status quo of which AMCs are paradigmatic, budget makers and profit seekers come to view AMCs as a proverbial
part of the problem, not its solution.
AMCs and Innovation
That AMCs have disappointed those who call for innovation cum renovation of their priorities does not mean that AMCs are not highly innovative—
sometimes around and sometimes beyond their core mission.
Innovation around the Core Mission. The basic and deepest-reaching
element of the mission of AMCs is the continuing creation of scientific
knowledge and its deployment in new technologies. Some of these discoveries emerge predominantly within the walls of the AMC—in the fields
of genetics and molecular biology, for example—and may yield valuable
patents for the universities in which they occur. Many are interorganizational products, emerging from “the interplay of universities, national laboratories, and industrial firms in an environment shaped by a growing body
of governmental rules and incentives” (Gelijns and Thier 2002: 73). The
biotechnology industry, for instance, arose from innovations in genetics and molecular biology, and the discovery of medical devices tends to
entail especially close interaction between clinicians and industry engineers. AMCs also collaborate with industry in the pursuit of translational
research, in the conduct of clinical trials and evaluations, in the training of
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scientists, and in the development of interdisciplinary and virtual research
centers (Gelijns and Their 2002). Moreover, in the dynamic health care
economy, AMCs constantly forge new relations with new types of firms, a
leading case in point being collaborations between universities and companies such as Apple and Google, which control oceans of data on their
customers that can identify with precision levels of education, places of
residence, and consumption habits (including the use of health care) and
can be linked to the incidence, progress, and treatment of disease in ways
that vastly expand the prospects for population health management.
Innovation around Delivery of Care. AMCs teem with innovations that
promise to produce not only continuous improvements in clinical quality
but also better value for money. This can be conveniently illustrated by the
titles of some capstone topics recently explored and pushed toward
development by students (some of them MDs, almost all of them employed
in one or another unit of an AMC in a large city in the northeastern United
States):
“Engaging Physicians in Data Driven Quality Improvement to Succeed
under Value Based Purchasing”
“Best Practices in Telepsychiatry and Their Potential Applicability to an
Urban Academic Health Center”
“Alarm Management to Promote Patient Safety”
“Progeny Use in Medical Genetics and Genomics Clinics”
“Implementing an Antimicrobial Stewardship Program . . . to Lower the
Incidence of Acquired Clostridium difficile in an Urban Public Safety
Net Hospital”
“Analysis of a Mobile Health Care Unit . . . [to Advance] Meaningful
Use of Medical Services for Improved Population Health”
“Is There a Need for Anemia Management Clinics?”
“Surgical Care Episode Standardization”
Creation of a New “Heart Center for Health”
“Finance and Quality Approaches to Dealing with Sepsis”
“Digital Communication Strategies in a Center for Sleep Medicine”
“A Provider Portal for Product Development”
And the list goes on: mobile care units, hospital-at-home programs, wellness
centers, and, of course, population health management.
These and kindred innovations are arguably both prolific and promising
precisely because they maintain and enhance the AMCs’ core mission. They
do not command automatic consensus, however. In each case mentioned
above, protagonists depicted highly time- and labor-intensive processes of
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discussion and negotiation, both within the innovating unit and between it
and other units, before agreement was reached, at which point organizational politics made a dramatic encore during implementation. In AMCs,
effective change is usually retail, seldom wholesale. As Edwards and
Saltman (2017: 9) wisely observe, organizational challenges in hospitals
“will only yield—and only to some extent—to re-thinking how to engage
the people inside the organization who receive operational directives, and
the structural environment and practical management realities . . . that
determine how they respond to those directives.”
Cooptative Innovation. The further one moves from the core mission,
the more problematic innovation seems to become. A case in point is what
might be called “cooptative” innovation, whereby AMCs follow a path,
well trod by their godfather, the NIH, that leads to the incorporation of
initiatives, to which they were hitherto indifferent if not disdainful, at the
margins of their organizational missions. A few years ago, for example,
Mary Ruggie (2004) examined the halting assimilation of complementary
and alternative medicine (CAM) into the institutional preserves of the NIH
and AMCs. Neither institution saw much point in exploring the scientific
merits of CAM until the influential Senator Tom Harken (D-IA) concluded
that bee pollen worked wonders for his allergies and urged the NIH to
sponsor research on this and related cures. Whatever their scientific and
personal opinions, NIH leaders invested modestly in a new program on
CAM and then increased the funding for a center, and today one finds at
paragons such as New York Presbyterian and Johns Hopkins random controlled trials on the curative effects of herbs and spices, tai chi, acupuncture,
and more. Into a comparable camp fall an ever-growing supply of new
intellectual and clinical fields to which AMCs expose their staff and students, such as information technology, medical humanities, interdisciplinary projects, decision theory, bioethics, and health care policy. Such
inclusive cooptative improvisations bespeak responsiveness and avert conflicts but nonetheless lie remote enough from the AMCs’ (and the NIH’s)
core mission that they risk being dismissed as tokenism.
Innovation to Gain Market Power. More troubling innovations may, and
increasingly do, derive from the pursuit of margin for the sake of mission.
“No margin, no mission” is a venerable mantra and one that today finds
AMCs hungry for the mentorship of business school gurus and consulting
firms but protesting all the while that excess medical revenues and operating margins are not truly the same as profits. The rationale is obvious: a
central fact of their organizational lives today (and for at least the last
two decades) is the financial squeeze by payers—Medicare, Medicaid, and
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managed care plans — who are determined to pay less to AMCs, compounded by slower gains in research funding that result when growth in
the number of competing applicants steadily exceeds growth in the available dollars.
At a premium here are strategies that fortify the bargaining leverage
of the AMCs in relation to payers and that bring in more diverse and
less vulnerable streams of revenue. Such projects tend to be proprietary
and more or less every AMC for itself, but the literature overflows with
reports from one or another AMC recounting how in the teeth of adversity
it reorganized its operations, diversified its business model, expanded the
spatial reach of its market, and the like. No margin, no mission, to be sure,
but is there no risk that margin may come increasingly to define (that is, set
the contextual parameters within which to contemplate) mission?
Market-minded innovation raises two big questions, one strategic, the
other purposive. The key strategic issue is what management analysts have
long termed span of control: how many subordinate units can leadership
oversee before lines of accountability and communication grow murky and
muddled? The corollary of span of control is organizational intelligence
(Wilensky 1967; March 1999): the channels of information by which
leaders come to know what is going on “down there” at lower levels of the
organization and “out there” in its satellites and in other organizations
with which leaders expect to communicate and coordinate. The enhanced
bargaining power a bigger AMC acquires may make it a better AMC—or
maybe not. A note of caution may be found in iconic high-performing
health care systems such as Mayo, Cleveland Clinic, and Kaiser-Permanente,
which have approached expansion gingerly, indeed timidly, not because
they lack confidence in their models but because they understand the
importance of organizational contingencies, such as an adequate supply
of physicians who share the culture of the parent organization, the presence of a reliable niche in the hospital marketplace, and the size of a (well)
insured local population whose choices may be in play. One riposte to
Steven Brill’s (2015: 445–46) proposal that policy makers should encourage “branded, integrated, and regulated oligopolies” that would “allow
hospital systems to become insurance companies” is skepticism whether,
in the words of one AMC leader, “We could be sure we could integrate
everything we added within our culture and standards.” Franchising, done
well, is harder than it sounds.
On the purposive front, although this energetic market entrepreneurship is said to be justified by a higher good—keeping the world safe for
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scientific innovation—it reinforces the increasingly for-profit character of
the US health care system in which AMCs operate. For-profit insurers
dominate the commercial market for coverage and have made long inroads
into public programs: Medicare Advantage plans now reach nearly onethird of Medicare enrollees, managed care plans serve more than 70 percent
of Medicaid’s beneficiaries, Medicare Part D runs exclusively via private
plans, and the Affordable Care Act (ACA) not only took all this privatization as a given but also crafted exchanges that are intended to channel
new business to private insurers. Partisans of market approaches contend
that the quest for profit (as long as it is pursued without force or fraud) is the
best of all possible incentives for the efficient satisfaction of the preferences of consumers. Critics rejoin that gauging success by the size and
speed of growth of return on investment to shareholders (with the correlative rolling of executive heads when these indicators fall short of expectations) is ill-suited to meeting the needs and demands of consumers of the
peculiar product that is health care. AMCs may have trouble securing their
place in a system that increasingly honors and rewards return on investment
and its corporate concomitants unless they absorb heavy doses of a foreign
corporate culture into the culture to which they have long pledged allegiance. Pondering the state of American medical education one hundred
years after the Flexner Report, Cooke et al. (2006: 1340) lament the “harsh,
commercial atmosphere of the marketplace” that has permeated many
AMCs. When students “hear institutional leaders speaking more about
‘throughput’, ‘capture of market share’, ‘units of service’, and the financial
‘bottom line’ than about the prevention and relief of suffering,” they “learn
from this culture that health care as a business may threaten medicine as a
calling.”
These developments of course do not settle but merely reprise the debate:
Do such infusions of profit-mindedness trigger efficiency-enhancing organizational adjustments that are long overdue? Or might they (to recall the
ironies of the Vietnam War, which required destroying villages in order to
“save” them) destroy the AMCs’ vaunted mission in the course of securing
the margins required to save it? If and when Brill’s integrated hospital
oligopolies become insurance companies, which ethos is likely to prevail:
the voluntarist, community-serving mission under the nonprofit halo with
which AMCs have long sheltered themselves or the conviction of the forprofit insurers that return on the investments of shareholders defines the
optimal ends and means of a twenty-first-century health care system?
Innovation in Social Spheres. Finally, demands for innovation may
nudge AMCs into unfamiliar sectors and unaccustomed interorganizational
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bonds, as exemplified by the (so far) halting progress of the Delivery
System Reform Incentive Program (DSRIP), launched in 2014 in New
York. The program awards $8 billion to health care systems that strive to
reduce use by Medicaid beneficiaries of avoidable inpatient and emergency department care by 25 percent within five years. Early reports on
the projects at their midpoint suggest that many AMCs have responded to
the new incentives in predictable fashion: using sizable sums to gear up for
action by acquiring new staff, assistants and deputy assistants to the new
staff, new information technology capacities, new office space, and other
infrastructure, and then, remembering (or being reminded) that the bulk
of the money is supposed to be going out the door to the communitybased organizations that provide or arrange for the social services (housing,
substance abuse counseling, nutrition, mental health care, among others)
that are expected to reduce the need for hospital care, they emit awkward
mating call to these organizations, which may strike the AMCs as deficient
in trained staff, information technology capacities, data collection, fiscal
reporting, and other prerequisites of the service delivery, and documentation thereof, that will enable the so-called partners to convince funders of
their success. One cannot helped wondering whether DSRIP should have
gone at it the other way round, that is, given grants to community-based
organizations, which would then reach out to and contract with health care
partners they deemed suitable. The larger point is that when AMCs venture far from their core mission into the realms of social determinants and
social services, the interorganizational relations that ensue may be rocky,
and implementation deserves close attention (which it seldom gets). Nor
does this larger point (which the full run of DSRIP may of course qualify
or refute) augur well for the entry of AMCs into the vexing world(s) of population health management.
Misplaced Concreteness
This overview (admittedly perfunctory) of types of innovation by AMCs,
and of the growing arduousness of innovation as it moves ever further from
the AMCs’ core mission, might seem to confirm the skepticism of David
Axelrod and his allies in the public health community toward institutions
that have, to recall the title of Stevens’s ([1971] 1998) classic book, severed
“American medicine” from “the public interest.” On this view, the health of
the public, like war, is too important to leave to the generals—in this case,
to the leaders of academic medicine (or to apologists who cite the suspect
scripture of organizational analysis to defend these institutions’ stubborn
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preoccupation with what they do best and most want to do, that is, with
their core mission). This indictment, however, suffers from lacunae of its
own, the most important of which is detachment from historical and political context.
Primary Care Shortage. Critiques of the acquiescence of the nation’s
medical schools in the “irresistible urge to specialize” are at least as old as
the Committee on the Costs of Medical Care (Stevens [1971] 1998: 196–
97). If, however, the United States suffers from a dearth of primary care
physicians (a proposition that the definitional and methodological questions discussed in Miriam J. Laugesen’s article in this special issue call
subtly into question), this is not mainly because AMCs refuse to boost their
numbers but, rather, because US policy makers, after decades of platitudinizing, decline to set rules for the training and payment games that favor
primary care. Surveying the scene, Iglehart (2008) concluded that in the
United States a strong tilt toward generalist physicians would require that
policy makers feel the pressure of a “vigorous public uprising,” which has
“not [been] on the American horizon” (Iglehart 2008: 643–50) then or since.
In other Western societies, which consider access to health care some sort
of right, the health care system is expected to honor above all the goal of
securing medically necessary and appropriate care for all at a cost bearable both for society and its households — an objective that demands an
adequate supply of frontline providers and may mean requiring or encouraging visits to gatekeeping generalist physicians. The number of specialists produced in their medical schools is set by calculations of the needs of
the population, and the pay these specialists receive (and therefore the gap
between the earnings of specialists and generalists) is limited by bargaining
in which governments play a deciding or at least a constraining role. Many
physicians in peer nations would like to become specialists and raise their
earnings by doing so; if they do not, it is because they cannot.
The United States, by contrast, has never recognized a right to health
care; allowed the providers of services (hospitals and physicians) to invent
its financing system (Blue Cross Blue Shield et al.) (Chapin 2015); premised that system on coverage for the potentially catastrophic costs of hospital care, not on meeting those of routine visits to primary care providers;
has largely ceded authority over the number, training, and credentialing
of specialists to specialty societies (Stevens 2006); and has done little to
narrow differentials in payment between generalists and specialists. If
medical undergraduates who envision a career in primary care in year
one may indeed emerge from year four convinced instead that the highest
callings of their profession are path-breaking biomedical research and
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innovation, publication in the New England Journal of Medicine, and an
income high enough to speed repayment of their medical school debts
(largely absent from the European scene), the conversion surely reflects
exposure to the deep-seated cultural norms of American AMCs. And critics are certainly entitled to wonder whether the AMC establishment has
given these norms the scrutiny they deserve. After all, as Mark Schlesinger
(personal communication, 2017) points out, that establishment “does have
the capacity, to some extent, to set the pace, call the tune, or otherwise
direct their innovative impulses in ways that will, over several generations
of training and research investment, gradually alter the path of the health
care system.” Here too, however, organizational dynamics are ever in play:
leaders of AMCs and of the organizations that represent them tend to reach
the pinnacles of their institutions not because they are itching for fundamental change but because they have proven themselves to be ardent,
effective—and sincere—defenders of the roles and missions that AMCs
are accustomed to perform and pursue. Furthermore, the enfolding constraints of policy and payment would remain potent even if medical school
deans went door to door extolling to their charges the virtues of treating the
undifferentiated patient.
The Paucity of Public Health. The proposition that the AMCs, if they
truly cherish their nominal mission (improving the health of the public),
would affirm and extend their commitment to preventing illness and promoting health by means of public health interventions is also less than
intuitively obvious. Many Western systems, which act as if universal and
affordable access to care is the best way to forestall illness and encourage
health, have public health sectors less institutionally articulated than that of
the United States. (Whether this puts them ahead or behind in the public
health game is a subtle issue well explored in the article by Sparer and
Beaussier in this special issue.) Public health aficionados have long argued
that (as one of Axelrod’s successors put it in a private setting) “we should
give the public not the care it wants but the care it needs” and that the
Bloomberg/Hopkins mantra, “saving lives millions at a time,” is the highest
policy wisdom. This conviction has found some resonance within the
establishment; a commission impaneled by the Pew Charitable Trust and
the Rockefeller Foundation Trust argued in 1993, for example, that academic medicine should be moving toward population health, a movement
into which the trusts recruited seventeen AMCs (Kaufman and Waterman
1993). But as Daniel Fox (2006) has explained, population health (and
its management) is not so easily sold to policy makers or to the public.
(Michael Bloomberg, who throughout three terms as mayor of New York
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City, made improvements in the health of the public his top goal, was distinctive, indeed probably unique, among prominent elected officials, the
exception that proves the rule [Farley 2015].) That acute care services get
the lion’s share of time, attention, and resources in modern health care
systems principally reflects loss aversion and intensity of preferences
(including, alas, a preference against delaying gratification): I can choose
to start my healthy diet tomorrow, but I cannot choose to stop the cardiac
arrest I am having today.
The alleged trade-offs between acute and preventive care, the wrongheaded striking of which has brought such censure on the nation’s AMCs, is
arguably, moreover, an issue of secondary importance. Bradley and Taylor
(2013) observe that in other Western nations, the health indices of which
tend to surpass those of the United States, combined spending on health
and social services is roughly comparable to that in the United States. The
difference—that others spend considerably more on social services than
on health while the United States does the reverse—suggests that the most
effective public interventions may be the layered policies of social protection on display in other Western welfare states. In a similar vein, scholars who have investigated the influence of social determinants on health
outcomes tend to have little patience for arguments that deplore the evils
of smoking, bad diets, and inactivity while addressing in passing if at all
the deleterious effects of income disparities, damaging work conditions,
stress, and kindred conditions. That AMCs should summon a stronger voice
for policies of social protection is hard to deny. That their preoccupation
with a core curative mission powerfully discourages such policies exemplifies the fallacy of misplaced concreteness.
Disinterest in the Disadvantaged. Finally, the notion that AMCs have a
special obligation not only to serve but also to superintend health care
arrangements for the residents in their service areas (some of which have
seen the replacement over time of middle-class residents by lower-income
ones with Medicaid or no insurance) harks back quaintly to American values
of voluntarism in the good old days when health was understood to be
a community affair at the center of which stood local hospitals. Since
the 1990s, many AMCs have answered the call, partly in response to demands
by federal regulators and state attorneys general that they honor their obligations to supply community benefits. As Blumenthal (2001: 61) observed,
“The acquisition of primary care practices, community hospitals, home
care agencies, and neighborhood health centers put AMCs in the middle of
their communities in a big way”—and to the tune of millions of dollars.
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And, as the AMCs are not slow to point out, many of them treat sizable
numbers of patients who lack coverage or are on Medicaid.
Health remains a community affair, to a point, but that point has long
been shrinking as larger metropolitan, regional, state, and above all federal forces complicate the contexts in which local actors operate. Chief
among these supralocal forces is of course coverage. In fall 2017, fiftytwo US senators and more than two hundred members of the House of
Representatives—all comfortably insured—labored day and night to write
legislation that would strip more than 24 million of their hard-pressed
fellow citizens of the coverage the ACA lately conferred on them. (Their
efforts passed the House and came within one vote of prevailing in the
Senate.) At the end of that year Congress adjourned, leaving in limbo health
coverage for 9 million children because, in a rush to enact tax cuts for the
affluent, the solons supposedly lacked time and money to reauthorize
the Children’s Health Insurance Program. In his January 7, 2018, article in
the New York Times titled “Medical Research? Congress Cheers. Medical
Care? Congress Brawls,” Robert Pear succinctly contrasted the state of
funding for CHIP—“in limbo”— with that of medical research, for which
“one theme ran through questions from members of both parties: ‘What
more can we do to help you?’” The needs of lower-income citizens are
best answered (as in other Western societies) not by the eleemosynary
exertions of AMCs and other providers but by national entitlements to
affordable coverage and care.
Conclusion
If the United States had the benefit of hindsight and a chance to start from
scratch, perhaps it would do AMCs differently. Instead of entrepreneurially fueled growth within a system of coverage, funded by myriad private
payers, that admits government into the mix mainly in a gap-filling role, and
instead of encouraging AMCs to thrive by forging cohesion around their
mission within a system that largely lacks both cohesion and coherence, the
nation might charter organizations to pursue research, render high-end care,
and offer training within a framework of affordable universal coverage and
firm rules of the game that allot financial support from public coffers and—
within this global budget—permit considerable operating autonomy. The
United States is not about to start from scratch, however. The ACA, which
built on the foundations of employer-based coverage by means of private
insurance and even so is now threatened with mutilation, illustrates all too
well the resilience of the status quo within which AMCs operate.
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In the face of multiplex and unwieldy structures and missions that might
seem prima facie to make successful AMCs impossible, these organizations
have coalesced around a core mission honoring medical innovation—
generated by the best science, deployed clinically by expert providers, and
taught rigorously to future physicians. And, especially during what might
be called their trente glorieuses (roughly 1945–75), these AMCs enjoyed
and repaid the generosity of an environment of funders and payers that
smiled on that core mission.
All the while, however, they faced critics who have insisted that the
AMCs’ center of institutional gravity makes too little room for primary
care, population-based strategies of prevention and promotion, and the
needs of the disadvantaged—an alternative mission that supposedly would
not only serve the genuine needs of the public but also markedly slow the
growth of health care costs. But these assaults misplace onto concrete
(and therefore presumably tangible, reachable, persuadable, accountable,
and changeable) organizations responsibility for failures of policy the
sources of which lie in the nebulae and vapors of public policy and in the
elusive politics that shape it. The late Daniel Patrick Moynihan, Democratic senator from New York, called AMCs “national treasures,” indeed,
“the very best [such institutions] in the world” (Fins, Leiman, and Pardes
2017: 16). Critics may dismiss these encomiums as (to borrow a Sondheim
lyric) “a toast to that invincible bunch / the dinosaurs surviving the crunch.”
(For more of the dinosaur trope, see Becker et al. 2010.) All the same, one
need not share Burkean angst over the fragility of precious institutions
to wonder whether it is not sometimes best to leave well enough alone.
American AMCs have successfully identified and accomplished a core
mission, much valued by the public. Their heart is in what they do, and they
do it well. Can policy makers not somehow find a way to secure their
foundations and finances and let them proceed in peace?
If one good cliché deserves another, however, one can counter leaving well enough alone with Lampedusa’s familiar dictum that things must
change if they are going to stay the same. Since the mid-1970s the broad
acclaim the AMCs enjoyed (outside the smallish circle of critics discussed
above) has become more conditional and contingent as the AMCs get
swept along by rising worries about the rate of growth of health care costs
and about the clinical and social value all that spending produces. Managed
care has sought to trim costs by prudent purchasing, selective contracting, shifting from specialist and inpatient to generalist and outpatient care,
and hard bargaining over prices; on all these counts AMCs represent the
costly high hanging fruit managers aim to prune. Cuts in Medicare (and
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Medicaid) that fall on beneficiaries are more painful politically than are
cuts in payments to providers who can suck them up (or not) as best they
can, and so the flow of public revenues to providers, AMC and other, grows
more slowly. Schemes to attain more value for money—as in value-based
purchasing—create new rules of the payment game and therewith high and
unshakeable anxiety within AMCs that their fiscal future may change on a
dime with the whims of economists and budget makers in Washington, DC,
imperiling their fiscal health, perhaps indeed their survival—decision
making under uncertainty indeed. (That uncertainty should, but rarely does,
apply as well to the designers of these payment systems. New financial incentives may be necessary to set behavioral change in motion, but
sufficiency—how far changes forego gaming in favor of the anticipated
higher value for money — depends heavily on how those incentives are
refracted into and within distinct organizational settings and cultures and
on how organizational leaders interpret the implications of the incentives
for, as Clifford Geertz put it, “how things go, have been going, and are
likely to go” within their institutions (Geertz 1995: 3). For a brilliant
discussion of such organizational refraction—in this case, variable hospital
responses to limits on the working hours of residents—see Kellogg 2011.
In so turbulent a political economy of health policy, no margin can be
trusted to protect mission, and critics predictably scoff that munificently
paid CEOs of well-funded AMCs are crying all the way to the bank. The
assertion is true—and also, in context, understandable. It is hardly surprising that leaders of AMCs bewail the difficulties their hard-nosed fiscal environments impose on them, and no less so that they redouble their
efforts to reap the financial rewards of innovations that keep their institutions afloat (at least temporarily).
Acute managerial stress may be inseparable from the convoluted politics
and technocratic policies that purport to contain health care costs in the
United States. In principal it would be wise to develop more stable financial resources for AMCs, but in practice no prominent politicians seem
prepared to invest heavy political capital in this arcane and touchy issue,
and intermittent efforts to supplement or supplant GME payments in
Medicare—where they have no logical reason to reside and where they
were expected to reside only until Congress found some other way to fund
them (Iglehart 2008)—with, say, funding by a trust fund derived from
taxes on private insurers, have never left the starting gate. The issues and
alternatives got considerable attention during the debate over the Clinton
health reform proposals of 1993–94, but reform-minded legislators
(such as Moynihan and Democrat Jay Rockefeller of West Virginia) and
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medical organizations clashed over how to fund GME and what strings to
attach to those funds (Iglehart 1994). Since then “a comprehensive public strategy . . . to cover the added costs of clinical care that accompany
medical education activities” (Commonwealth Fund 2002: 58) has continued to elude consensus. Then again, perhaps AMCs should be careful
what they wish for: one wonders whether they would fare better on the
whole under a more stable system of public funding (with the controls and
constraints that inevitably come with it) or under the nerve-racking carte
blanche for laissez faire to which they have become (uncomfortably but
adroitly) accustomed.
AMCs are unlikely any time soon to escape the ambivalence and ambiguity that have come to complicate their lives. The states of siege and
crisis they have deplored for decades are not likely to lift and resolve. Elite
commissions and task forces will continue to deliberate every few years
and then issue largely invariant laundry lists of musts and shoulds, among
which the audience of AMCs will pick and choose (or ignore) according
to their organizational cultures and their leaders’ tolerance and taste for
managerial improvisation. Policy makers will continue to misplace their
faith on organizational solutions—MCOs, accountable care organizations,
the diffusion of high-performing systems, and badgering of AMCs to step
up their multitasking and cure all the system’s ills—for want of political will to set the system-wide rules for coverage, prices, and other fundamentals that frame the health care systems of other Western nations. As
long as they feel misunderstood and besieged, moreover, AMC leaders are
likely to continue to invest most of their formidable political capital in
seeking to secure their sector, not in pushing policy makers toward a system
of affordable universal coverage accompanied by system-wide rules of the
game binding on all stakeholders.
A half century ago AMCs were in a “state of rapid functional transition” (Stevens [1971] 1998: 375), and the condition, still acute today, is
very likely chronic. The AMCs will soldier on, savoring the broad and still
solid support for their core mission throughout society but lamenting fiscal
pressures that, legitimated in the name of cost containment and value for
money, increasingly cloud the connections between general social approbation and the particulars of policy. They will continue to improvise variations on their core mission, for instance, the extension and application of
evidence-based medicine, the amassing of big (and ever-bigger) data, the
refinement and application of artificial intelligence, the elaboration of electronic health records and other advances in information technology, refinements in the protection of patient safety and the reduction of medical error,
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“virtual electronic specialty consultations,” and other accouterments of
“learning health systems” (Grumbach, Lucey, and Johnston 2014: 1109–
10) that have (or are said to have) the additional advantage of enhancing
the effectiveness and efficiency of their work. AMCs will also, for reasons
both of self-protection and responsiveness to external demands, continue to
push further along entrepreneurial frontiers—mergers, acquisitions, diversification of facilities, patenting, accountable care organizations, expansion
into new markets—that overlay their core mission with the commercial
trappings of the increasingly for-profit US health system and that entail
tasks for which they may not be (or in truth much want to be) highly adept.
They will rationalize these endeavors as necessary and perhaps sufficient to
assure them the margins they need to ride the high road along the endless
frontier of science. Ends can justify means; all the same, one hopes that
amid their entrepreneurial adventures they will remember how to find their
way home.
n
n
n
Lawrence D. Brown is professor in the Department of Health Policy and Management at Columbia University’s Mailman School of Public Health. He served as chair of
the Department of Health Policy and Management for ten years and in Columbia
University’s Public Policy Consortium for three years. He is the author of the 1983
Brookings Institution book Politics and Health Care Organization: HMOs as Federal
Policy and articles on the political dimensions of community cost containment,
expansion of coverage for the uninsured, national health reform, the role of analysis
in the formation of health policy, and cross-national health policy.
lbrowncol@aol.com
Acknowledgments
Warm thanks to Pierre-Gerlier Forest, Annetine Gelijns, Yuna Lee, Mark Schlesinger,
and an anonymous reviewer, all of whose comments on an earlier version much improved
this article.
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