Universities are having a hard time lately. They’re beset with protests the like of which we’ve not seen since the Vietnam War days, with animated crowds, sit-ins, violent clashes with police or counter protesters, even storming of administration buildings. Classes and commencements have been cancelled. Presidents of some leading universities seemed unable to clearly denounce antisemitism or calls for genocide when asked to do so in Congressional hearings. Protesters walked out on Jerry Seinfeld’s commencement speech; for heaven’s sake – who walks out on Jerry Seinfeld?
Administrators in Meeting World. Credit: Bing Image Creator
Derek
Thompson wrote a great piece for The Atlantic that tries to pinpoint the
source problem: No
One Knows What Universities Are For. The sub-title sums up his thesis: “Bureaucratic bloat has siphoned power away from instructors
and researchers.” As I was nodding along with most of his
points, I found myself also thinking: he might as well be talking about healthcare.
Mr.
Thompson starts by citing a satirical
piece in The Washington Post, in which Gary Smith, an economics
professor at Pomona College, argues that, based on historical trends in the
growth of administration staff, the college would be best served by gradually
eliminating faculty and even students. The college’s endowment could then be
used just to pay the administrators.
“And just like that,” Professor Smith says, “the college
would be rid of two nuisances at once. Administrators could do what
administrators do — hold meetings, codify rules, debate policy, give and attend
workshops, and organize social events — without having to deal with whiny
students and grumpy professors.”
It’s
humorous, and yet it’s not.
The growth
in universities’ administrative staff is widespread. Mr. Thompson acknowledges:
“As the modern college has become more complex and
multifarious, there are simply more jobs to do.” But that’s not always helping
universities’ missions. Political scientist Benjamin Ginsberg, who published The Fall of the Faculty: The Rise of the All-Administrative
University and Why It Matters in 2014, told Mr. Thompson: “I
often ask myself, What do these people actually do? I think they spend much of their day living in an
alternate universe called Meeting World.”
Similarly, Professor Smith told Mr., Thompson it’s all about empire building; as Mr. Thompson describes it: “Administrators are emotionally and financially rewarded if they can hire more people beneath them, and those administrators, in time, will want to increase their own status by hiring more people underneath them. Before long, a human pyramid of bureaucrats has formed to take on jobs of dubious utility.”
All
of these administrators add to the well-known problem of runaway college tuition
inflation, but a more pernicious problem Mr. Thompson points to is that “it
siphons power away from instructors and researchers at institutions that
are—theoretically—dedicated to instruction and research.”
The
result, Mr. Thompson concludes is “goal ambiguity.” Gabriel Rossman, a
sociologist at UCLA, told him: “The modern university now has so many
different jobs to do that it can be hard to tell what its priorities are.”
Mr. Thompson worries: “Any institution that finds itself promoting
a thousand priorities at once may find it difficult to promote any one of them
effectively. In a crisis, goal ambiguity may look like fecklessness or
hypocrisy.”
So it is
with healthcare.
Anyone who
follows healthcare has seen some version of the chart that shows the growth in
the number of administrators versus the number of physicians over the last 50 years;
the former has skyrocketed, the latter has plodded along. One can – and I have in
other forums – quibble over who is being counted as “administrators” in these
charts, but the undeniable fact is that there are a huge number of people
working in healthcare whose job isn’t, you know, to help patients.
But, as
Mr. Thompson worries about with universities, the bigger problem in healthcare
is goal ambiguity. All those people are all doing something that someone finds
useful but not necessarily doing things that directly related to what we tend
to think is supposed to be healthcare’s mission, i.e., helping people with
their health.
Think
about the hospitals suing patients. Think health insurers denying claims or
making doctors/patients jump through predetermination hoops. Think about the “non-profits” who not only have
high margins but also get far greater
tax breaks than they spend on charity care. Think about healthcare
“junk fees” (e.g., facility fees). Think about all the people in healthcare
making over a million dollars annually. Think about pharmaceutical companies
who keep U.S. drug prices artificially high, just because they can.
As TV’s
Don Ohlmeyer once said in a different context: “The answer to all of your questions
is: Money.”
Healthcare
is full of lofty mission statements and inspiring visions, but it is also too
full of people whose jobs don’t directly connect to those and, in fact, may
conflict with them. That leads to goal ambiguity.
Mr. Thompson concluded his article:
Complex organizations need to do a lot of different jobs to appease their various stakeholders, and they need to hire people to do those jobs. But there is a value to institutional focus…The ultimate problem isn’t just that too many administrators can make college expensive. It’s that too many administrative functions can make college institutionally incoherent.
Accordingly,
I’d argue that the problem in healthcare isn’t that it has too many administrators
per se, but that the cumulative total of all those administrators has resulted
in healthcare becoming institutionally incoherent.
Famed
Chicago columnist Mike Royko once offered a solution to Chicago’s budget problems.
“It’s simple,” he said. “You ask city employees what they do. If they say something
like “I catch criminals” or “I fight fires,” them you keep. If they say
something like “I coordinate…” or “I’m the liaison…”, them you fire.”
Healthcare
should have that kind of institutional focus, and that focus should be around
patients and their health, not around money.
Twenty
years ago Gerry Anderson, Uwe Reinhardt, and colleagues posited “It’s the
Prices, Stupid” when it came to what distinguished the U.S. healthcare
system, but now I’m thinking perhaps it’s the administrators.
