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rial authority. Their success comes not from

to pay doctors according to the independent-

any inherent aspect of medical practice but

craftsman model. For example, Medicare's

from government protection.12 Licensing of

payment system generally does not reward

coordination. Instead, Medicare and other fee-

medical professionals, state health insurance

for-service payers tend to favor technologically

regulations, corporate-practice-of-medicine

intensive specialist services over those of gen-

laws, and policies that encourage fee-for-ser-

eral practitioners who might be best suited to

vice payment (i.e., Medicare, Medicaid, and

play the role of project manager. The mis-

the federal tax code) hold at bay the market

match between payment systems and patients'

forces that would improve coordination of

needs can be seen in the fact that the supply of

care by subjecting physicians to managerial

gerontologists is not increasing, in spite of the

authority.

obvious demographic basis for greater

Senior Management

demand and the value gerontologists can add

as project managers for those who are least

Coordinated health care teams in turn

able to coordinate their own care.10

would benefit from senior-level management

Physicians' resistance to managerial author-

that constantly examines how well their plans

ity is legendary. According to one colorful

are working, retains those that deliver positive

account:

outcomes, and discards those that do not.

When bottlenecks or errors arise, manage-

While many physicians fall prey to an

ment must brainstorm solutions, test them,

illusion of omnicompetence and believe

and implement those that work. In other

that their medical training endowed

words, senior management must be account-

them with superior management judg-

able for overseeing processes that lead to the

ment, most are incapable of submitting

best possible outcomes for patients.

to the authority of anyone, even a fellow

Such organizational advances are not

physician. Many physicians selected

entirely foreign to medicine. Some hospitals

their profession based upon their need

rely on "intensivists" to coordinate treatment

for autonomy and individual achieve-

in intensive care units, though this innovation

ment. As a consequence, many lack the

has yet to be widely adopted. Gerontologists

interpersonal skills or civility to func-

coordinate care for elderly patients, yet remain

tion as part of a larger enterprise . . . A

a relative anomaly, despite the obvious value

few less-temperate administrators actu-

they could provide to the growing number of

ally pop off in medical staff meetings

adults who struggle to care for their children

about how different things will be

and their aging parents at the same time.

"when all you bastards finally work for

Intensivists employ checklists of standard pro-

me."11

cedures to reduce errors in intensive-care

units.13 These advances illustrate how man-

In the home-building analogy, it is as if the

agement techniques borrowed from industrial

concrete contractor, the drywall contractor,

settings can be used to improve health care.

the electrician, and the plumber all refuse to

Yet prevailing payment and workforce policies

Government

work under a general contractor. Instead,

have inhibited these and similar innovations.

interference holds

they each try to do their jobs independently,

regardless of the impact on the rest of the

at bay the market

A Role for Corporations

project. No one craftsman is in a position to

forces that would

take responsibility for delivering the overall

finished product, and quality suffers as a

The challenge of developing organization-

otherwise improve

result.

al competence is the chief focus of the mod-

coordination

ern corporation.14 The very purpose of cor-

Physicians have been more successful

of care.

than other professionals in resisting manage-

porations is to reduce transaction costs

4