Key factors in the transition to IHCOs.

Our profession has come to expect that Professor John Griffith's writings will be thorough and perceptive, and that they will reflect the highest standards of scholarship. We are not disappointed by his "Managing the Transition to Integrated Health Care Organizations." Well-thought-out presentations such as this one invite less in the way of criticism than an elaboration of points that stand out as being of more-than-usual significance. In this case, the points that invite comment are: * the inherent strengths of the not-for-profit, community-based, integrated health care organization (IHCO); * the important role that values play in the transition being discussed; and * the continued significance of the medical profession to the success of the IHCO. Inherent Strengths of the Not-for-Profit, Community-Based Form of Organization Much of the discussion of for-profit versus notfor-profit in the hospital field has been defined in terms of charity and tax exemption. Griffith suggests that the distinctiveness of the not-forprofit form has a broader dimension, which he describes using terms such as community ownership, community orientation, and community vision. In addition to charity, community-owned hospitals have traditionally engaged in activities that, although of public benefit, do not generate an attractive financial return. Education and research are common examples, but every community-owned hospital that has a community vision can provide a much longer list, comprising what we at Henry Ford Health System refer to as the "community dividend." These "community dividend" projects tend to focus on improving community health status; addressing the problems of minorities, the poor, and the uninsured; and providing leadership in dealing with the issues of cost and excess capacity. Professor Griffith points out that the movement towards the IHCO form of organization has been stimulated in large measure by ". . . a sharply increased price orientation by health insurance buyers . . ."-a major expression of which has been the growth of capitated financing and managed care. The concept of community ownership has significance in this context, as well. During its recent resurgence, the managed care movement has concentrated on cost reduction-and has enjoyed tangible success. However, this focus on cost has been accompanied by the public concerns about "quality" that Griffith identifies, together with the search for legal recourse and other remedies. These public concerns include the question of whether patients can afford to trust providers who may be directed or financially induced to minimize services. In these circumstances, the IHCO should enjoy a strategic advantage. Regardless of how it is organized and financed, health care is a service in which the recipient seeks to benefit from the professional judgment and skill of the provider. The recipient, therefore, has legitimate reason to be concerned about anything that might either lead the provider to pursue goals other than the best interest of the patient or to limit the provider's ability to exercise professional judgment on the patient's behalf. To the extent that it is seen to be ultimately accountable to the community, the IHCO can credibly present itself as a trustworthy protector of the community's interests in these matters, an agency that can be relied upon to provide the services its patients need-whether it is financially advantageous to do so or not, and a credible advocate for professional standards and patient rights in the process of resolving customer/provider conflicts. As Professor Griffith points out, the objectives of what he calls the anti-IHCO are to maximize profit for stockholders and to meet the needs of its members. Compared to an IHCO, it will be difficult in most cases for the anti-IHCO to claim equal credentials as a protector of the interests of the patient and the community. The IHCO also provides a framework in which purchasers of care, employers, labor unions, and other groups representative of community interests can participate in decision making on matters affecting the provision of health services. …