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Paola Adinolfi · Elio Borgonovi Editors

The Myths
of Health Care
Towards New Models of Leadership and
Management in the Healthcare Sector
Foreword by Henry Mintzberg
The Myths of Health Care
Paola Adinolfi Elio Borgonovi
•

Editors

The Myths of Health Care

Towards New Models of Leadership
and Management in the Healthcare Sector

Foreword by Henry Mintzberg

123
Editors
Paola Adinolfi Elio Borgonovi
CIRPA (Interdepartmental Centre for Public Administration and Health Institute
Research in Economics, Law and “Carlo Masini”
Management of Public Administrations) University “Luigi Bocconi” of Milan
University of Salerno Milan
Fisciano Italy
Italy

ISBN 978-3-319-53599-9 ISBN 978-3-319-53600-2 (eBook)

https://doi.org/10.1007/978-3-319-53600-2
Library of Congress Control Number: 2017932085

© Springer International Publishing AG 2018

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To Graziano, Stefano and Matteo
To Mattia, Milo and Bianca
Wishing that they could live in a healthy and
peaceful society
Foreword

Needless to say, it is a great compliment to me and my work on the myths of health

care that Paola Adinolfi and Elio Borgonovi have elected to do this volume. I am
amazed how much this book contains, and how thorough these chapters are. We
publish in parallel, this book based on talks I gave at the University of Salerno at
the invitation of Paola Adinolfi, which uses a summary article I did earlier, and my
book Managing the Myths of Health Care, which is going to appear around the
same time. Too bad we could not have had each other’s manuscript, to incorporate
with our own views. But the happy part is that the readers will have both, and will
thereby be able to probe in greater depth, having the interdisciplinary perspective
from Paola and Elio’s book. I am confident that having these two books together
will shed greater light on the important field of health care, and I hope that we can
continue to share our ideas in the future.

September 2016 Henry Mintzberg

John Cleghorn Professor of Management Studies
Desautels Faculty of Management, McGill University, Montreal, QC, Canada

vii
Preface

It can be considered widely held that health care models are significantly condi-
tioned by sets of beliefs which are in turn parts of broader philosophical ideas
rooted in the culture of the time. Such beliefs may be more or less true, nevertheless
they are vitally important in shaping health care models. Henry Mintzberg identified
some false sets of beliefs—he calls “health myths”—which in his view are at the
basis of the mess we currently face in health care.
It is indeed difficult for any one individual to see the fallacy of such myths,
because they are below the surface. Furthermore, because of their invisibility, they
are rarely challenged: debate on health care management is mainly focused on
managerial-organizational models, as well as on specific techniques and tools, while
discussion on ideas is surprisingly poor. We wanted to fill this gap: without
informing Mintzberg, we asked a number of academic and practitioners, equally
distributed between supporters and critics, to reflect on the “health myths”. We
aimed at bringing Mintzberg’s myths to light, being open to any possible outcome:
either overcoming them or discovering their “Holy Grail”.
Among the academics, we invited senior and junior scholars from the field of
management, accounting and organization studies, enrolled in CERGAS (the
Research Centre for Health and Social Services) at Bocconi University of Milan
(Patrizio Armeni, Oriana Ciani, Francesca Lecci, Federico Lega, Marco Morelli,
Anna Prenestini, Rosanna Tarricone and Alexandra Torbica) and in CIRPA
(Interdepartmental Centre for Research in Economics, Management and Law of
Public Administrations) at the University of Salerno, a leading university in the
South of Italy for research and action-research on public sector management and
health care (Carmela Annarumma, Antonio Botti, Giuseppe Festa, Giuseppe
Iuliano, Gaetano Matonti, Rocco Palumbo, Gabriella Piscopo, Paolo Tartaglia
Polcini, Alessandra Storlazzi, Aurelio Tommasetti, Massimiliano Vesci). We also
engaged academics from the University of Chieti-Pescara (Massimo Sargiacomo),
the University of Florence (Mario Del Vecchio), the University of Lazio and
Cassino (Lorenzo Mercurio), the Polytechnic University of Marche (Luca Del
Bene), the Polytechnic University of Milan (Emanuele Lettieri), the University of
Naples “Federico II” (Mariavittoria Cicellin, Gianluigi Mangia, Stefano Consiglio),

ix
x Preface

the University of Naples “Parthenope” (Luigi Moschera), the Second University of

Naples (Ettore Cinque, Corrado Cuccurullo, Mario Pezzillo Iacono, Marcello
Martinez), the University of Rome (Alessio Santoro, Andrea Silenzi), the
University of Sannio (Vincenza Esposito), the University of Venice (Salvatore
Russo), and the University of Verona (Giuseppe Favretto). In addition, contributors
from Switzerland (Stefano Calciolari) which shows a mixed public-private health
care system, Sweden (Evert Gummesson), which shows a largely publicly funded
and universal health care system, have been invited, as well as from Ireland
(Gerardine Doyle) and the United Kingdom (Michael Drummond) which adopt a
mainly Beveridgean health model.
Young promising scholars, bringing their fresh vision to inspire the future shapes
of the health care system, have joined outstanding scientists, who can bring a long
experience and a deep knowledge of the health care system. Among others, Michael
Drummond is considered the founder of Health Economic Evaluation and author of
several papers published in leading journals of the field, Editor-in-Chief of Value in
Health; Evert Gummesson, Emeritus Professor of Service Marketing and
Management at the Stockholm Business School, is an international pioneer in the
field of service and one of the fathers of leadership in service. Also, we included
eminent scientists from other disciplines: Engineering (Cristina Masella), Medicine
(Annamaria Colao), and Philosophy (Matteo Motterlini).
We did not want to confine the discussion to the realm of academic conversation,
so we also invited practitioners who cope every day with the challenges of
increasingly complex health care systems, able to contextualize their reflections by
connecting to concrete examples and practical activities. We included professionals
and consultants who had experience in health care organizations: Vittorio Bertelè is
a clinical pharmacologist, director of the regulatory policy at Mario Negri Institute;
Enrico Coscioni, a renowned heart surgeon in Southern Italy, is advisor for the
Campania’s Health Systems, among the most problematic regional health services
in Italy; Marina Davoli is the scientific director of the Italian National Health
Outcome Program and director of the Department of Epidemiology of the Lazio
regional health system, another regional health service in deep financial crisis;
Chiara Marinacci is fellow of the General Directorate for Health Planning of the
Italian Ministry of Health; Maurizio Mauri, a radiologist who was Health Director
in some big hospitals in Northern Italy, is now a hospital planner; Joseph Polimeni,
after having managed several health care organizations in Central Italy, is currently
the State Sub-Commissioner for the financial recovery plan of the Campania
Regional Health Service. The consulting industry is represented by Daniela
Scaramuccia, who was the Ministry of Health in the Tuscany Region (4.5 million
inhabitants), and Alberto Calvo, both affiliates of one of the chief consulting
companies operating in the health sector (Value Partners Management Consulting).
The pharmaceutical industry is also represented: among the contributors, we invited
Maurizio De Cicco, Vice President of Farmindustria, accountable for leading
innovation and Agenda talks with the Italian Medicine Agency.
Preface xi

We also invited a general, member of the Italian Airforce (Lt. Gen. Fernando
Giancotti), currently Commander of the Air Education and Training Command,
who published essays and textbooks on the US Air Force Leadership and a book in
Italy widely used for education on leadership and change management.
Finally, we decided to invite key actors in the Italian health care arena, who are
in a position to look at the broader system: Francesco Bevere, after having per-
formed as a senior manager in different health care organizations operating both in
the North and the South of Italy, and as head of the Health Planning Directorate
of the Italian Ministry of Health, is currently the Director in chief of the National
Health Agency (the consulting body for the Health Ministry); Renato Botti, after
long experience as a senior manager of both for-profit and not-for-profit organi-
zations, is now the chair of the Directorate of Health Planning of the Ministry of
Health; Silvio Garattini is one of the most prestigious researchers in the field of
pharmacology: in 1963 he founded the Mario Negri Institute, a not-for-profit
research institute that is well known in the international scientific community; he
was principal investigator of hundreds of studies in this field and was member of
several national, European and international committees and regulatory agencies;
Walter Ricciardi, Professor of Public Health, is member of the External Advisory
Board to the WHO European Regional Director for the development of the
European Health Policy, member of the National Committee for the evaluation
of the Italian National Health Service, President of the Italian Higher Institute of
Health; Maria Grazia Sampietro has long managerial experience in health and social
services and is currently the Director in Chief of the Welfare Directorate of INPS
(the Italian National Institute for Social Security); Umberto Veronesi is an out-
standing oncologist surgeon who developed in late 1970 an innovative and less
aggressive approach to breast cancer. He has also top management experience as
director of the Italian Cancer Institute based in Milan: in 1982 he founded in Milan
the private European Institute for Oncology (IEO). Last but not least, Umberto
Veronesi was the Ministry of Health of the Italian Government from April 2000 to
June 2001.
We selected the contributors in order to maximize the diversity of perspectives:
different cultural backgrounds; different geographical areas; both academic and
practitioners (sometimes the two cooperating in the same contribution); senior and
junior positions.
A common element to all contributors is having encountered, at a certain point
of their professional path, Mintzberg’s provocations: some of them participated as
discussants to the conferences organized in 2007 and 2010 at the University of
Salerno. Others have been mentioning Mintzberg on other occasions, assuming
different positions: from those who have been struck on the road to Damascus and
fell in love with Mintzberg’s theses, to those who were severely critical.
The outcome of this joint effort is presented in the second section of the volume,
after an introductory section which includes an outline of health myths, as originally
xii Preface

proposed by Henry Mintzberg, a historical analysis of their consolidation over the

centuries, as elaborated by the two editors of the volume, as well as an overview
of the comments proposed by the invited contributors. In the third section we build
on the common points to provide the foundation of a rich, higher order reflection on
the current changes and challenges in the health care arena. We conclude our trip
into the complexity of health care management with no definitive answers but many
questions.
As editors, we are extremely grateful to all the authors for having managed their
contributions according to the requested terms and modalities. Academics are busy
running their laboratories and classes; moreover, they are rewarded for producing
science, rather than for reflecting on such production. Practitioners are also very
busy running their organizations. Nevertheless, all the invited authors have
unsparingly offered their time and intellectual energy by contributing to our edi-
torial project. We also thank the practitioners and academics missing from the
volume who could have legitimately participated in it. In some cases, a collabo-
ration by them was sought but for one reason or another did not occur. In particular
we thank Dr. Fulvio Moirano and Profs. Maria Aristigueta, Luca Anselmi and
Simone Lazzini, who kindly welcomed our invitation, but could not complete the
work. Although the issues involved have been covered by other contributions, we
regret having lost the richness of their specific views.
We sought to avoid any possible influence on the content of the contributions
(this attempt would anyway have been self-defeating), therefore we provided very
poor indications: we just invited the contributors to comment on Mintzberg’s article
“Managing the myths of health care” (unfortunately, Mintzberg’s complete
manuscript was not yet available), focusing in particular on one of the myths, and
adopting a fluid, discursive approach, without technicalities or specialized lan-
guage. In some cases, we assisted the authors to elucidate and enlarge upon what
they intuitively wanted to contribute. We have learned a lot along the way, so this
collaboration has been one of the most rewarding aspects of editing the book.
Coordinating over 60 contributors has indeed been a huge enterprise, and our
warmest thanks go to Dr. Rocco Palumbo, a promising young research fellow who
unsparingly supported our efforts and put the contributions together.
Finally, our deep thanks to Henry Mintzberg, who inspired our editorial project,
in that he tore the veil which constitutes at the same time a shroud and a shield
disguising the true reality of health care management. We had the pleasure of
meeting him personally, so we had the privilege of knowing him not only as
scientist, but also as person. He came to the University of Salerno the first time in
2007, to illustrate his challenging arguments, and we still have a vivid memory of
that day. He arrived on time, with a backpack on his shoulders and checked shirt.
Moved by the reverent homages from deferent academic and institutional author-
ities, and the endless standing ovation and round of applause from an overcrowded
hall, he felt he should put on a jacket and tie. With his humble smile and his
willingness to learn, he was able to floor even the impeccable Chancellor, Prof.
Raimondo Pasquino. Before an attentive audience, the Canadian “guru” started to
Preface xiii

illustrate with disarming simplicity his view on managing health care, highlighting
the unescapable conundrums of management and crumbling the intellectual
framework of health care management orthodoxy. To us, Henry Mintzberg
appeared himself as a conundrum: a complex and provokingly simple scientist, a
humble and refined speaker, an irreverent and respectful scholar, a generous teacher
and an eager learner.

Fisciano, Italy Paola Adinolfi

Milan, Italy Elio Borgonovi
April 2017
Contents

Part I Managing in Health Care: Cues and Reflections

1 Managing the Myths of Health Care . . . . . . . . . . . . . . . . . . . . . . . . . 3
Henry Mintzberg
2 The Historical Evolution of Health Concepts and Approaches:
The Challenge of Complexity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Paola Adinolfi and Elio Borgonovi
3 A Plural Analysis of Health Myths: Overview of the Volume . . . . . 25
Paola Adinolfi and Elio Borgonovi

Part II Going Through Health Myths

4 Myth #1: The Healthcare System Is Failing . . . . . . . . . . . . . . . . . . . 43
Umberto Veronesi, Maurizio Mauri, Mario Del Vecchio,
Patrizio Armeni, Vincenza Esposito, Mario Pezzillo Iacono,
Lorenzo Mercurio and Joseph Polimeni
5 Myth #2: The Healthcare System Can Be Fixed by Clever
Social Engineering . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Emanuele Lettieri, Cristina Masella, Corrado Cuccurullo
and Fernando Giancotti
6 Myth #3: Healthcare Institutions as Well as the Overall System
Can Be Fixed by Bringing in the Great Leader . . . . . . . . . . . . . . . . 87
Anna Maria Livia Colao, Pasquale Antonio Riccio, Antonio Botti,
Aurelio Tommasetti and Massimo Sargiacomo
7 Myth #4: The Healthcare System Can Be Fixed by Treating
It More as a Business . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
Federico Lega, Emanuele Vendramini, Giuseppe Festa
and Enrico Coscioni

xv
xvi Contents

8 Myth #5: Health Care Is Rightly Left to the Private Sector,

for the Sake of Efficiency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
Oriana Ciani, Aleksandra Torbica, Francesca Lecci, Marco Morelli,
Michael Drummond, Rosanna Tarricone, Maurizio de Cicco,
Salvatore Russo and Luca Del Bene
9 Myth #6: Health Care Is Rightly Controlled by the Public Sector,
for the Sake of Equality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
Andrea Silenzi, Alessio Santoro, Walter Ricciardi, Anna Prenestini,
Stefano Calciolari, Silvio Garattini, Vittorio Bertelè,
Riccardo Mercurio, Stefano Consiglio and Mariavittoria Cicellin
10 Myth #7: The Myth of Measurement . . . . . . . . . . . . . . . . . . . . . . . . . 177
Matteo Motterlini, Carlo Canepa, Sabina Nuti, Marina Davoli,
Chiara Marinacci, Renato Botti, Giuseppe Iuliano, Gaetano Matonti,
Paolo Tartaglia Polcini, Ettore Cinque, Francesco Bevere
and Paola Adinolfi
11 Myth #8: The Myth of Scale. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211
Rocco Palumbo, Gabriella Piscopo, Maria Grazia Sampietro,
Marcello Martinez, Louis Moschera, Gianluigi Mangia,
Daniela Scaramuccia and Alberto Calvo
12 Health Myths and Service-Dominant Logic . . . . . . . . . . . . . . . . . . . . 231
Evert Gummesson, Gerardine Doyle, Alessandra Storlazzi,
Carmela Annarumma, Giuseppe Favretto, Aurelio Tommasetti
and Massimiliano Vesci

Part III Lessons Learnt

13 Looking Through the Lens of the Complexity Paradigm . . . . . . . . . 255
Paola Adinolfi and Elio Borgonovi
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265
Contributors

Paola Adinolfi Director of CIRPA (Interdepartmental Centre for Research in

Economics, Law and Management of Public Administrations), University of
Salerno, Fisciano, Salerno, Italy
Carmela Annarumma Department of Management & Innovation Systems,
University of Salerno, Fisciano, Salerno, Italy
Patrizio Armeni Centre for Research in Health and Social Care Management
(CERGAS), University “Luigi Bocconi,” Milan, Italy
Vittorio Bertelè Laboratory of Drug Regulatory Policies, IRCCS Istituto di
Ricerche Farmacologiche Mario Negri, Milan, Italy
Francesco Bevere AGENAS—National Agency for Health Services, Italian
Ministry of Health, Rome, Italy
Elio Borgonovi Public Administration and Health Institute “Carlo Masini,”
University “Luigi Bocconi,” Milan, Italy
Antonio Botti Department of Management & Innovation Systems, University of
Salerno, Fisciano, Salerno, Italy
Renato Botti School of Management, Italian Ministry of Health, Rome, Italy
Stefano Calciolari Institute of Economics (IdEP), Università della Svizzera
Italiana, Lugano, Switzerland
Alberto Calvo Value Partners Management Consulting S.P.a, Milan, Italy
Carlo Canepa Center for Research in Experimental and Applied
Epistemology, University Vita-Salute San Raffaele, Milan, Italy
Oriana Ciani Centre for Research in Health and Social Care Management
(CERGAS), University “Luigi Bocconi,” Milan, Italy

xvii
xviii Contributors

Maurizio de Cicco Chairman of the Board of Directors, Managing Director

Roche, Italy; Vice President of Farmindustria, Monza, Italy
Mariavittoria Cicellin Department of Economics, Management and Institutions,
University of Naples Federico II, Naples, Italy
Ettore Cinque Department of Economics and Management, Second University of
Naples, Caserta, Italy
Anna Maria Livia Colao Department of Clinical Medicine and Surgery,
University of Naples Federico II, Naples, Italy
Stefano Consiglio Department of Social Sciences, University of Naples Federico
II, Naples, Italy
Enrico Coscioni Department of Ascending Aorta and Thoracic Surgery,
University Hospital “San Giovanni e Ruggi d’Aragona,” Salerno, Italy
Corrado Cuccurullo Department of Economics, Universita’ degli Studi Della
Campania “Luigi Vanvitelli,” Capua, Caserta, Italy
Antonio D’Andreamatteo Department of Management and Business
Administration, University “G.d’Annunzio” of Chieti, Pescara, Italy
Marina Davoli Director of the Department of Epidemiology ASL ROMA1, Lazio
Region, Operational center of the National Outcome Programme for the National
Agency of Regional Health Services, Rome, Italy
Luca Del Bene Department of Management, Polytechnic University of Marche,
Ancona, Italy
Gerardine Doyle College of Business, University College Dublin, Belfield,
Dublin, Ireland
Michael Drummond Centre for Health Economics, University of York, York,
North Yorks, UK
Vincenza Esposito Department of Law, Economics, Management and
Quantitative Methods, University of Sannio, Benevento, Italy
Giuseppe Favretto Department of Management, Università Degli Studi Di
Verona, Verona, Italy
Giuseppe Festa Department of Economic and Statistical Sciences, University of
Salerno, Fisciano, Salerno, Italy
Silvio Garattini Directorate, IRCCS Istituto di Ricerche Farmacologiche Mario
Negri, Milan, Italy
Lt. Gen. Fernando Giancotti Commander, Italian Air Force Air Education and
Training Command, Bari, Italy
Evert Gummesson School of Business, Stockholm University, Stockholm,
Sweden
Contributors xix

Mario Pezzillo Iacono Department of Law, Economics, Management and

Quantitative Methods, University of Sannio, Benevento, Italy
Luca Ianni Department of Management and Business Administration, University
“G.d’Annunzio” of Chieti, Pescara, Italy
Giuseppe Iuliano Department of Management & Innovation Systems, University
of Salerno, Fisciano, Salerno, Italy
Francesca Lecci Department of Policy Analysis and Public Management, Bocconi
University, Milan, Italy
Federico Lega Department of Public Policy & Management, SDA Bocconi
School of Management, Milan, Italy
Emanuele Lettieri Department of Management, Economics and Industrial
Engineering, Politecnico di Milano, Milan, Italy
Gianluigi Mangia Department of Economics, Second University of Naples,
Caserta, Italy
Chiara Marinacci Health Planning General Directorate of the Italian Ministry of
Health, Rome, Italy
Marcello Martinez Department of Economics, Second University of Naples,
Caserta, Italy
Cristina Masella Department of Management, Economics and Industrial
Engineering, Politecnico di Milano, Milan, Italy
Gaetano Matonti Department of Management & Innovation Systems, University
of Salerno, Fisciano, Salerno, Italy
Maurizio Mauri “CERBA” Foundation (Centro Europeo Ricerca Biomedica
Avanzata), Milan, Italy
Lorenzo Mercurio Department of Law, Economics, Management and
Quantitative Methods, University of Sannio, Benevento, Italy
Riccardo Mercurio Department of Economics, Management and Institutions,
University of Naples Federico II, Naples, Italy
Henry Mintzberg Desautels Faculty of Management, McGill University,
Montreal, Canada
Marco Morelli Corporate and Real Estate Finance Department, SDA Bocconi
School of Management, Milan, Italy
Louis Moschera Department of Economics, Second University of Naples,
Caserta, Italy
Matteo Motterlini Philosophy Department, Center for Experimental and Applied
Epistemology, University Vita-Salute San Raffaele, Milan, Italy
xx Contributors

Sabina Nuti Management and Healthcare Laboratory, Sant’Anna School of

Advanced Studies, Pisa, Italy
Rocco Palumbo Department of Management & Innovation Systems, University of
Salerno, Fisciano, Salerno, Italy
Gabriella Piscopo Department of Management & Innovation Systems, University
of Salerno, Fisciano, Salerno, Italy
Joseph Polimeni Siena University Hospital, Siena, Italy
Anna Prenestini Centre for Research in Health and Social Care Management
(CERGAS), University “Luigi Bocconi,” Milan, Italy
Walter Ricciardi WHO Collaborating Centre for Health Policy, Governance and
Leadership in Europe, Institute of Public Health, Catholic University of the Sacred
Heart of Rome, Rome, Italy
Pasquale Antonio Riccio Health Campus NPO, Naples, Italy
Salvatore Russo Department of Management, University of Venice, Venice, Italy
Maria Grazia Sampietro National Social Security Institute, Rome, Italy
Alessio Santoro Department of Public Health and Infectious Diseases, University
of Rome La Sapienza, Rome, Italy
Massimo Sargiacomo Department of Management and Business Administration,
University “G.d’Annunzio” of Chieti, Pescara, Italy
Daniela Scaramuccia Value Partners Management Consulting S.P.a, Milan, Italy
Andrea Silenzi WHO Collaborating Centre for Health Policy, Governance and
Leadership in Europe, Institute of Public Health, Catholic University of the Sacred
Heart of Rome, Rome, Italy
Alessandra Storlazzi University “Suor Orsola Benincasa” - Facoltà di Scienze
della Formazione, Naples, Italy
Rosanna Tarricone Department of Policy Analysis and Public Management,
Centre for Research in Health and Social Care Management (CERGAS), Bocconi
University, Milan, Italy
Paolo Tartaglia Polcini Executive Committee CIRPA (Interdepartmental Centre
for Research in Economics, Law and Management of Public Administrations),
University of Salerno, Fisciano, Salerno, Italy
Aurelio Tommasetti Department of Management & Innovation Systems,
University of Salerno, Fisciano, Salerno, Italy
Aleksandra Torbica Department of Policy Analysis and Public Management, and
Senior Researcher, Centre for Research in Health and Social Care Management
(CERGAS), Bocconi University, Milan, Italy
Contributors xxi

Mario Del Vecchio School of Medicine, University of Florence, Florence, Italy;

Director of the Observatory on Private Healthcare Consumption OCPS-SDA,
Bocconi University, Milan, Italy
Emanuele Vendramini DISES—Department of Economic and Social Disciplines,
Catholic University of the Sacred Heart, Piacenza, Italy
Umberto Veronesi European Institute of Oncology, Milan, Italy
Massimiliano Vesci Department of Management & Innovation Systems,
University of Salerno, Fisciano, Salerno, Italy
About the Editors

Paola Adinolfi (BA in Bocconi University; MA in

Warwick University-Industrial Relation Research Unit;
PhD in Birmingham University-Institute of Local
Governments) is Full Professor of Organization Studies at
the University of Salerno in Italy. Formerly, the Director
of the Department of Management & Information
Technology, she now chairs the Interdepartmental Centre
for Research in Law, Economics and Management of
Public Administrations (CIRPA). Since the 2000s, Paola
has been directing the PhD programme in “Management
of Public Organizations” and the Master course
“Leadership in Healthcare Services” (DAOSan), orga-
nized by the University of Salerno with Campania
Region, University of Naples, and University of Sannio.
DAOSan ex-alumni represents a renowned and dynamic
community of practitioners in healthcare management in
Southern Italy. She has been elected to the board of
ASSIOA, the Italian Association of Organization Studies,
and of Azienda Pubblica, the leading Italian journal on
public management, and is a member of other scientific
boards and committees in public agencies and academic
journals regarding her fields of competence: public
management, healthcare management, and organization
and human resource management.

xxiii
xxiv About the Editors

Elio Borgonovi is Full Professor of public adminis-

tration, and healthcare and not-for-profit organization
management at Bocconi University in Milan, Italy. After
graduating from Bocconi University, he has been a
researcher, Associate Professor, and then Full Professor
at Bocconi University and Parma and Trento State
University. In 1978, he founded the healthcare and
social services management research center (CERGAS)
and the public administration, healthcare, not-for-profit
division at SDA Bocconi School of Management. In his
career, he has been Director and President of CERGAS,
SDA Dean, President of ASFOR (the Italian Association
of School of Management), Vice President of AIDEA
(the Italian Academy of Management), member of the
board of EFMD (European Foundation for Management
Development), and EQUIS (European Quality
Improvement System). In the early 1990s, he designed
and promoted an innovative 4-year bachelor program at
Bocconi on public administration and international
organization economics and management, currently
GIO (Government and International Organization)
Master of Science. Over the last 45 years, he was a
member of several advisory boards, committees, and
research groups in both public administration and
healthcare authority at local, regional, and national
levels; and a member of scientific boards of national and
international journals. Currently, he is Director of the
laboratory on health services performance at AGENAS,
the national technical agency for healthcare services.
 Part I
Managing in Health Care: Cues and
Reflections
Chapter 1
Managing the Myths of Health Care

Henry Mintzberg

1.1 The Myths of Health Care

Myths abound in management, for example that senior managers sit on “top” (of
what?), that leaders are more important than managers (try leading without
managing), and that people are human resources (I am a human being). Myths
abound in what is called the system of health care too, not least that it is a system,
and is about the care of health (mostly it is a collection of treatments for disease).
Combine these two sets of myths, as is increasingly common these days, and you
end up with the mess we now face in the world of health care.
Let us begin with the myths of managing now prevalent in health care and then
turn to some reframing that may help to escape this mess.
Myth #1: The health care system is failing. Speak to people almost anywhere in
the world and they will tell you how their system of health care is failing. The truth
is quite the opposite: In most places in the developed world, health care is suc-
ceeding—expensively. In other words, success is the problem, not failure. Consult
almost any statistic. We are living longer, losing fewer infants, and so on, in large
part because of advances in treatments. The trouble is that many of these are
expensive, and we do not want to pay for them—certainly not as healthy people
through our insurance premiums or taxes. So health care services get squeezed, and
it looks like the system is failing. In fact, as we shall discuss below, the problems
are not in the health care services themselves so much as in the consequences of our

Source: Mintzberg H. Managing the Myths of Health Care. World Hospitals and Health
Services: The Official Journal of the International Hospital Federation 2012; 48(3):4–7.
Copyright © 2012 IHF. Reprinted with permission

H. Mintzberg (&)
Desautels Faculty of Management, McGill University, 100l Sherbrooke West, Montreal H3A
lG5, Canada
e-mail: [email protected]; [email protected]

© Springer International Publishing AG 2018 3

P. Adinolfi and E. Borgonovi (eds.), The Myths of Health Care,
https://doi.org/10.1007/978-3-319-53600-2_1
4 1 Managing the Myths of Health Care

interventions to fix this ostensible failure. We consider three interventions in par-

ticular: social engineering, leadership, and business practice.
Myth #2: The health care system can be fixed by clever social engineering. The
system is broken so the “experts” have to fix it: usually not people on the ground,
who understand the problems viscerally, but specialists in the air, such as econo-
mists, system analysts, and consultants, who believe they understand them con-
ceptually. Thanks to them, in health care we measure and merge like mad,
reorganize constantly, apply the management technique of the month, “reinvent”
health care every few years, and drive change from the “top” for the sake of
participation at the bottom. Do all this and all will be well, we are told. But is it
ever? In particular, at this so-called bottom, the real experts struggle to cope with
the pressures, not least from these very “solutions,” most of which seem to make
things increasingly convoluted. What if, instead, we came to appreciate that
effective change in health care has to come largely out of the operations, and diffuse
across them rather than forced down into them? Consider, for example, the changes
in recent times that have made the greatest differences, not only in cutting costs—
that is the easy part—but also in improving quality. Day surgeries have to be near
the top of that list. This idea came from engaged clinicians, not detached social
engineers.
Myth #3: Health care institutions as well as the overall system can be fixed by
bringing in the heroic leader. New leadership can certainly help, at least when it
replaces a leadership that was worse. But what does effective leadership mean in a
field where the professionals have so much of the power? In hospitals, for example,
physicians are usually far more responsive to their own hierarchies of professional
status than the managerial hierarchies of formal authority. Hence what can be called
“heroic leadership,” so fashionable now in business (witness the whole system of
bonuses), can be bad for health care, let alone for business itself. Far more nec-
essary is what can be called engaging management: managers who are deeply and
personally engaged so as to be able to help engage others.
Myth #4: The health care system can be fixed by treating it more as a business.
This is a particularly popular prescription in the United States. Perhaps no country on
earth treats health care more as a business, or is more encouraging of competition in
this field. But given America’s current state of performance—far more expensive
than anywhere else, with overall quality rankings that are mediocre—shall we take
this as testimonial to the wonders of competition and business practices in the field of
health care? The United States spends about 31¢ of every health care dollar on
administration; Canada, with much less competition and far less of a business ori-
entation in health care, spends about 17¢, and achieves better measures of quality. To
quote from an article in the New York Times: “Duplicate processing of claims, large
numbers of insurance products, complicated bill paying systems and high marketing
costs [plus all the ‘paperwork required of American doctors and hospitals that simply
do not exist in countries like Canada or Britain’] add up to high administrative
expenses” (Bernasek 2007). In the name of competition, American health care in fact
suffers from individualization: every professional and every institution for his, her, or
itself. So again, let us try it differently: Health care functions best as a calling, not a
1.1 The Myths of Health Care 5

business; as such, it needs greater cooperation, not competition, among its many
players and institutions. Physicians may be well paid, but these are smart people
capable of earning large incomes elsewhere. What keeps many, if not most, of them
in health care is the sense of service. This applies equally, if not more so, to the
nurses, who do not earn that kind of money, and many of the managers too. What
happens to health care as a calling when it is seen as “one-stop shopping,” hospitals
as “focused factories,” patients as “customers” and “consumers,” and physicians as
“industry players” (as described by Herzlinger 2006)?
Myth #5 and 6: Health care is rightly left to the private sector, for the sake of
efficiency. Health care is rightly controlled by the public sector, for the sake of
equality. Take your choice, according to the country in which you live. In fact, if
you live where the services are largely public, you hear a great deal about the
private sector (as in Canada now). And if you live where they are largely private,
then you hear a great deal about the public sector (as in the recent debates in the
United States Congress). That is because, nowhere in the world today can the field
of health care function without serious involvement of both government controls
and market forces. Many Americans, and not only on talk radio shows, are sharply
critical of the role of the state in health care. In two influential publications, Porter
and Teisberg were highly dismissive of the state as a player in this field. Their book
Reforming Health Care (2006) referred to government-controlled regulations as
“never a real solution” (although it certainly is in most developed countries).
Concerning the unsatisfactory performance of American health care over many
years, they claimed in their related Harvard Business Review article (2004) that
“while this may be expected in a state-controlled sector, it is nearly unimaginable in
a competitive market.” (Again, the facts suggest exactly the opposite.) Of particular
importance is that many of the most important services in health care come from
neither the public nor the private sector. Canada and the United States sit near the
two extremes on this issue, yet the vast majority of hospitals in both countries are in
the plural sector, namely in the form of organizations that are owned by no-one
(so-called “voluntary” in the United States), and that includes the most prestigious.
Efficiency and equality certainly matter in health care, but hardly more so than
quality, which often seems to be delivered best by organizations that are autono-
mous—controlled neither by the state nor owned by private shareholders.
Presumably this helps to reinforce the engagement of their professionals with regard
to their sense of calling. Of course, all the sectors have a role to play in health care:
the public sector, largely to maintain a certain level of equality (as in the new
American legislation) as well as in regulation; the private sector, significantly to
provide supplies and equipment as well as some of the more routine services; and
the plural sector, for the delivery of many of the key professional services,
including research. (And the latter might well include pharmaceuticals. In the
twentieth century, arguably the three most significant pharmaceutical developments
—penicillin, insulin, and Salk vaccine—all came out of not-for-profit laboratories.)
The Myths of Measurement and of Scale Measurement is a fine idea, as long as it
does not mesmerize the user. Unfortunately, it so often does: both managers who
rely on it for control and physicians who believe that being “evidence-based”
6 1 Managing the Myths of Health Care

always has to trump being “experienced-based.” Management and medicine alike

have to balance these two in order to be effective. Unfortunately, too much of health
care at both the administrative and clinical levels has been thrown out of balance by
their obsessions with measurement. In the management of health care, the frus-
tration of trying to control rather autonomous professionals has led the adminis-
trators and social engineers to a reliance on measurement. And this, it should be
noted, is no less prevalent in private sector control by insurance companies and
HMOs, etc., than in public sector control by government agencies. The problem
with measurement is that, while the treatments exist in standard categories—certain
medications for manic depression, particular forms of angioplasty for various heart
conditions, etc—their outcomes are often not standard, and therefore can be tricky
to pin down by measurement. That is because we as individual patients are not
standardized, and so our treatments have to be tailored to our individual needs and
conditions. It is often said that “If you can’t measure it, you can’t manage it.” Well,
who has ever adequately measured the performance of management? (Don’t tell me
it can be done by looking at a stock price.) In fact, who has ever even tried to
measure the performance of measurement itself? I guess we must conclude there-
fore that neither management nor measurement can be managed. So what can be
done if we cannot rely wholly on measurement? That’s easy: use judgment.
Remember judgment? Can you imagine medicine without judgment? Well, then, I
suggest that you not try to imagine management without judgment either.
Measurement favors large scale; in fact scale is measurement. So a society mes-
merized by measurement is a society obsessed with large scale. Hence the small
hospitals are the ones that get closed. Herzlinger wrote in her 2006 Harvard
Business Review article that “Health care is still an astonishingly fragmented
industry. More than half of the US physicians work in practices of three or fewer
doctors; a quarter of the nation’s 5000 community hospitals and nearly half of its
17,000 nursing homes are independent.” But what is wrong with that? She added
that “You can roll a number of independent players into a single organization…to
generate economies of scale.” Picture that! Notice the term: economies of scale. Not
effectiveness of scale but economies of scale. Too much of the management of
health care has come to be about using scale to reduce measurable costs at the
expense of difficult-to-measure benefits. I am not trying to make the case that
smaller is always more beautiful, only to plead that bigger is not always better.
Scale, too, has to be judged, especially for its impact on performance. Health care as
a calling works best in units that are as humanly small as the best of technology
allows. This, in fact, seems to hold true even in pharmaceutical research. To quote
Roger Gilmartin when he was chief executive of Merck: “Scale has been no
indication of the ability to discover breakthrough drugs. In fact, it has been the other
way—you get bogged down” (Clifford 2000). All of this suggests that it is time for
some reframing in the management of health care. What follows is not social
engineering so much as a suggested set of guidelines.
1.2 Reframing Management: As Distributed Beyond the “Top” 7

1.2 Reframing Management: As Distributed Beyond

the “Top”

As noted at the outset, management on “top” is a myth. Aside from that ubiquitous
chart, and those famous bonuses, what is management on top of exactly? Indeed, in
hospitals, “top” managers often sit on the ground floor (perhaps to be able to make a
quick getaway). Seeing yourself on top of an organization all too often means not
being on top of what is going on in that organization. Should these top managers
have the power to make decisions about the purchase of expensive equipment,
independent of the physicians who use them? That hardly makes more sense than
leaving those decisions to the physicians themselves. These are not financial
decisions or technical decisions but hospital decisions, and so require collaboration
on the part of managers and physicians. And, make no mistake about it, involve-
ment in such decision-making places the physicians squarely in the realm of
management—as soon as we get past the notion that management is something
practiced only by people called managers. Many health care organizations require
“distributed management,” which means that managerial activities be performed by
whoever has the necessary skills, knowledge, and perspective to carry them out
most effectively—and that often means collaboratively.

1.3 Reframing Strategy: As Venturing, not Planning

If you want to understand what strategy means in a professional organization such

as a hospital, stay away from almost all the strategy books. They tell you about
strategic planning from the top; recognize instead strategic venturing at the base. If
strategy concerns the positioning of products and services for users, then in a
hospital the services are specific kinds of treatments for specific diseases. And
where do these come from? Rarely from any “top” management and rarely in any
planning process. They come mostly from the venturing activities of professionals:
concern about a new disease here, championing of a new treatment there. In other
words, the strategy of a hospital is largely the sum total of the many ventures of its
professional staff. So here, especially, is where we see distributed management:
Professionals on the ground, who are not managers, are responsible for most of the
strategic initiatives in health care. Sure there are other, more conventional strategies
determined at large—for example, about what services to offer and where to locate
them. But much of that is built into the structure and history of the institution.
Hospitals may engage in strategic planning, but a great deal of this, in my expe-
rience, does not amount to much. Too often it is just another indication of what can
be called “the administrative gap”—the disconnect between the machinations of
management and the operations of clinicians (Henry Mintzberg 1994, 2007).
8 1 Managing the Myths of Health Care

1.4 Reframing Organization: As Collaboration Beyond

Control, Communityship Beyond Leadership

With management as distributed and the strategy process as venturing, the nature of
most health care organizations can be better understood. The prevailing model in
business is what can be called the “machine organization”: top-down, hierarchically
focused, control-oriented, numbers-driven, and outputs-standardized. Managers
rule. But a very different model, that can be called the “professional organization,”
is more common in health care: expert-driven, skills-oriented, and highly oriented
to pigeonholing, which means getting the client into the right box (mania, hernia,
etc.) so that the most appropriate intervention can be applied. Such pigeonholing
describes the great strength of the professional organization as well as its debili-
tating weakness. The professionals get used to operating in their own pigeonholes,
as free as possible of the influence of their own colleagues, let alone the controls of
the managers. Unfortunately, as human patients we are sometimes square pegs
forced into these round holes. Some of us have this habit of getting illnesses that cut
across the disease categories, or worse still, that do not fit them well (as in
auto-immune diseases). Then we require interventions that cut across the pigeon-
holes, which are often resisted by medical specialists used to operating within them.
In other words, we need collaboration from people who are mostly inclined to avoid
it. How to organize around this problem? The inclination has been to use solutions
designed for the machine organization—centrally imposed control systems, per-
formance measures, financial incentives and the like, or else expecting managers up
the hierarchy to force the professionals to collaborate. But these hardly work well
with independent professionals. Resistance to collaboration in the professional
organization will more likely be overcome by drawing on the professionals’ sense
of calling, and enhancing their organization as a community of service. Put dif-
ferently, when people are committed to their organization, and not just to their own
profession, they are more likely to collaborate effectively. A good sense of this can
be had from some comments made by Atul Gawande in one of his New Yorker
articles on health care: The Mayo Clinic is among the highest quality, lowest cost
healthcare systems in the country. A couple of years ago, I spent several days there
as a visiting surgeon. Among the things that stand out from that visit was how much
time the doctors spent with patients. There was no churn—no shuttling patients in
and out of rooms while the doctor bounces from one to the other. The core tenant of
the Mayo Clinic is “The need of the patient first”—not the convenience of the
doctors, not their revenues. The doctors and nurses, and even the janitors, sat in
meetings almost weekly, working on ideas to make the service and the care better,
not to get more money out of patients decades ago Mayo recognized that the first
thing it needed to do was eliminate the financial barriers. It pooled all the money the
doctors and the hospital system received and began paying everyone a salary, so
that the doctors’ goal in patient care could not be increasing their income almost by
happenstance, the result has been lower costs (Gawande 2009, pp. 14–15).
1.5 Reframing Scale: As Human Beyond Economic 9

1.5 Reframing Scale: As Human Beyond Economic

None of the guidelines suggested above are helped by large scale—not community,
not engagement, not collaboration, not closing the gap between administration and
operations. Nor does large scale help to humanize the practice of medicine. There
can, of course, be technical reasons to favor large scale, for example, in order to
purchase necessary expensive equipment. This suggests that we should no more
reject large scale than embrace it. But the unfortunate fact is that, because of our
mesmerization with measurement, far too often we embrace large scale, conve-
niently forgetting the human factors. Imagine if we made small scale the default
position, so to speak—in other words put the onus on the proponents of large scale,
in health care institutions as well as in health authorities, to make their case for scale
on social grounds, judgmentally as well as numerically, beyond the technical and
economic grounds.

1.6 Reframing Managing Style: As Caring More Than

Curing

Nursing, focused on care, may be a more appropriate model for managing than
medicine, focused on cure. Our health care institutions, in other words, require care
more than cure: the engagement of their managers to help them function more
smoothly, rather than having the power of heroic leaders to run around fixing
things. There was a cartoon once that showed a group of surgeons around a patient
on an operation table, with the line “Who opens?” In medicine, we know who
opens; in management often we do not—not even if someone should open. That is
why management has to be a fundamentally cooperative practice, of a style far from
heroic leadership. Managing in health care should be about devoted, continuous,
holistic and pre-emptive care more than interventionist, episodic, narrow, and
radical cures.

1.7 Reframing Managing Style: As a System Beyond Its

Parts

I opened this article with the claim that we do not have a system of health care so
much as a collection of disease treatments. Even my own examples have come
largely from the latter. (Hospitals, it should be remembered, account for only about
30 percent of health care expenditures.) Especially the promotion of health, but also
the prevention of disease, are muscled aside by our focus on the treatment of
disease, even though investment in the former can be far more cost-effective. An ad
appeared some years ago for SAP Canada, headed “This is not a cow.” It showed a
10 1 Managing the Myths of Health Care

picture of a cow, with lines drawn where it would be quartered, with the text: “This
is an organizational chart that shows the different parts of a cow.” In a real cow the
parts are not aware that they are parts. They do not have trouble sharing infor-
mation. They smoothly and naturally work together, as one unit. As a cow. And you
have only one question to answer. “Do you want your organization to work like a
chart? Or a cow?” Why can’t health care work like a cow: why can it not be a true
system of cooperation and collaboration? Note that the parts of a cow are not
“seamless.” They are distinct, necessarily so. But in a healthy cow, they work
together harmoniously. Can this happen in health care? I believe so, and have been
working with colleagues for some years to that end. Our management and medical
schools at McGill University have teamed up to create a master program for health
leadership that seeks to encourage all of these guidelines (www.mcgill.ca/imhl). It
brings practicing managers from all over the world in all aspects of health care—
hospitals, community care, public health, government ministries, etc., most of them
with clinical backgrounds—together in an ongoing forum that meets periodically
over a year and a half to address the major issues of health care. These include
• The Gap Issue: How to bring the administration of health care closer to the
operations, connecting it for support beyond control?
• The Collaboration Issue: How to get the different parts of health care working in
greater cooperative harmony?
• The Engagement Issue: How to enhance engagement through the promotion of
human scale beyond economic scale?
• The Sector Issue: What are the appropriate roles of the three sectors, especially
the plural sector that sits between the now dominant public and private sectors?
• The Performance Issue: How to balance the intrinsic needs for efficiency,
equality, and quality in health care?
We have been especially struck by the natural propensity of managers in such a
program to work together on such issues, reaching out beyond their own personal
needs and those of their institutions, into their local communities and out to the
needs of health care in general. On a number of occasions, groups in the class have
brought into our forum key issues of concern in their communities, to enable the
class to address them in a process we call “friendly consulting.” A group of
managers from Quebec, for example, invited the three commissioners of a major
government health care commission into the class for a workshop on some of these
issues. And two physician managers from Uganda brought our classroom to a
conference they organized in Kampala for 60 health care managers from seven
African countries, on the subject of how to scale up their management infrastruc-
tures. What this has made clear is that an immense amount of energy and goodwill
exists in the field of health care, to work collaboratively to render it more effective,
on both the local and the global levels. We just need to get past the myths.
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