Victor G. Rodwin¹, Jin Ye Yeo²

¹Wagner School of Public Service, New York University, New York, NY, USA; ²JHMHP Editorial Office, AME Publishing Company

Correspondence to: Jin Ye Yeo. JHMHP Editorial Office, AME Publishing Company. Email: jhmhp@amegroups.com

Expert introduction

Prof. Victor G. Rodwin (Figure 1) is Professor of Health Policy and Management (HPAM), at the Wagner School of Public Service, New York University and Co-Director (with Michael K. Gusmano) of the World Cities Project, a joint venture of Wagner/NYU and Lehigh University. Prof. Rodwin developed and teaches Wagner’s introductory course on HPAM and classes on comparative analysis of health systems and healthcare reform. He is also the author of over a hundred scholarly articles, and books: The Health Planning Predicament: France, Quebec, England, and the United States (University of California Press, 1984); The End of an Illusion: The Future of Health Policy in Western Industrialized Nations (with J. de Kervasdoué and J. Kimberly, University of California Press, 1984); Public Hospitals in New York and Paris (with C. Brecher, D. Jolly, and R. Baxter), New York University Press, 1992); Growing Older in World Cities: New York, London, Paris and Tokyo (with MK. Gusmano, eds), Vanderbilt U. Press, 2006); Health Care in World Cities: New York, Paris and London (with MK. Gusmano and D. Weisz), Johns Hopkins U. Press, 2010.

Prof. Rodwin’s most recent work (in collaboration with MK. Gusmano and Daniel Weisz) has focused on health care system performance in world cities, as measured by amenable mortality, hospitalizations for ambulatory-care sensitive conditions, rehospitalizations, and inequities in access to primary as well as specialty health services. He is currently studying the Swiss health system following a sabbatical leave in 2020, at Unisanté in Lausanne. In addition he pursues his research on health services in world cities of BRIC nations and his exploration of how health care and public health systems are evolving in world cities following COVID-19.

Figure 1 Prof. Victor G. Rodwin

Interview

JHMHP: What inspired you to venture into the field of health policy and management?

Prof. Rodwin: Since my graduate studies at the University of California, Berkeley, I was interested in the links between public health, planning, and the challenge of implementing change. As the great public leader, Rudolf Virchow, once wrote: “Medicine is a social science and politics is medicine on a large scale.” I was inspired by this statement because I was always drawn more to the social sciences, in general, than to specific disciplines within this area. My undergraduate major was in Economics and I studied a bit of sociology and anthropology but my graduate studies were in public health and urban and regional planning. This field of study emphasizes a focus on real world problems related to cities and how a variety of disciplinary perspectives and methods can deepen understanding of these problems and raise the level of professional competence in addressing them.

I completed my Ph.D at Berkeley’s Department of City & Regional Planning where I completed my preliminary examinations in planning theory, comparative economic systems, and health planning and policy. These are the studies that inspired me to venture into the field of health policy and management (HPAM). After completing my doctoral dissertation that resulted in my first book, The Health Planning Predicament: France, Québec, England and the United States, I obtained a post-doctoral fellowship with Dr. Philip R. Lee, a most inspiring mentor who had recently established the Institute for Health Policy Studies (IHPS) at the University of California, San Francisco. Previously he worked for President Lyndon Johnson as Deputy Secretary for Health in the U.S. Department of Health and Human Services. Dr. Lee believed that health policy could be improved by drawing on the perspectives and research of diverse social science disciplines. He drew a large number of social scientists, as well as public health physicians and ethicists from Stanford University and from Berkele, to the IHPS, organized weekly seminars and frequent conferences, and shuttled back and forth to Washington DC to testify before Congressional committees on timely research relevant to pending legislation.

When I worked as a post-doctoral fellow with Dr. Lee, my interests were focused on comparative analysis of health systems and policy in the former Soviet Union and in France. Dr. Lee encouraged me to pursue these interests which led me to spend four months in Leningrad studying the Russian language and Soviet socialized medicine and several years in France studying the politics and management of French national health insurance where I was hired as a consultant to a former Director of France’s National Health Insurance Fund. These experiences strengthened my interests in comparative analysis as an important and – at the time – under-developed aspect of HPAM and led me to continue in this direction.

JHMHP: Are there any areas of health policy and management (HPAM) that you believe have been overlooked or received insufficient attention?

Prof. Rodwin: Yes, I believe there is an unfortunate gap between theory, policy, and practice in the field. HPAM, including hospital planning and management typically address “wicked problems” that are affected by their unique institutional contexts and whose potential “solutions” are shaped by the ways in which they are formulated (1). It is for this reason that it is important for policy analysts and managers to mind this gap. I have written a paper with my colleague, David Chinitz, elaborating on this issue (2). We highlight four interrelated problems that appear to sustain the theory-policy-practice gap and impede attempts to reform health care systems: 1) The dominance of micro-economic thinking in health policy analysis and design, and the inadequate attention to other social science perspectives, 2) The lack of comparative studies of diverse health care organizations, even within a single nation, let alone among different countries, 3) The separation of HPAM from the rank and file of health care, particularly physicians and nurses, and 4) The failure to provide in-depth exposure to medical students of critical issues in the field of HPAM.

This is not the place to elaborate further on this paper. I would merely add a few more concerns. Since the field of HPAM is necessarily interdisciplinary, we need to work harder to improve communication among clinicians working in the trenches, those working as leaders in hospitals and as policy analysts trained in the social sciences, mostly economics and finance. The clinicians must learn more about management and the social sciences; and managers and policymakers must learn more about medicine and public health.

JHMHP: How have health policies in the United States evolved over the years?

Prof. Rodwin: Following World War II, federal health policy focused largely on subsidizing the biomedical research establishment, expanding and modernizing hospitals and increasing the healthcare workforce. We developed an acute-care system at the expense of community-based ambulatory care (CBAC) which includes primary care providers and specialists working outside of hospitals. Likewise, we invested more heavily in training a skilled healthcare workforce and upgrading hospital infrastructure than on assuring equitable access to health services. The result of this approach to our healthcare sector has been to nurture bio-medical research and the pharmaceutical and health care industries, to the point where they have become a strategic employment and export sector for the nation. This has resulted in powerful lobbies not only to defend these industries but also to promote the interests of health insurers and provider groups – public and private hospitals as well as physicians – all of which sustains the status quo and challenges the quest to alleviate inequities in access to health care and contain rising healthcare costs.

Our healthcare spending, as a share of Gross Domestic Product (GDP), has not led to impressive population health status; the United States has some of the worst health status indicators among OECD (Organization for Economic Cooperation and Development) nations. Nevertheless, we are widely recognized as a pathbreaker in developing diverse managed care (MC) models along a continuum of more or less integrated health services among hospitals and CBAC. What is distinctive about these models is their market-driven character. Over the past three decades, a proliferation of different MC models have emerged ranging from Independent Practitioner Associations (IPAs), Preferred Provider Organizations (PPOs), and most recently Accountable Care Organizations (ACOs) or more simply a health insurance plan’s “networks” of physicians and hospitals, selected to provide health services at discounted prices. Although private, nonprofit integrated health systems have spread across the U.S. from Intermountain Health Care in Utah, Geisinger Health System in Pennsylvania, the Mayo Clinic Health System in Minnesota, Iowa and Wisconsin, they have never evolved into dominant forms of healthcare provision.

In contrast, for-profit, investor-owned MC organisations have grown rapidly over the past decade to include roughly half of all Medicare beneficiaries, an even higher share of Medicaid beneficiaries and a dominant market share of private health-insurance plans offered by employers. This reflects the growing corporatization of healthcare, which is challenging the traditional view that health care is a “community affair.” Over the past decade, the hospital industry – investor-owned, as well as nonprofit has consolidated horizontally thereby creating mega-hospital systems that, in turn, integrate vertically with physician groups (3). In 2022, 52% of physicians were salaried employees of hospitals even when they continued to work in their private offices in CBAC and another 22% were employed by other corporate entities (4). These trends have developed through a capitalist process that economist Joseph Schumpeter called “creative destruction” (5).

JHMHP: In your opinion, what are some critical areas of health policies that should be evaluated and addressed?

Prof. Rodwin: For me, the most important thing that current health policies must address is how the health sector transforms in response to two trends affecting all healthcare systems: 1) Population aging and the rise of chronic disease, and 2) Technological change. These trends raise the controversial issues of whether emerging patterns of integration, which are often driven by investor-owned corporations, private equity capital and greed, will contain rising costs while improving access, coordination, and quality.

Given the great diversity of MC models in the U.S. – public, nonprofit, investor-owned, local within a single or several states, and national corporate organizations – healthcare managers must now confront at least two issues. First, little is known about the comparative performance of the diverse organizations that provide health insurance and access to health care delivery organizations because their most critical performance measures are proprietary. Second, although the increasing vertical integration of hospitals and CBAC has effectively transformed many component parts of the U.S. health sector, costs have not been contained, equity of access has not been improved, and there is no convincing evidence that coordination of services, safety, administrative efficiency, let alone consumer satisfaction and outcomes, have improved. Indeed, based on Commonwealth Fund’s international surveys of 11 OECD nations, U.S. performance on most of their 70 performance measures is low (6).

What concerns me most about the process of healthcare transformation in the U.S. is the increasing power of private hospital systems and MC organisations in shaping the health sector in response to their corporate boards and/or investors. The corporatization in U.S. hospital systems and MC organisations extends well beyond these giant organizations to dental practices, home health services, substance abuse, eating disorder and autism services, urgent care facilities and emergency medical transportation. Moreover private equity firms have started investing in all of these areas, which intensifies the pace of mergers, acquisitions, and public offerings (7).

JHMHP: Your research also focuses on health and healthcare in world cities, and you and Professor Michael Gusmano have agreed to serve as Guest Editors of our Series on this theme. Could you tell us why you happened to become interested in world cities and why you feel this is an important area of study for hospital management and health policy?

Prof. Rodwin: United Nations’ demographers project that the urban population, worldwide, will grow to about 70 percent by 2050. Since global cities exhibit glaring disparities in health outcomes among their diverse populations and neighborhoods, we recognized that cities, particularly world city metropolitan areas with over 10 million inhabitants, have great opportunities to improve population health. At the start of our project, originally funded by the RW Johnson Foundation, we focused on the four most populous cities among the wealthiest nations of the world: New York, London, Tokyo, and Paris, but we have also published articles on cities in BRIC nations (Brazil, Russia, India, and China): Shanghai, Mumbai, Delhi, and São Paulo.

A second reason for focusing on world cities in the wealthiest nations is that there is an extensive literature about their architecture, urban design, histories, economic development, and socio-demographic characteristics. What surprised us was how little was known about their public health infrastructure and health system characteristics. All of these cities are known for their economic success, mayoral leadership, and creativity. They exercise a dominant influence – for better or for worse – over megacities in the developing world, which are far greater in size and face even greater challenges. Few would deny that all of these world cities contribute massively to their national economies and economic growth. They serve as transportation gateways to the rest of the world, bastions of cultural expression and media, and centers for corporate headquarters with their affiliated financial and specialized legal services. Saskia Sassen calls them “global cities” because they function as strategic hubs of “command and control” in the global economy (8). Small wonder that in his 1961 science fiction story, The Martian Shop, Howard Fast had his Martian visitors establish outposts in these cities (9).

A third reason to focus on these cities relates not to their strengths but also to their vulnerabilities. Since the COVID-19 pandemic struck them with particular ferocity, it raised fundamental questions about the future of these “vulnerable giants” (10). Given the growth of urbanization, the quality of life in cities will depend on our capacity to meet the challenges posed by the increasing frequency of heat waves, flooding and a host of other problems raised by spatial and social inequalities among diverse urban populations.

A fourth reason why we chose to compare these four world cities relates to their striking similarities. Although world cities consider themselves unique within their respective nations, they share more in common than they do with their respective nations. For example, older people concerned about their health often consider world cities attractive places in which to live due to their excellent medical care, medical schools, bio-medical research institutes, and public health infrastructure. Also, world cities attract some of the wealthiest, as well as some of the poorest populations of their nations, which forces their healthcare systems to confront the challenge of flagrant inequalities in health status, access to health services, and social and economic inequalities that affect population health. Finally, these cities share more in common than their respective nations with respect their ethnic diversity and immigrant populations, living in close proximity to one another.

By comparing how these cities confront common challenges, our Series in JHMHP seeks to identify promising practices and interesting failures for hospital management and health policy; and on this basis suggest some lessons for world cities in wealthy nations as well as for rapidly growing megacities worldwide.

Reference

1. Rittel HW, Webber MM. Dilemmas in a general theory of planning. Policy sciences. 1973;4(2):155-169.  

2. Chinitz DP, Rodwin VG. On Health Policy and Management (HPAM): mind the theory-policy-practice gap. International Journal of Health Policy and Management. 2014;3(7):361.
3. Khullar D, Casalino LP, Bond AM. Vertical Integration and the Transformation of American Medicine. The New England journal of medicine. 2024;390(11):965-967.
4. Richman BD, Schulman KA. Restoring Physician Authority in an Era of Hospital Dominance. JAMA. 2022;328(24):2400-2401.
5. Schumpeter JA. Capitalism, socialism and democracy. routledge; 2013.
6. Schneider EC, Shah A, Doty MM, et al. Mirror, Mirror 2021 — Reflecting Poorly: Health Care in the U.S. Compared to Other High-Income Countries (Commonwealth Fund, Aug. 2021). Available online: https://www.commonwealthfund.org/publications/fund-reports/2021/aug/mirror-mirror-2021-reflecting-poorly
7. Olson LK. Ethically challenged: private equity storms US health care. Johns Hopkins University Press; 2022.
8. Sassen S. The Global City. Brown Journal of World Affairs; 2005. Available online: https://www.saskiasassen.com/pdfs/publications/the-global-city-brown.pdf
9. Fast H. The Martian Shop. Bantam Books; 1961. Available online: https://writing.upenn.edu/~afilreis/50s/fast-martian-shop.html
10. Rodwin VG, Gusmano MK. World cities and national policy in the time of COVID-19. Health Affairs Forefront. 2020;10.1377/forefront.20200618.523168