What Is Healthcare All About? Care, Science, or Just Cost?

I am writing this blog post while Congress is debating whether and how to change the U.S. healthcare system. This is something that, according to the news, will be determined in three days and will be decided by a simple majority without analysis of consequences by the Congressional Budget Office and without hearings involving the affected parties. This seems like a bad time to talk about long-term planning and a broader view of healthcare.
Let me do it anyway, starting with an important research paper by Mary Dunn and Candace Jones in Administrative Science Quarterly.  They looked at a central input to healthcare: medical schools, which educate the doctors who are in charge of providing the type of medical care that requires the MD degree and who direct the medical care done by others, such as nurses and lab technicians.  Although medical care is much bigger than doctors, they are at its core, so how they are educated is consequential. The paper found that medical schools have had an enduring division between two logics on how to think about healthcare, and one of these has become more influential over time. This view of education, and healthcare, is very new and needs some explanation.
Much simplified, the logics are as follows. One is that education is the transfer of scientific knowledge, so that this knowledge can be used in practice. So, medical school is about the science of medicine.  The other is that education instills values, and the guiding value for medicine is to care for people. So, medical school is about care, which can include care for people who are not yet patients and people who cannot be cured.
Dunn and Jones wrote a fascinating paper on how these two logics were in contention over decades. Advocates of each logic recognized the conflict with the other and fought for resources and attention to be devoted to their own logic. They saw an emphasis of their favored logic as essential for the health of medical education and the health of the nation more broadly. I don’t have room to describe their discussion here, but an important conclusion is that the care logic has grown in importance, and a key element of its growth was greater public discussion on managed care, with its emphasis on preventive medicine and focus on reducing costs.
This conclusion has become even more important in light of recent events. Managed care helped make the care logic more prominent, which facilitated useful initiatives such as thinking of public care more broadly to include prevention of disease and thinking of patients as individuals in need of care instead of just as cases with prognoses. But it also had two other effects that play a role in current politics around healthcare. First, the science part of medicine became less important, which now has become part of a greater movement against science having a role in state decisions overall. Second, cost is now a key consideration in health, which is clear given that estimates of tens of millions of people losing health insurance are acceptable as long as costs go down. Cost savings are even more important than the science behind estimating that tens of millions will lose their insurance, with the health consequences this will have.

The Manager as a Temp: Preparing for the Modern Labor Market

The news keeps telling us that employment is becoming a more-temporary state, with job changes both the result of footloose employees and of firms treating their workers as easily replaced, downsized, and upsized as needed. Not to mention that many now work as contractors, not employees, like Uber drivers. In these stories, the managers are typically cast as the bad guys treating everyone else as expendables. There is some truth to that, but there is a flip side: managers are also temporary. They are quickly moved around or even fired, and they also try to use job changes to move up faster than they could by staying in place.
How can managers be temps? Not only are managers credible to their subordinates only if they are expected to stick around for a while, but their chances of being promoted depend—ironically—on being able to signal that they are in it for the long run, even in a firm that habitually lets managers go. Well, for every problem that can’t be solved, there is a business school claiming to solve it. Research in Administrative Science Quarterly by Gianpiero Petriglieri, Jennifer Petriglieri, and Jack Denfeld Wood looked at how the participants in an MBA program used their education to make themselves more portable across firms and jobs. They were learning to turn themselves into managerial temps and use it to benefit their careers.
Like any education, business school is a journey, and the path and destination are unique for everyone. But there were clear patterns that tell us a lot about careers, and about management, in the current labor market. One path was to use the education to adapt both skills and identity to how firms now treat their workers, including managers. This is an instrumental pathway, where the idea is to understand the rules of the game and play it well. The other path was to use the pathway to explore one’s own preferred role in this world, and shape an identity that matches this discovery. This is a humanistic pathway, where the idea is to understand the parts available in the play and audition for the one that is the best fit.
These paths cannot easily be taken while working, because the everyday demands of actually managing make the learning process difficult, and changing identity isn’t possible either because everyone looks for and values constancy. So education acts as a valuable hiding place—a bubble, or a deep dive—where changes can happen and it is possible to emerge fully formed, or at least nearly so.
The next question is of course what the manager temps will do when they manage worker temps. Will work get easier when both manager and managed understand that they are not in the firm to stay, and the most stable part of their identity is its portability? To know that we have to wait for more research.

Committing to Change: How Change Agents Become Effective

Management practice has its fair share of cynics, and one story that many cynics will tell is that there are three sources of inefficiency in organizations. The first is that they can’t change into better practices, the second is that they pay for consultants who can’t help them change into better practices, and the third is that they pay for business schools to teach their managers, who end up not being able to change them into better practices. As a faculty member of a school that benefits a lot from the third source, I can at least say I agree with the cynics on the first two. But then, what can be done?

New research by Melissa Valentine in Administrative Science Quarterly has looked closely at consultants and organizational change, and offers some very helpful insights. She studied efforts to improve a cancer treatment center, so the changes were not just simple matters of reducing cost but had significant health outcomes. What did she find? First, it is completely true that significant consultant effort can be invested with no real change as a result. Money wasted, in other words, but perhaps worth trying because it is likely that nothing would have happened without the consultants either.
But consulting changing nothing was just one result – there were also some consultant efforts that did produce better practices. Importantly, the difference in how the consultants and the cancer center interacted in the unsuccessful  and successful cases was so systematic that this research gives clear guidance on what needs to be done to improve organizations. The difference can be summed up in one word: commitment.  And I will write the rest of the blog without any reference to interpersonal relationships, although I admit to being tempted.
Consultants hear from organizational members what works well and what does not, and they collect ideas on how improvements can be done and who would be in favor of them and under what conditions. This is done every time and has nothing to do with success or failure.  The success came from taking one more step. Whenever possible improvements were suggested and had some level of support across the organization, the managers who would be responsible for making changes were asked to renegotiate their obligations to each other and to implement the necessary changes. The renegotiation is needed because changes in complex organizations typically cross boundaries of managers and are most effectively handled by direct negotiation, not by referring up to the shared manager. Immediate implementation is needed because it is easy to give nice-sounding promises without accepting the cost of actually following through.  In other words, the success came from making managers decide what to commit to and then making them commit.
This was not just done as a final set of activities after delivering a report. It was a continuous effort, step by step, in which managers made adjustments and re-adjustments, set time tables and expected commitments, set new goals and measures, and followed up. The process also went far beyond managers, because hospitals also have another very powerful group: the doctors. Efforts to integrate their concerns were made in both the successful and unsuccessful project, but again, the successful project pushed all the way to commitment. In the successful case, the key decision makers ended up feeling obliged to fulfill promises they had made to others in the organizations – not to the consultants – and as a result, the organization changed.
The implication is clear. Consulting is often seen as an effective way of making changes because changes require a time investment, and organizations typically don’t have the resources to do their regular work and make time investments all at once. But increasing the capacity to propose change does not relieve the organization of the responsibility to negotiate, decide, and commit. Without those added activities, it is paying for nothing.

In the Fight: What U.S. Army Mental Health Tells Us about Goal Conflict

Goal conflict is a necessary and central part of how organizations work. This is true even if we ignore personal goals that may differ from the organization’s and focus only on the goals that all have to meet, at the same time, for the organization to function well. Cars are made in production lines that require quality, speed, and low cost. Airlines require safety, service, and low cost. Health care requires personal attention, standardized procedures, treatment of all possible conditions, and again low cost. And finally, important for this blog, an army requires its soldiers to inflict injury on others, risk or experience injury themselves, and maintain mental health good enough to go out and do it all over again.

A paper in Administrative Science Quarterly by Julia DiBenigno looked at the goal conflict between the U.S. Army’s commitments to providing mental health care and keeping its force mission-ready, and her findings are important for any organization. She addressed a fundamental problem of goals that are in conflict: usually each goal is assigned to specialists with expertise in that specific goal, so resolution does not happen inside someone’s head but rather as an interaction between the people in charge of each specific goal. Usually that is done by prioritizing one goal and assigning the other goal to a service-providing or supervisory function in the organization.
The U.S. Army exists for fighting, and naturally commanders are in charge. But mental health care is also a high-priority goal because the recent wars have put a heavy load on each soldier, and post-traumatic stress disorder and affiliated conditions take highly trained soldiers out of action. Many even commit suicide, spreading the pain more broadly to also affect families of military personnel. This is recognized as a key problem by everyone involved, but solving it involves negotiation between specialists. This leads to push-and-pull with two frequent results: the health care provider is coopted by the commander and serves the commander’s purpose, or the health care provider stays anchored in the care identity and interferes with the commander’s purpose. As a result, most conflicts are poorly solved: analysis found that 5 percent ended with a good mutual solution, in 85 percent either the commander or the health care provider won the battle, and in 10 percent both lost out.
But here is the key message of the article. The statistics I cited were for only two of the four brigades DiBenigno studied. In the other two, 89 percent of conflicts led to a good mutual solution, in 7 percent one party won but not the other, and in 4 percent both lost. This is a really large difference, and the reason for it boiled down to one minor change in organizational structure with major consequences for the process. In the successful brigades, each health care provider was embedded in the clinic but also assigned as a point of contact with specific commanders, which led to longer and more personal interactions than in the other two brigades. The result was an anchored personalization: the provider was anchored in a group of other mental health professionals who shared knowledge and norms, and the provider had a personal network of commanders that allowed learning each commander’s needs and earning trust as well.

The personal interaction proved to be central to understanding each other’s thinking and finding adaptive actions in each situation. It had a massive effect on the ability to find good solutions, especially because the goal conflict was unique in each case. Mental health issues are complex, but so are the needs of military units and their commanders. Perhaps most remarkable is the origin of the difference in problem-solving capacity: just a simple change in organizational structure that regulated which care providers interacted with which commanders created a total change in how these interactions were done. It’s an important lesson for organizational design – how it is done determines what happens later.

DiBenigno, Julia. 2017. “Anchored Personalization in Managing Goal Conflict between Professional Groups: The Case of U.S. Army Mental Health Care.” Administrative Science Quarterly, forthcoming: 0001839217714024.

Protest Outside, Protest Inside: How Social Movements Create Labor Unions

Occupy Wall Street protest with union members
Executives of large firms have been known to worry about social movement activity of three kinds. There are movements that encourage various kinds of costly state actions, such as cleaning up pollution or reducing carbon emission, which at some level will lead to taxation to cover the cost. There are movements that engage in boycotts and other actions to discourage firms from various cost-saving misbehaviors such as farming out production to nations with very loose labor and environmental protections. And inside the firm, labor movement advocates take action through established unions or through trying to form new unions where none yet exist. Responding to all this activity can exhaust executives, and they might not like to hear that these movements are related to each other.

How they are related is the topic of an article in Administrative Science Quarterly by John-Paul Ferguson, Thomas Dudley, and Sarah SouleThey look at how social movements outside the firm but in the same city influence unionization drives inside the firm. This is interesting because social movements and unions operate very differently, with unions under much stricter rules and restrictions, so the influence is not a result of workers learning anything useful about unions by taking part in social movements. In fact, it is not even clear that they do take part in social movements, because the mechanism behind this effect requires only that workers can see social movements, not that they participate.
Unions are built on procedures and ideas, with workers’ rights and equal opportunity among the most important ideas. It would make sense that the presence of similar progressive ideas in social movements in the same community could inspire union activity in firms, whereas social movements with more conservative ideology might have less effect on unionization because they have much less overlap with the ideology driving unionization.
This is exactly what the authors found to be true in U.S. cities. Protests in a city led to unionization drives in the same city, and this effect was stronger when the protests were related to progressive causes, including civil rights and gender equality. So protests outside a firm filter into unionization inside, specifically when the outside protests concern issues that workers inside also care about.  But there are additional details that make things even more interesting. Unions are not the only way for workers to solve problems. The Civil Rights movement and the women’s movement also had successes with changing the law, which meant that workers could contest gender or racial discrimination through the legal system rather than through unionizing. As a result, these movements’ effects on unionization were significantly reduced after the legal changes. So ideology matters, but competition from the law does as well.

Protests outside create unions inside, except when there are laws outside that make unions less necessary. What does that mean for our situation now? The laws outside are being weakened, and protests are getting stronger. Could it be a time for more unions?

Action, Embodiment, and Mission: How Leaders Can Make Work Meaningful

Here is a story that may or may not be true: John F. Kennedy met a custodian mopping floors in the NASA headquarters after normal work hours and asked, ‘‘Why are you working so late?’’ The custodian responded, ‘‘Because I’m not mopping the floors, I’m putting a man on the moon.’’ The story is almost too perfect to be true, but it is a close match to historical events that show how the U.S. space program gained its remarkable success, and it offers important lessons in leadership.

In a new article in Administrative Science Quarterly, Andrew Carton reports on Kennedy’s leadership of NASA in the 1960s, which culminated with the moon landing, and key lessons it offers to leaders today. At the center is the knowledge that when people find meaning in their work, everyone benefits: the organization benefits because its employees work harder and smarter, and they benefit because work is a big part of life and success and meaning at work increase well-being. So what’s the dilemma? Usually meaning is best gained from a great goal, but such goals are often abstract and distant from any one task at work. Linking lofty goals to concrete actions is difficult to begin with, but it gets harder as the goal gets loftier. So meaningful work is wonderful, but it’s hard to create.

Here are two examples. First, Amazon seeks to give meaning through its goal of being the earth’s most customer-centric company.  How easy is it for this mission to give meaning to one of its distribution center workers, who could be pulling products from shelves or overseeing a robot pulling products from shelves?  Second, it is part of INSEAD’s mission to reduce poverty in the world, because economic growth is the cure for poverty, and improved management helps economic growth. But the daily work of INSEAD professors and staff is still education.

Kennedy found a way to direct NASA that provided a simple, powerful, and very general way to address this dilemma. First, he distilled NASA’s mission to one of advancing science. But advancing science is not the daily work of a custodian, or even of an expert in electronics who is designing control circuits, so the gap between the lofty goal and concrete actions remained. So in between he placed the concrete objective of a manned mission to the moon before 1970. That concrete objective was not the same as advancing science, but it was an embodiment of the advancing science mission that staff members could more easily relate to. From that embodied objective more concrete plans and projects could be rolled out, and anyone working for NASA – even outside NASA – could gain meaning through connecting to them.


There are other important leadership lessons in the article, but the idea of finding a way to embody an overall mission in a more concrete objective is the most important one. It is also related to an essential insight in management. Much management practice centers on fluffy performances such as missions, speeches, goal statements, and quick tours and interactions. None of this helps if it is disconnected from the activities and meaning of organizational members.  All of it contributes to success if it is oriented toward the embodiment of concrete activities that people can use to choose actions and construct meaning. 

Trailblazers or Tokens? Women in Top Management and Boards

A famous career effect on women is the glass ceiling – at some point in the career, women find that it is hard to get promoted, harder than it is than for comparable men. Because this has been known for a while and is known to be an unfair and poor use of human capital, there is increasing pressure from institutional investors for firms to promote women’s advancement. This has created a paradox where many, but not all, firms are still set in their usual ways of treating men and women differently, but their owners are seeking change. What are the effects?

A new paper in Administrative Science Quarterly by Eunmi Mun and Jiwook Jun has now discovered what happens as a result of these pressures for fairness. It turns out that they come from two places. One is institutional investors, who are concerned with fairness and best use of human capital. The other is corporate social responsibility (CSR) associations and employees, who see fair treatment of employees as an important corporate responsibility.  Both of these help women gain higher-level positions in firms that they would otherwise not have received. But there is a catch, or more accurately, two catches.

The first catch is that at least now, the benefit of having institutional investors and CSR representation in a firm mainly leads to a few women entering the very top positions. So, it can give a board membership that otherwise would not be possible, or top executive level position which would be difficult otherwise, but at any lower level they simply don’t have any effect. That’s why women in the top levels could be tokens to show outsiders that the firm is fair, but without really changing the inside of the firm.

The second catch is that the emphasis on breaking the glass ceiling is not an international trend. Much of it is driven by Europe and North America, and has effects worldwide because so much of the world’s capital, and hence institutional investors, comes from these nations. In fact, I did not mention that this research is on Japanese firms, and the effect of institutional investors is from foreign institutional investors, not domestic ones. The domestic ones don’t help women’s careers. That does not mean that the token effect is only outside Europe and North America – this research is pioneering in showing that it exists precisely because Japanese firms are more open about their internal hiring at lower levels than firms in most other nations are.
So where does that leave women’s careers? A few token hires do not really break the glass ceiling, they just hide it. In many of these boards, one out of 12 members was a woman. But the research suggests that they could be trailblazers too. Another finding in the paper is that women in the board also helped women in non-managerial positions, so maybe they are the start of more equal careers. Although we should be careful about drawing too optimistic conclusions – women in the board had no effect on women in managerial positions. We need to wait and see before we know how this unfolds.

The Reaper is Sociable: Leadership of Extravert CEOs

There are two important trends in the world of business today.  The first is that traditional large corporations are gradually becoming less important, as new technologies, improved markets, and better financing allow smaller firms to be founded and operate more easily. My predecessor as editor of the journal Administrative Science Quarterly, Jerry Davis, has written a book on that. There is also another trend that seems to indicate that the opposite is happening. There is a small set of extremely large corporations in services, industry, and finance that are amassing exceptional power. Added up, these trends mean that the number of somewhat-large, but not the largest, corporations is declining.

One result of these trends is that researchers are now looking more closely at CEO personality, because in both the smallest and the largest firms any departure from rational decision making is very consequential. It can destroy a small firm, and it can wreak havoc on the world around a large firm.  A paper in Administrative Science Quarterly by Malhotra, Reus, Zhu, and Roelofsen has now examined the extraversion of CEOs and how that influences mergers and acquisitions done by their firms. Extraversion is a personality trait and is one that we understand well and like a lot, at least at parties. Extraverts liven up the world around them because they are sociable, active, and very likable. This is a good thing, but also something that is hard to connect to management.

The connection lies in the less well known side of that personality trait. Extraverts are also agentic – it is very important for them to take care of their own interest and to get ahead of others. Sociability and likability are parts of that trait, because extraversion means that they get to dominate their surroundings.  And outside of parties, the same agentic traits can be reflected in them having clear goals to benefit themselves as much as possible, possibly at the expense of others, and of being skilled at persuading others that their initiatives are good. Does the extravert sound less appealing now, but also more consequential as a manager?
Acquisitions are a great way to test the consequences of extraversion because they eliminate the acquired firm and usually harm the acquiring firm, because on average, acquiring firms lose money by over-paying for the acquisition. As a result, a CEO with the firm’s best interest at heart will be very selective about when to acquire another firm and will typically focus on smaller acquisitions that help the firm acquire important technology, market access, and other missing pieces, while being relatively inexpensive because small firms are often overlooked, or even not listed in the stock market. But small firms are also boring, and not something an extravert wants to acquire in order to grow the firm fast and look good doing it.
So what did the authors find? Indeed extravert CEOs acquire more often, and they acquire larger targets. They are especially likely to do so when they have freer hands, such as when they are in less competitive industries or when they are powerful relative to the board of directors. Turn extravert CEOs loose, and you will see firms around them get eaten up. Of course, all of this would be OK if the acquisitions turned out to be a good thing. Do we know if they did? Well, extraverts got a more positive immediate reaction from the stock market than others, but let’s not believe that this means a lot. First, keep in mind that investors are just another set of people to impress, and extravert CEOs are good at that. Second, better reaction to one acquisition than others does not say much because most acquisitions are not welcome. Third, immediate reaction is very different from the long-term benefit of an acquisition.
So we know that extravert CEOs benefit themselves by getting attention from acquisitions, and by growing the firm so that they in turn can get paid more – a larger firm means better pay. We don’t know whether that helps the firm. And somehow, I can’t help but wonder whether our not knowing is something that the extravert CEO likes a lot.

Excellence in Research and Food: What we have learnt from Cattle Ranching

Administrative Science Quarterly is a research journal that for the last few years has published roughly 20 articles per year, which is slightly more than what some other journals will publish in 1.5 months. ASQ is very selective, yet we have found a way to be even more selective by also recognizing excellence in the articles we publish. Every year an award is given to one article for its scholarly contribution over the previous 5 years. These articles are available here, and I will give one example in this blog. It is about grass-fed beef.
Those who are into gourmet or health food dining will recognize grass-fed beef as specially produced to the cleanest, most environmental, and most original standards, and as being a premium product that can be obtained in the best restaurants and stores. They are unlikely to know that grass-fed beef used to be sold at a discount because it lacked the fat marbling and tenderness of beef from cattle produced the standard way, with a finishing period where the cattle were eating corn and grain in feedlots. How did the discounted product of the past become today’s premium product?
The answer is given in an ASQ article by Klaus Weber, Kathryn Heinze, and Michaela DeSouzey. It involves a social movement that helped drive forward activists and entrepreneurs who coalesced around the ideas of authenticity in farming, sustainable nature management, and using only natural materials and processes. All of these principles were in opposition to normal farming methods, which the activists saw as industrial, non-sustainable, and relying on artificial materials and approaches. These activists were a social movement, but they did not have a company, a set of customers, a way to market what was special about grass-fed beef, or even a clear way to earn a living. Instead, they produced a language, a social grouping, and a belief system that a set of entrepreneurs could organize around.
The next steps were creation of the new market for the now-premium product of grass-fed beef. Farms switched to grass-fed methods, often helped by other farms or by publications devoted to these methods. The entrepreneurs and other parts of the industry, including the social movement, created informal standards for how to conduct grass-fed farming. They sought out customers for the growing set of producers and volume of (now-premium) beef. Throughout this process, a social movement organized around ideas of protecting nature, preventing cruelty to animals, and promoting human health rallied resources in ways that created a new niche of an industry, and an opportunity for entrepreneurs.
The key insight from this research is the sequence of events: entrepreneurs with new ideas and products can in principle build markets through individual efforts, but it is difficult to accomplish. Once a social movement has made a cultural foundation, entrepreneurial effort is much easier, so it is accelerated and more likely to succeed. The sequence leading to the grass-fed beef you may be eating soon started with an idea and a language to use in making it a reality.

Is Women’s Liberation for Men Only?

I understand that the title of this blog post is confusing and borderline annoying, so I will come straight to the point: There is new research evidence that women’s career opportunities can be made more equal to men’s if their male bosses think they should be. Not if their female bosses do. I think this is surprising and worrying enough that I should explain what is going on.

This concern is based on research evidence from a paper in Administrative Science Quarterly by Seth Carnahan and Brad Greenwood, and it is based on law firm careers. You might think that lawyers have specialized careers, and you would be right. They are specialized in ways that are useful for testing the theory, however, because the top-class law firms in the sample recruit very similar people, so there is little of the variation among employees that could be used to explain any differences between men and women. Also, heavy-handed discrimination is not possible here because lawyers know how to, you know, file lawsuits. As you can imagine, finding any discrimination at all between men and women in this context would be surprising and interesting. It gets especially interesting because we can use politics to find out what managers want, assuming that liberal lawyers have liberal views including gender equality and that conservative lawyers don’t. Donations to the Democratic and Republican parties are good measures of ideology.

So we know whether the managers (partners) are liberal or conservative, and we know the gender of the employees (associates), and that’s all we need. Carnahan and Greenwood went ahead and analyzed the data, finding that conservative offices hired fewer female associates. Liberals practiced equality in hiring, and the difference reached levels that can be measured even for these elite lawyers. Same story for assignments to task forces and for promotions: women are better off working for liberals.
But then the surprise comes: distinguishing between male and female managers, they found that the helping of women could be shown for only liberal male partners, not liberal female partners. So women’s equality in law firms seems to be for men only to decide. How is that possible? It seems unlikely that women partners care less, especially if they are also liberal. But how much change people make depends on how much they try and how much power they have. That’s where the men have the edge. There are more of them and they are in more senior positions, so ultimately what counts is how men view women’s careers.

Earlier I wrote one blog post on the book Lean In criticizing its depiction of women’s career opportunities and another blog post on research correcting this depiction. Lean In is too optimistic about women’s opportunities to make changes for themselves. This research presents one more problem for the Lean In idea because it suggests that what women think of themselves or of other women is less consequential because they have less power. Real-life careers are not about leaning in, but pulling up.