Renegotiating health care: an interview with Leonard Marcus, PhD - Conflict Management - Interview

Physician Executive, July-August, 1999 by Richard L. Reece

Q. HOW DID YOU become Director of the Program for Healthcare Negotiation and Conflict Resolution at the Harvard School of Public Health?

Marcus: I got into the field of negotiation and conflict resolution when I was teaching courses on health care organizations and health policy at Mass General Hospital back in the mid-80's. I received a fellowship in the Kellogg National Leadership Program. Each year, the Kellogg Foundation selects about 40 people for the purpose of encouraging leadership, generally across the country.

One of the provisions was that they support and fund study on a topic, however fellows must choose an area that they've never studied before. I had originally chosen health care finance and they found that I had written one paper on that subject, so they said no, you've got to find something that you've never studied. I thought long and hard and came upon the topic of negotiation and conflict resolution. Their provision also was that you couldn't study this by merely reading books, you had to really jump into the topic. Over the three years I traveled to the Middle East, the Soviet Union, and China and interviewed people, looked at the questions of conflict resolution. I also studied with people in this country at Harvard. at George Mason University, with people at CDR Associates in Colorado, and truly developed a broad understanding of the field and its applications.

When my fellowship ended, I asked my new conflict resolution buddies. "Well who is doing this work in health care?" That link--between the growing, still rather young field of conflict resolution and what was going on in health care--really hadn't been constructed and I shifted my career interest to look at negotiation and conflict resolution as it pertained to health care.

In 1990 I had a faculty position at Boston University with an emphasis on negotiation and conflict resolution and a grant from the National Institute for Dispute Resolution (NIDR). NIDR sponsored our training in negotiation and conflict resolution with the assumption that we would be creating a new field of practice.

Here in Massachusetts, I went to the medical society, hospital association, and nursing association and I asked them to recommend their best and brightest. The Boston Globe did a story about the fact that I was looking for potential mediators and we received 160 applications. I interviewed 60 people and we chose 25 to be in that original class. Though they received the training for free, their expectation was to become the leaders of this emerging field.

It was back in 1990 that we really got off the ground. The program was instituted at the Boston University School of Public Health. In 1995, we had an opportunity to move the program to the Harvard School of Public Health and we have been here ever since.

Q. I just read your book, Renegotiating Healthcare, Resolving Conflict to Build Collaboration, co-authored with Barry Dorn, MD, Phyllis Kritek, Velvet Miller, and Janice Wyatt. Why did you give the book this title?

Marcus: We recognized that we are, in effect, renegotiating the very assumptions and premises that have guided the health care system over the last few decades--the advent of managed care, reimbursement changes, the financing of health care, a shift towards primary and preventive care. Nationally, we are changing these key assumptions and premises. We know from the social science research in the field that conflict and change are often closely associated with one another. And that certainly has been the case with the changes that have been going on in the health care system this decade.

There has been a tremendous change, when we consider what the system looked like ten years ago. Managed care penetration, Medicare reimbursement after the Balanced Budget Act, the organization of health care--all are very different now. Medical practices are being organized in new ways. We hoped that the book would be a guide for that process of renegotiation.

The second part of the book's title, "Resolving Conflict to Build Collaboration," is an acknowledgement that while conflict can be destructive, it also can provide opportunities for people to look at where there are problems, to identify and correct those problems, and end up on the other side with something even better than what they began with. We are hoping that people will recognize the opportunity to turn problems into solutions and that the book provides guidance in that effort.

Q. I believe the conflict escalated after the defeat of the Clinton health care plan and the for-profit industry rushed in to fill the vacuum, and it seems this explosive growth of managed care has generated more heat than light.

Marcus: It is true that the Clinton efforts--and certainly the fact that this intervention did not have its intended results--put a spotlight on the health care system. But don't forget they were responding, in part, to a set of forces and factors that were affecting the health care system that preceded their work and that still continues. The pressures regarding the economics of health care were there before the Clinton work and there have been increasing pressures afterwards. The problem of the uninsured certainly was not solved by that task force. That was there before they had begun their work.