Counterpoint article.

A Side effect of the evidence-based movement in medicine has been mounting pressure to make policy and management evidence-based. For that reason, I believe Dr. Finkler's question "Evidence-based financial management-what are we waiting for?" can be answered, at least in part, by a brief examination of the development of evidence-based medicine (EBM). EBM has a long history, its philosophical origins dating back to the 19th century and even earlier. In 1835, the Paris Academy of Science commissioned a report on statistical research performed by surgeon and urologist Jean Civiale. By collecting statistical data on an expansive scale across the European continent, Civiale contended that a new bloodless procedure for extracting bladder stones was superior to the then more common technique of surgically removing the stones (Poisson et al., 1835). While the contents of Civiale's report may no longer be salient to the current treatment of this particular medical problem, the report serves to illustrate the trend of the role of quantification in 19th century medicine in ways that still resonate with 21st century medicine. Even as early as the 18th century, primarily because medical practitioners received more patients if they had higher rates of success, physicians and surgeons began to enumerate their successes (and failures) annually in tabular form (Trohler, 2000). Viewed historically, Civiale's method of quantitative comparison was not fundamentally innovative. However, he was able to carry out his research on a much larger scale than his 18th century predecessors were because he was supported by the French Ministry of Public Instruction (Lecuyer, 1987). This government support exemplifies how reliance on aggregate data came to be seen as a fundamental method of answering questions considered to be in the public interest. It also suggests a partial answer to Dr. Finkler's question.

Evidence-based financial management is waiting for health care organizations, as well as government bureaucracies, to see the advantage of utilizing the results of evidence-based financial management research in the health care field and to provide funding to carry out the research necessary to inform it. The growth of EBM, originating in 19th century Paris, has made great strides only during the past several decades, principally due to the availability of a huge funding pool for both research and its dissemination (equally important), provided partly by national governments, and partly by the pharmaceutical industry. Management research, in the main, lacks such funding opportunities.

Evidence-based practice (EBP), the stepchild of EBM, seeks to integrate the results of EBM with clinical expertise and patient values. But there is "consistent evidence of failure to translate research findings into clinical practice" (Grimshaw, 2003). Figures from additional sources bolster this position. Between 30-40 percent of patients do not get treatments of proven effectiveness for their ailments, and 20-25 percent of patients receive care that is not necessary or is potentially harmful (Schuster, McGlynn & Brook, 1998; Grol, 2001).

EBP assumes that: (1) professionals have the motivation, skills, energy and time to practice EBM; (2) that professionals work in environments conducive to such practice; (3) and that the individual professional largely determines whether to apply EBP--all of which, I suggest, are unwarranted assumptions in the field of medicine, and perhaps even more unwarranted in the field of evidence-based health care financial management. To subscribe to such assumptions ignores the difficulty of separating common occurrences and processes which can reasonably be asserted to form the basis of managerial practices, reflecting the conditional, contextual and relatively changeable nature of managerial tasks and behaviors. First, limitations exist on the extent to which findings from studies of management practice can be generalized between situations or health care organizations. Second, in many of today's health care systems, managerial tasks are determined not so much by managers or their actions but by employers whose actions are, only infrequently, evidence-based. Third, managerial practices are dependent upon organizational arrangements and cannot easily be separated from their context to form the object of research. Managers are seldom the masters of their destinies, having only a constrained control over their job and what is expected of them.

In short, we are also waiting for a change in health care organizational climate. In addition to the points enumerated above, most health care organizations are, whether openly or tacitly acknowledged, in competition with other health care organizations for business, not unlike their counterparts in the service industry. Strategies designed to attract a competitor's business, or to decrease costs to the organization, are played close to the vest. Thus, there is a structural incentive for not sharing the results of service-improvement and cost-saving measures.

While I agree with Dr. Finkler's notion that financial management in health care should be evidence-based, given the progress with EBP in medicine, I am less optimistic that the barriers (both structural and organizational) to evidence-based financial management will soon be breached. Any gains in evidence-based financial management decision-making in the foreseeable future will be accomplished in small increments, at best. This is, of course, not to say that researchers in the domain of financial management should abandon the quest for integrating managerial decision-making with research results, but that financial management researchers should be more circumspect regarding their expectations of the "brave new world" which Dr. Finkler envisions.

REFERENCES

Grol, R.T.P.M. (2001). Successes and failures in the implementation of evidence-based guidelines for clinical practice. Medical Care, 39(8 Suppl. 2), 1146-54.

Grimshaw, J. (2003). Future prospects for evidence-based practice: getting closer to the destination. Alf Nachemson Lecture, Institute for Work and Health Annual Meeting, Toronto, Aug.

Lecuyer, B.P. (1987). The statistician's role in society: the institutional establishment of statistics in France. Minerva, 25, 52-3.

Poisson, S.D., Double, F.J., Larrey, D.J., & Dulong, P.L. (1835). Rapports: recherches de statistique sur l'affection calculeuse, par M. Le docteur Civiale. Comptes Rendus Hebdomadaires des Seances de l'Academie des Sciences, 1,171-2.

Schuster, M.A., McGlynn, E.A., & Brook, R.H. (1998). How good is the quality of health care in the United States? The Milbank Quarterly, 76(4), 517-63.

Trohler, U. (2000). To improve the evidence of medicine: the 18th century British origins of a critical approach. Edinburgh: Royal College of Physicians.

Clifford Melick is a member of the Editorial Board for RESEARCH IN HEALTHCARE FINANCIAL MANAGEMENT.