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Paul Willging Says...

February 1, 2006
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Today's Association Upheavals put LTC Unity at Risk

Today's association upheavals put LTC unity at risk So what is going on in long-term care's trade associations? Upheaval seems to be the order of the day. I began writing this column just a few weeks after Hal Daub left the American Health Care Association (AHCA), an event whose surrounding circumstances raised more than one eyebrow in Washington, D.C. Bruce Yarwood's appointment as AHCA's current president marked the fourth incumbent in that position in the past six years. Nor has turnover during that period been limited to AHCA. The Assisted Living Federation of America (ALFA) has had three presidents during that time, and the American College of Health Care Administrators (ACHCA) has had two. Only Larry Minnix, president and CEO of the American Association of Homes and Services for the Aging (AAHSA), seems to have discovered the secret of longevity (and, hopefully, I haven't jinxed him by making that observation).

In the spirit of full disclosure, I hasten to add that I served as president of two of those organizations, AHCA and ALFA. That might, on one hand, suggest that I've been too close to the turnover to objectively assess the reasons for it. But I might also have been in the best position to isolate its significance. I leave it for my readers to decide.

It's easy, of course (and superficial) to attribute the departure of any CEO simply to "conflict"-conflict in personalities, conflict in management styles, conflict over policy. I guess, to same extent, that is a part of the equation, even in those cases when it is the president who decides that, for mostly personal reasons, the time has come to move on. The story of such "amicable" transitions is, after all, made incredibly more compelling when the president describes "tension" within the organization. But having been personally involved in two of those transitions, I can assure you that such analyses don't go deep enough. Tension-be it a product of personality, management style, or policy-is usually rooted in much deeper concerns.

I would argue that such transitions are more often than not the result of the failure of all parties to share common missions or the same definition of "value."

Let's start with AHCA. From its inception in the late 1940s through most of the next two decades, AHCA's focus was as much on camaraderie and professional development as it was on effective representation in the public-policy arena. At its second annual convention in 1949, AHCA saw as its primary objectives:

  • to improve the standards of service and administration of member nursing homes;
  • to secure and merit public/official recognition and approval of the work of nursing homes;
  • to adopt and promote programs of education, legislation, better understanding, and mutual cooperation.

Representation was almost an afterthought, and understandably so. Not until the advent of Medicaid in 1965 did the lobbying function begin to take on the importance it has today. Unwittingly, Medicaid became the primary source of financial support, public or private, for nursing facilities. The industry took on many of the characteristics of a public utility (with very few of the attendant advantages). And with that financial imperative came a necessary emphasis on public policy. The industry became what economists refer to as a monopsony-essentially, a single-customer market. Since the customer was government, the focus of the association had to move from an inward emphasis (e.g., professional development) to an external one (i.e., influencing legislation and regulation).

That was, in reality, the reason for a transition in AHCA's leadership in 1984, when I assumed the position of executive vice-president. It was assumed, given my background with the federal government, that I was in a position to move the organization more vigorously into the realm of public-policy representation. (That confidence on the part of AHCA's leadership might or might not have been well founded-I leave that also for my readers to decide.)

But I came quickly to my own conclusion that, while enhanced emphasis on lobbying was important, and even imperative, it could not become the sole rationale for a trade association's existence-at least not one purporting to represent the entire nursing home industry. That conclusion was based on the makeup of the industry itself. In the 1980s and 1990s, AHCA represented (and still represents today) an extremely diverse clientele. It has both proprietary and nonproprietary members. It has the big guys with hundreds of facilities, as well as the "mom and pops." It looks out for the interests of those in states with differing levels and forms of reimbursement and licensure. And as a federation (as opposed to a direct membership organization), it represents multiple state associations, with their own panoply of interests and characteristics.

Not all of these entities share a single-minded dedication to representation as AHCA's primary-some would argue exclusive-focus. For many (as one of my early chairpersons was fond of informing me), the purpose of an association was to "associate," with the annual convention being members' primary interest. Others looked to professional development. For many, it was the association's publications that served as the principal attraction.