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vi Contents

PART THREE
Macro Perspectives / 281

CHAPTER 10 Strategic Thinking and Achieving Competitive Advantage 282

CHAPTER 11 Managing Strategic Alliances 321
CHAPTER 12 Health Policy and Regulation 347
CHAPTER 13 Health Information Systems and Strategy 379
CHAPTER 14 Consumerism and Ethics 399
CHAPTER 15 Globalization and Health: The World Is Flattening 431
APPENDIX Acronyms 461
GLOSSARY 464
AUTHOR INDEX 478
SUBJECT INDEX 487

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 CONTRIBUTORS

Jeffrey A. Alexander, PhD Martin P. Charns, MBA, DBA

Richard C. Jelinek Professor of Health Management Professor of Health Policy and Management School of
and Policy School of Public Health Public Health, Boston University
University of Michigan Director HSR&D Center for Organization, Leadership and
Ann Arbor, Michigan Management Research (COLMR)
VA Boston Healthcare System
Jane Banaszak-Holl, PhD Boston, Massachusetts
Associate Professor of Health Management and Policy,
School of Public Health Jon Chilingerian, PhD
Associate Research Scientist, Institute of Gerontology Associate Professor of Human Services Management
University of Michigan Director of the AHRQ Doctoral Training Program
Ann Arbor, Michigan Director of the Brandeis University-Tufts School of
Medicine MD-MBA Program
Elizabeth H. Bradley, PhD, MBA The Heller School for Social Policy and Management
Professor of Health Policy and Administration Brandeis University
Director, Health Management Program Waltham, Massachusetts
Director, Yale Global Health Initiative
Yale School of Public Health Ann F. Chou, PhD
New Haven, Connecticut Associate Professor of Health Administration and Policy
Department of Health Administration and Policy College
Lawton Robert Burns, PhD, MBA of Public Health
The James Joo-Jin Kim Professor, Professor of Health University of Oklahoma
Care Management, and Director of the Wharton Oklahoma City, Oklahoma
Center for Health Management and Economics
The Wharton School, University of Pennsylvania
Philadelphia, Pennsylvania

vii
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viii Contributors

Ann Leslie Claesson, PhD, PSP, FACHE Timothy Hoff, PhD

Faculty Associate Professor of Health Policy and Management
Capella University University at Albany School of Public Health
Minneapolis, Minnesota Rensselaer, New York

Thomas D’Aunno, PhD Peter D. Jacobson, JD, MPH

Professor of Health Policy and Management Professor of Health Law and Policy
Mailman School of Public Health, Columbia University Director, Center for Law, Ethics, and Health
New York, New York University of Michigan School of Public Health
Ann Arbor, Michigan
Mark L. Diana, MBA, MSIS, PhD
Assistant Professor, Department of Health Systems John R. Kimberly, PhD
Management Henry Bower Professor of Entrepreneurial Studies
Tulane University Professor of Management
New Orleans, Louisiana Professor of Health Care Management
Professor of Sociology
Amy C. Edmondson, PhD Executive Director, Wharton/INSEAD Alliance
Novartis Professor of Leadership and Management The Wharton School, University of Pennsylvania
Harvard Business School Philadelphia, Pennsylvania
Boston, Massachusetts
Kristin Madison, JD, PhD
Bruce Fried, PhD Professor of Law
Associate Professor and Director, Residential Masters University of Pennsylvania Law School
Programs Philadelphia, Pennsylvania
Department of Health Policy and Management
University of North Carolina at Chapel Hill Ann Scheck McAlearney, ScD
Chapel Hill, North Carolina Associate Professor, Health Services Management
and Policy
Mattia J. Gilmartin RN, PhD College of Public Health, Ohio State University
Associate Professor Columbus, Ohio
Hunter College, Hunter-Bellevue School of Nursing,
City University of New York Eilish McAuliffe, MSc, MBA
New York, New York Director of the Centre for Global Health
Director of Health Services Management
Christian D. Helfrich, MPH, PhD Senior Lecturer in Health Policy and Management
Research Investigator Trinity College
Northwest Health Services Research and Development Dublin, Ireland
Center of Excellence
VA Puget Sound Health Care System
U.S. Department of Veterans Affairs
Seattle, Washington

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 Contributors ix

Mario Moussa, PhD, MBA Stephen L. Walston, PhD, FACHE

Adjunct Senior Fellow Professor of Health Administration and Policy
Leonard Davis Institute of Health Economics Department of Health Administration and Policy College
University of Pennsylvania of Public Health
Philadelphia, Pennsylvania University of Oklahoma
Oklahoma City, Oklahoma
Ingrid M. Nembhard, PhD, MS
Assistant Professor Bryan J. Weiner, PhD
Yale University School of Public Health Professor, Department of Health Policy and Management
Yale University School of Management UNC Gillings School of Global Public Health
New Haven, Connecticut Chapel Hill, North Carolina

Dr. Kevin W. Rockmann, PhD Gary J. Young, JD, PhD

Associate Professor, School of Management Director, Northeastern University Center for
George Mason University Health Policy and Healthcare Research
Fairfax, Virginia Professor of Strategic Management
and Healthcare Systems
Lauren Taylor, MPH Northeastern University
Research Associate Boston, Massachusetts
Yale School of Public Health
New Haven, Connecticut Edward J. Zajac, PhD
James F. Beré Professor of Organization Behavior
Sharon Topping, PhD J. L. Kellogg Graduate School of Management
Professor of Management Northwestern University
College of Business Evanston, Illinois
University of Southern Mississippi
Hattiesburg, Mississippi

Karen A. Wager, DBA

Professor and Associate Dean for Student Affairs
Medical University of South Carolina
Charleston, South Carolina

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 Copyright 2012 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
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 FOREWORD

For twenty five years and five editions we have attempted their potential. Issues of maintaining a motivated workforce,
to provide an integrative perspective to the organization assuring state of the art practice patterns, coordinating
and management of health services; presenting the major various disciplines and specialties to the benefit of patient
management theories, concepts, and practices of the day. care and accommodating an ever expanding technology
We have also provided practical illustrations and guidelines to within a market economy that would benefit the patient and
assist managers and prospective managers in the provision of the larger community have been and will continue to be the
health services in a variety of settings. major responsibility of management.
As we go to press we have entered the era of health care This 6th edition provides readers with the relevant theories,
reform, presenting new and perhaps not so new challenges concepts, tools, and applications to address operational
and opportunities. Under the leadership of Rob Burns, issues that managers face on a daily basis. As described in the
Elizabeth Bradley and Bryan Weiner, the invited chapter lead chapter the key challenge facing organizations and their
authors have provided a thoughtful and in-depth analysis of managers is to deliver “value”—the ratio of quality to cost.
the theories, concepts and approaches that managers and While this has always been a concern, the reality of present
prospective managers need to address the critical issues in the day economics and the developing science has made this
provision of health services as well as meet the challenges and imperative.
opportunities resulting from health care reform. The book is divided into three sections. The first section
The passage of health care reform brings a great deal provides two insightful introductory chapters presenting
of uncertainty as it attempts to address the long standing the challenges of providing health services and some of the
problems of access, quality, cost containment and significant conceptual maps necessary to help guide managers in
disparities under unprecedented economic conditions. Much the decision making process and providing a framework for
has changed as reflected in the mandates regarding access understanding the role and contributions of management and
to coverage, coverage itself, the role of public and private leadership within a variety of health care settings.
programs and health insurance exchanges as well as the role of The next section focuses on the Micro Perspective—
comparative effective studies, payment reforms, accountable Managing the Internal Environment. This perspective
care organizations and patient-centered medical homes. addresses the classic issues of organization design, motivation,
While these represent significant changes in the operation communications, power, organizational learning, performance/
of the delivery system, the fundamental managerial challenges quality improvement and managing groups and teams. Each
remain and will continue to require skillful attention if health chapter provides an “In Practice” scenario that sets the scene
care and the various delivery organizations are to realize for the concepts and tools for effective management.

xi
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xii Foreword

The last section, the Macro Perspective—Managing the complex regulatory environment and finally the recognition
External Environment, focuses on the organizational context that we live in a globalized world.
and addresses the challenge of achieving competitive Health services management has come of age and Burns,
advantage, and managing alliances. Four new chapters will Bradley and Weiner and their colleagues have presented the
help prepare managers for the uncertainty of the years ahead. theories, concepts and guidelines that future managers will
These include the challenges of managing an ever expanding need to succeed in the years ahead.
information technology, consumerism, an increasingly

Stephen M. Shortell, Ph.D Arnold D. Kaluzny, Ph.D

Blue Cross of California Distinguished Professor Emeritus of Health and Policy &
Professor of Health Policy & Management Management,
Professor of Organizational Behavior, Gillings School of Global Public Health, and Senior
Haas School of Business and Dean, School Research Fellow
of Public Health Cecil G. Sheps Center for Health Services Research,
University of California, Berkeley University of North Carolina at Chapel Hill,
Berkeley, California Chapel Hill, North Carolina

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 PREFACE

INTRODUCTION emerging issues in health care such as public reporting, pay

for performance, information technology, retail medicine,
This book is intended for those interested in a systemic ethics, and medical tourism. Finally, this sixth edition expands
understanding of organizational principles, practices, and upon a major theme of the fifth edition: health care leaders
insights pertinent to the management of health services must effectively design and manage health care organizations
organizations. The book is based on state-of-the-art while simultaneously influencing and adapting to changes in
organization theory and research with an emphasis on environmental context. Managing the boundary between the
application. Although the primary audience is graduate internal organization and its external environment is therefore
students in health services administration, management, a central task of healthcare leadership.
and policy programs, the book will also be of interest to
undergraduate programs, extended degree programs, executive
education programs, and practicing health sector executives
ORGANIZATION
interested in the latest developments in organizational The organization of the book reflects this expanded theme.
and managerial thinking. It is also intended for students of Part 1 provides an overall perspective on the health care
business, public administration, medicine, nursing, pharmacy, sector, discusses the distinctive challenges facing health
social work, and other health professions who will assume care organizations, and examines the roles of leaders and
managerial responsibilities in health sector organizations or managers in influencing organizational culture, performance,
who want to learn more about the organizations in which and change. Part 2 focuses on core leadership and managerial
they will spend the major portion of their professional lives. tasks within organizations. These include motivating people,
Previous editions have been translated into Polish, Korean, guiding teams, designing structure, coordinating work,
Ukrainian, and Hungarian, and we look forward to the book’s communicating effectively, exerting influence, resolving
continued use by our international colleagues. conflict, negotiating agreements, improving performance,
and managing innovation and change. Part 3 describes the
broader context in which health care organizations operate
TEXT APPROACH and discusses the managerial implications of several emerging
The sixth edition broadens the view of health care sector trends and issues. These include the growth of strategic
beyond the traditional focus on hospitals and other provider alliances in the health sector, the expansion and complexity of
organizations to include suppliers, buyers, regulators, health law and regulation, the uses and challenges of health
public health and financing organizations. It offers a more information technology, the rise of consumerism in health
comparative, global perspective on how the United States care, and the global interconnectedness of health systems.
and other countries address issues of health and health care. The sixth edition includes a new introductory chapter
Additionally, the book discusses managerial implications of (Chapter 1) and new chapters focusing on improving quality

xiii
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xiv Preface

(Chapter 9), strategic thinking (Chapter 10), health policy of concepts and principles to practical managerial and
and regulation (Chapter 12), health information technology organizational issues. Second, a glossary appears at the
(Chapter 13), consumerism and ethics (Chapter 14), and end of the book, which includes all of the key terms and
global health and health care management (Chapter 15). It their definitions.
combines several chapters that appeared in the fifth edition in
order to highlight connections among important managerial INSTRUCTOR RESOURCES
and organizational issues that can be easily missed when
the issues are discussed in separate chapters. Two prominent Instructor Companion Site
examples are Chapter 3, which includes organization design, The Instructor Companion site for this text offers many
work design, and coordination; and Chapter 7, which includes valuable support materials. To access the Instructor
power and politics, conflict management, and negotiation. Companion site, go to http://login.cengage.com.
Finally, several chapters that also appeared in the fifth
edition have been thoroughly revised and updated, including If you have a Cengage SSO account: Sign in with your
the chapters of leadership and management (Chapter 2), e-mail address and password.
communication (Chapter 6), and innovation and learning If you do not have a Cengage SSO account: Click Create
(Chapter 8). My Account and follow the prompts.
The following support materials are included:
FEATURES • Electronic Instructor’s Manual—The Instructor’s Manual
The sixth edition continues several popular features from the that accompanies this book includes an overview of the In
fifth edition. These include: Practice and Debate Time material from the text; suggested
solutions to the end-of-chapter discussion questions and
• An explicit list of topics provided at the beginning of each
case studies; teaching tips and exercises; complimentary
chapter
reading lists; suggested solutions to the Vignette material
• Specific behaviorally-oriented Learning Objectives highlighted in the study guide; and an overview of additional Debate
at the beginning of each chapter Time material from the study guide.
• A list of Key Terms that readers should be able to define • PowerPoint presentations—This book comes with
and apply as a result of reading each chapter Microsoft PowerPoint slides for each chapter. They’re
• An “In Practice” column describing a practical situation included as a teaching aid for classroom presentation, to
facing a health services organization. make available to students on the network for chapter review,
• A section in several chapters called “Debate Time,” which or to be printed for classroom distribution. Instructors,
poses a controversial issue or presents divergent perspectives please feel free to add your own slides for additional topics
to stimulate the reader’s thinking. you introduce to the class.
• Comprehensive Managerial Guidelines and Summary points • ExamView®—ExamView®, the ultimate tool for objective-
at the conclusion of each chapter. based testing needs, is a powerful test generator that enables
instructors to create paper, LAN, or Web-based tests from
• Discussion Questions that help reinforce chapter test banks designed specifically for their Cengage Course
concepts. Technology text. Instructors can utilize the ultra-efficient
QuickTest Wizard to create tests in less than five minutes by
NEW TO THIS EDITION taking advantage of Cengage Course Technology’s questions
The sixth edition includes the seven new chapters banks, or customize their own exams from scratch.
described above as well as two new features. First, a • Sample Course Syllabus—The Sample Syllabus was
brief case study appears in each chapter, with questions developed to help instructors customize specific course
designed to stimulate discussion and encourage application titles.

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 Preface xv

WebTutor on Blackboard and WebCT for Health Management and Economics. His research focuses
• WebTutor—Designed to accompany specific Delmar, on hospital-physician relationships, strategic change,
Cengage Learning textbooks, WebTUTOR™ is an eLearning integrated health care, supply chain management, health care
software solution that turns everyone in your classroom management, formal organizations, physician networks and
or training center into a front-row learner. Blackboard and physician practice management firms. Dr. Burns is the author
WebCT components are offered across all of our disciplines. of, and contributor to several books, as well as numerous
Each WebTutor may include chapter learning objectives, articles, on Health Care Management. He is the recipient of
online course preparation, study sheets, glossary flashcards, numerous grants, awards and Fellowships and has held many
discussion topics, Web links, and an online forum to academic positions throughout his career. Dr. Burns has also
exchange notes and questions. In addition online chapter provided expert witness testimony for the federal government
quizzes are provided in various formats including, matching as well as for the private sector. He is a member of the
exercises, completion, and multiple-choice questions with Academy of Management, the American Hospital Association
immediate feedback for correct and incorrect answers. and the Association for Health Services Research. Lawton
Multiple-choice questions also include rationales for right R. Burns has a Bachelor of Arts Degree in Sociology and
and wrong choices. Whether you want to Web-enhance Anthropology, a Master’s Degree in Sociology and a Doctor of
your class, or offer an entire course online, WebTUTOR™ Philosophy Degree in Sociology.
allows you to focus on what you do best, teaching. Elizabeth H. Bradley, Ph.D. is a Professor of Epidemiology
WebTutor on Blackboard (ISBN 1-4354-8815-6) and Public Health at the Yale School of Public Health, where
she directs the Health Management Program and Global Health
WebTutor on WebCT (ISBN 1-4354-8816-4) Concentration. She is also the Director of the Yale Global
Health Initiative. She has extensive academic and research
STUDENT RESOURCES experience in the public health arena and is the recipient of
numerous honors and research grants. Her research focuses
To access additional course materials, please visit the on health services, with an emphasis on management
Student Companion site at www.cengagebrain.com. At the and quality improvement. Dr. Bradley is a member of the
CengageBrain.com home page, search for the ISBN of your Gerontological Society of America, the Academy of Health,
title (from the back cover of your book) using the search box and the Association of University Programs in Health
at the top of the page. This will take you to the product page Administration. She is a faculty Associate of the American
where these resources can be found. College of Healthcare Executives and a full member of the Yale
The Student Companion site for this text provides the Cancer Center Prevention/Control Program. She is also the
following support materials: author of over one hundred published papers and the author
• Electronic Study Guide—The Study Guide includes of, and contributor to, numerous books and articles in the
Vignettes which present additional case study material health field. Elizabeth Howe Bradley has a Bachelor of Arts
followed by critical thinking questions; assignments for Degree in Economics, a master of Business Administration
the students to complete either in class or on their own and a Doctor of Philosophy Degree in Health Policy and
to help them practice the skills they will need on the job; Health Economics.
and additional Debate Time scenarios. Bryan J. Weiner is a Professor in the Department of
Health Policy and Management, Gillings School of Global
Public Health at the University of North Carolina at Chapel
ABOUT THE AUTHORS Hill. He is the author of, and the contributor to, numerous
Lawton Robert Burns is the James Joo-Jin Kim Professor, and books and articles. He is a member of the Academy of
Professor of Health Care Management in the Health Care Health, the Academy of Management, the American Public
Management Department at the Wharton School, University Health Association, and the Society for Behavioral Medicine.
of Pennsylvania. He is also Director of the Wharton Center Dr. Weiner has a Bachelor of Arts Degree in Psychology,

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xvi Preface

a Master of Arts Degree in Organizational Psychology, and a lives. Through the five editions of this book, over the past
Doctor of Philosophy Degree in Organizational Psychology. twenty five years, they have helped educate a generation
of health services researchers, policy makers, managers,
and health professionals. We hope that the sixth edition
ACKNOWLEDGMENTS sustains the tradition of excellence that these gentlemen have
We believe that the major strength of this text is the diversity established.
of the talented authors, who contributed multiple perspectives, Finally, we wish to acknowledge Lauren Taylor and Rachelle
experiences, skills, and expertise to each chapter. The new and Alpern for their excellent editorial assistance.
substantially revised chapters reflect the breadth and depth Lawton Robert Burns
of the authors’ expertise, as well as their fresh perspectives. University of Pennsylvania
We wish to acknowledge with gratitude the immeasurable
contribution that Stephen Shortell and Arnold Kaluzny have Elizabeth H. Bradley
made in the fields of health care management research and Yale University
education. As scholars, advisors, mentors, and colleagues, Bryan Jeffrey Weiner
they have deeply influenced our work and our professional University of North Carolina at Chapel Hill

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 PART ONE

Introduction

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 Chapter 1
The Management Challenge of
Delivering Value in Health Care:
Global and U.S. Perspectives
Lawton Robert Burns, Elizabeth H. Bradley, and Bryan J. Weiner

CHAPTER OUTLINE
• The Challenge: Deliver Value
• Challenge of Rising Health Care Costs: Supply- and Demand-Side Drivers
• Other Challenges Exacerbating the Value Challenge
• Complexity of the U.S. Health Care System
• Why Changing the Health Care System Is So Difficult
• Systemic Views of U.S. Health Care
• Organization and Management Theory
• Summative Views of Organization Theory
• Organization Theory and Behavior: A Guide to This Text

LEARNING OBJECTIVES
After completing this chapter, the reader should be able to:
1. Understand the challenge of delivering value in health care
2. Identify the major forces affecting the delivery of health services
3. Distinguish the similarities and differences in the forces shaping health services globally
4. Understand why it is difficult to change the health care industry
5. Develop a system view of health care delivery
6. Understand the different types of firms operating in a health care system
7. Identify, understand, and apply the major perspectives and theories on organizations to real problems facing health
care organizations
8. Develop mental agility in analyzing problems from multiple theoretical lenses

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CHAPTER 1 • The Management Challenge of Delivering Value in Health Care: Global and U.S. Perspectives 3

KEY TERMS
Ambidexterity Iron Triangle
Bending the Cost Curve Macro Perspective
Bounded Rationality Micro Perspective
Bureaucracy Open Systems Theory
Classical School of Administration Population Ecology
Complex Adaptive System Resource Dependence Theory
Contingency Theory Scientific Management School
Decision-Making School Social Network Approach
Evidence-Based Medicine Strategic Management Perspective
External Environment System Perspectives
Health Systems Triple Aim
Hospital-Physician Relationships Value
Human Relations School Value Chain
Institutional Theory

IN PRACTICE: The GAVI Alliance

The Global Alliance for Vaccines and Immunization (GAVI) was launched at the World Economic Forum on January 31,
2000. GAVI was a partnership of developing countries, organizations involved in international development and finance,
the pharmaceutical industry, and philanthropic organizations. The Bill and Melinda Gates Foundation provided seed funding
of $750 million for GAVI, followed by funding from several countries. GAVI was established to improve the distribution of
new and underused vaccines to low-income countries and thereby reduce childhood mortality and morbidity, and increase
the health status of these populations (Martin and Marshall, 2003; Milstien et al., 2008; GAVI Alliance, 2010).
A number of managerial challenges faced the GAVI Alliance in achieving its goals. First, the vision of the GAVI Alliance
had to motivate local countries to participate in this vaccination program and gradually increase their own funding for it.
Second, local countries needed to accept the responsibility to deliver the vaccine programs and the attendant results. Third,
these countries had to help develop and manage local infrastructure to deliver the vaccines to rural populations—often
referred to as the last hundred yards or miles of the supply chain. This meant the countries needed not only transportation
and distribution networks but also a cadre of local health care workers with training in vaccine storage and administration.
Fourth, the GAVI Alliance had to manage diverse stakeholders including the World Health Organization (WHO), the World
Bank, UNICEF, large pharmaceutical firms that manufactured the vaccines, and the Gates Foundation. Fifth, the GAVI Alliance
had to operate with a lean structure such that bureaucracy did not slow its progress. Sixth, the alliance had to develop
leverage over pharmaceutical firms to purchase the needed drugs at a lower cost which local countries could afford. Last,
the GAVI Alliance needed a clear governance structure with defined responsibilities for partners.
Between 2000 and 2009, GAVI directly supported the immunization of 256.7 million children for Hepatitis B, Haemophilus
influenzae type B (Hib), and yellow fever. GAVI also speeded up population access to underused vaccines, strengthened
health and immunization systems, and helped spawn innovative public-private partnerships (PPPs) in financing to expand
vaccine coverage in 72 developing countries (GAVI Alliance, 2010). In January 2010, 10 years after the initiation of the GAVI
Alliance, The Gates Foundation committed an additional $10 billion over the next 10 years.

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4 PART 1 • Introduction

IN PRACTICE: The GAVI Alliance (Continued)

Despite its success, GAVI has not been without its problems. Although the alliance necessarily focused heavily on
developing partnerships and initiating vaccine coverage, less attention was paid to implementation of plans and mobilization
of resources for ongoing treatment (in-country follow-up). One reason may be that vaccine costs have risen both absolutely
and as a percentage of the total health expenditures, and vaccinations may not be the top priority of developing-country
governments (Milstien et al., 2008; Muraskin, 2004). Finally, the alliance partners need to grapple with the large supply chain
“system costs” required to handle, transport, and store the drugs (Lydon et al., 2008) and the issue of securing long-term
financial commitments from its partners.

CHAPTER PURPOSE managing change, forging strategic plans and leadership) are
critical components of the manager’s “tool kit” in any health
A central challenge in delivering health care services in the care system.
new millennium is the challenge of delivering value. Value is
created when additional features of quality or customer service
desired by a customer can be provided at the same cost or THE CHALLENGE:
price, or when a given set of features of quality or customer DELIVER VALUE
service can be delivered at a lower cost or price relative to other
producers. Although investments in health care delivery can The key challenge facing health care firms is to deliver value,
improve health status, which in turn can support economic defined as the quotient of quality divided by cost. That is,
growth and political stability (Burns, D’Aunno, and Kimberly, firms are asked to deliver a higher level of quality at the same
2003; Esty et al., 1999; Sachs, 2001), still the value of health cost, the same level of quality at a lower cost, or higher
investments are not always transparent. For instance, despite quality at a lower cost. This challenge has been proposed to
evidence of the benefits of immunization coverage (Martin (a) providers, in the form of accountable care organizations
and Marshall, 2003; World Health Organization, 1996) (ACOs) and pay-for-performance, (b) suppliers, in the form of
and a steady increase globally during the 1970s and 1980s, demonstrating the comparative clinical effectiveness of their
immunization coverage declined sharply in the 1990s due to products (versus alternate therapies), and (c) insurers and
curtailed government funding in low-income countries. The providers, in the form of value-based purchasing.
GAVI Alliance entered in 2000 and, during its first 10 years, In order to create and deliver value, health care organizations
averted four million deaths and immunized a quarter of a must find a way to address three health policy goals of our
billion children against deadly or disabling diseases (GAVI health care system since the late 1920s: improve the quality
Alliance, 2010). of care, improve access to care, and reduce cost and cost
Why was this approach not already taken? To effect major acceleration—e.g., bending the cost curve, or the reducing
changes in health care delivery and increase value, as the GAVI of health spending relative to projected trends (Commonwealth
Alliance has, organizations require extraordinary approaches. Fund, 2007a).
Such approaches critically hinge on several management Numerous health services researchers have questioned
competencies. These include assembling (global) alliances, whether all three goals are simultaneously attainable (Chen, Jha,
clarifying the governance structure of the alliance, developing Guterman et al., 2010; Katz, 2010) or require a balancing act
the local health care infrastructure to deliver the needed (Berwick et al., 2008). The achievement of these three goals
services, balancing global and local commitments, and is sometimes referred to as the iron triangle of health care
developing local ownership of health initiatives. Managerial (Kissick, 1994). Picture an equilateral triangle, with three equal
skills (including but not limited to developing alliances, angles of 60 degrees, and assume that each angle is one of
negotiating governance and roles, conflict management, these three policy goals. Any effort to address one policy angle

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CHAPTER 1 • The Management Challenge of Delivering Value in Health Care: Global and U.S. Perspectives 5

widens that angle (e.g., access) at the expense of one or both Health costs in the United States have been rising at roughly
of the other two angles (e.g., quality or cost). For example, 3–4 percent annually (net of inflation) for the past six
the recent health insurance reform in the United States— decades (Altman, 2010). Some have argued that public and
the Patient Protection and Affordable Care Act—expands private sector efforts work to temporarily rein in this rate of
insurance coverage to 30 million citizens, but its savings will increase, only to see the cost escalation return (Altman and
reportedly be more than offset by higher expenditures (and Levitt, 2002).
escalating costs) resulting from the expansion of coverage Why do costs rise inexorably? Many experts argue that
(CMS, 2010). the underlying driver of rising costs is technology and its
Provider organizations in the health care industry have broad application to new patients and patient indications
nevertheless been periodically challenged to accomplish (Aaron and Ginsburg, 2009; Commonwealth Fund, 2007b;
the quality and cost goals at the same time. In July 2009, Congressional Budget Office, 2008). Following Weisbrod
providers from 10 U.S. markets convened in Washington to (1991), technological improvements spur higher prices,
discuss how they deliver care to the Medicare population higher demand, and higher costs—all of which call for
that is above average in quality and below average in cost, greater insurance coverage for the new technology, which
compared with national data contained in the Dartmouth then drives further technological innovation. Technology
Atlas (Institute for Healthcare Improvement, 2009). In contributes to rising costs in other ways. In contrast
past decades, providers have been asked to demonstrate a to other industries, health care technology is often a
similar value (quality/cost) proposition using a series of complement rather than a substitute for labor—e.g.,
management techniques, such as total quality management requiring many technicians to utilize the new equipment.
(e.g., reducing process variation and simultaneously raising Moreover, providers often compete for patients based on
the level of process performance), supply chain management the sophistication of the services and equipment they offer,
(e.g., standardizing products to achieve consistency in use leading to expensive excess capacity and duplication in a
and lower unit cost), and clinical integration (standardizing local market (“technology wars”). Insurance is another driver
care paths and protocols to reduce clinical practice variations of rising costs, as broader coverage (e.g., for more people, or
and improve quality of care). In this past decade, the Institute more benefits) increases demand and thus health spending,
of Medicine (2001) articulated six “aims for improvement” in as well as the attendant problem of moral hazard (Arrow,
a high-performing health care system: care should be safe, 1963) whereby the insured utilize more health care than they
effective, patient-centered, timely, efficient, and equitable. would if they paid for services out of pocket (i.e., from their
The balancing of broad health policy goals is apparent on a own resources without insurance).
global scale as well. The World Health Organization (WHO, There are several supply- and demand-side drivers of
2000) uses three criteria to rank national health systems: rising health costs. On the supply side, costs are driven
health status (similar to quality), responsiveness to the by imperfect information markets whereby purchasers and
expectations of the population (similar to access), and social consumers of health care are not able to discern quality
and financial risk protection (similar to cost). differences perfectly among health care providers, make few
repeat purchases, and enjoy less transparency of pricing,
which allows great variation in the economic rents earned
CHALLENGE OF RISING by providers of the same product or service. Such rents also
HEALTH CARE COSTS: result from provider market power. Costs are also driven in
SUPPLY- AND DEMAND- part by providers’ practice of defensive medicine, providers’
focus on acute rather than chronic care or prevention, and
SIDE DRIVERS poor coordination of services among providers. Finally, costs
One reason why the health system is challenged to deliver are driven by geographic variations in the supply of hospital
value is that the denominator—health costs—has been beds and specialist physicians, which may induce demand
rising steadily over time and proven difficult to restrain. (Roemer, 1961).

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6 PART 1 • Introduction

GEOGRAPHIC VARIATION IN HEALTH CARE SPENDING:

A CLOSER LOOK
Health care expenditures in the United States have been rising for years, but per capita spending on health care varies
widely across the country. In 2004, for example, Medicare expenditures per beneficiary ranged from roughly $4,000
in Utah to $6,700 in Massachusetts. Even greater differences appear in comparisons of smaller geographic units and
individual medical providers. Some estimate that Medicare spending would decrease by 29 percent if spending in medium-
and high-spending areas matched spending in low-spending areas (Wennberg, Fisher, and Skinner, 2002).
Why does health care spending vary so much across the country? The reasons are complex and difficult to tease apart.
Differences in prices of health care services and severity of illness play an important role, but together these factors account
for only half of the geographic variation in spending. Regional differences in the supply of specialist physicians and health
care facilities are also thought to play a role. Regional differences in provider willingness to adopt new technologies or
provide costly treatments that might or might not improve health care outcomes are also thought to increase costs.
Scholars and policy makers looking to slow the rate of growth in health care expenditures (“bend the cost curve”) point to
organized delivery systems that focus on coordinated care and prevention as a promising way to reduce the costs associated
with the efficiencies, misaligned incentives, and poor quality attributed to the highly fragmented nature of the health care
system that currently exists in the United States. In his efforts to promote health reform, for example, President Barack Obama
praised the Mayo Clinic in Minnesota and the Cleveland Clinic in Ohio as examples of hospitals providing the highest-quality
care at costs well below the national norm, and suggested that all providers in the country practice their type of medicine.

DEBATE TIME: Defensive Medicine

Do physicians order unnecessary tests out of fear of being sued by patients? If so, how much does “defensive medicine”
contribute to the escalating costs of medical care in the United States? These issues are hotly debated. On the one hand,
physicians practicing in high-liability specialties like obstetrics report that they routinely order more tests than are medically
necessary in order to reduce the risk that they will end up in court (Studdert et al, 2005). In a recent Wall Street Journal
article, a physician noted, “Doctors get sued for failure to diagnose and not ordering tests… It’s something that I do think
about and in some cases it does influence my decision” (Searcey and Goldstein 2009). Pointing to escalating malpractice
insurance premiums, some professional associations and lawmakers argue that significant cost savings could be achieved in
the U.S. health care system through the passage and enactment of tort reform (e.g., limiting the size of malpractice liability
awards). Others, however, argue that defensive medicine and malpractice liability do not contribute significantly to overall
health care costs. According to a recent study, total spending on medical malpractice was $30 billion in 1997, a substantial
amount to be sure, but less than 1 percent of total U.S. health care spending (Towers Perrin, 2008). Estimating the cost of
defensive medicine is especially difficult because physicians order tests and procedures for many reasons that are difficult to
disentangle. For example, fear of being sued can be mixed with the desire to provide the best care possible. Also, physicians
can increase their incomes by ordering more tests and performing more procedures.
What do you think?
• How much defensive medicine occurs? How much do you think it contributes to health care spending? What,
if anything, should be or could be done about it? What are the costs and benefits of the strategies you propose?
• Medical malpractice liability insurance is increasing at an alarming rate for some specialties and in some states.
What, if anything, should or could be done about it? What are the costs and benefits of the strategies you propose?

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CHAPTER 1 • The Management Challenge of Delivering Value in Health Care: Global and U.S. Perspectives 7

On the demand side, costs are driven by the tax-free else pays for it. Another axiom following from the technological
treatment of health care benefits (which contributes to imperative is that cost and price are the key issues germane to
richer health benefit packages and induces moral hazard), all parties. Indeed, the one issue that currently unites the entire
as well as public and private sector financing of health care value chain in health care is reimbursement; many analysts
through a third-party payment system of insurers and other anticipate that it will be the patient/consumer that unites the
fiscal intermediaries outside the patient-provider relationship. chain in the future. Finally, technological innovation and its
Favorable tax treatment and a third-party payer system attendant costs spur the spread of insurance coverage for such
combine to insulate the consumer/patient from the true cost innovation, which increases spending on innovation, which
of the health care services they demand. In addition, demand fuels yet more innovation (Weisbrod, 1991).
is driven by a country’s national wealth, the expectations of
its population, the highly technological nature of health care OTHER CHALLENGES
services, and the health behaviors of its population. These
supply and demand drivers are listed in Table 1.1.
EXACERBATING THE
There are a handful of axioms governing the demand side
VALUE CHALLENGE
of this vast system that may be peculiar to health care. The Complicating the difficulty of providing value, health care
first is that technological innovations and their application are systems face a number of other challenges. These include:
desired by providers, desired by patients, and drivers of rising increasing patient demand and expectations, increasing
health care costs (“the technological imperative”) (Fuchs, payer and societal demands for accountability, unexpected
1986; Gelijns and Rosenberg, 1994). A second axiom is that epidemiological shifts, calls for greater patient safety, increasing
technology drives specialization in the medical (and nursing) complexity, strains on federal and state government budgets,
field, which further drives up health care costs. A third axiom inadequate supply of primary care practitioners, reported
is that every citizen deserves the finest health care now made shortages of specialists and other health personnel, erosion
available by these technological developments (often defined as of the public’s trust in physicians and hospitals, growing
the product or service offered by my firm) as long as someone concerns over privacy of personal health information, lack

TABLE 1.1 Supply- and Demand-Side Drivers of Health Costs

Supply-Side Drivers Demand-Side Drivers
Imperfect information regarding price and quality Tax treatment of health care benefits
Provider market power Third-party payment system
Non-price competition (e.g., technology wars) Breadth and depth of insurance coverage
Technology and its diffusion Moral hazard
Geographic variations Rising national income
Poor coordination among providers Poor healthy behaviors
Private sector financing of care, which supplements
Fee-for-service payment systems public spending, encourages greater coverage, and may
promote cost-shifting
Excess capacity
Acute care focus of delivery system
Limited primary care
Malpractice fears and pressures

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 BLACK CURRANT JAM AND MARMALADE.

No fruit jellies so easily as black currants when they are ripe; and
their juice is so rich and thick that it will bear the addition of a very
small quantity of water sometimes, without causing the preserve to
mould. When the currants have been very dusty, we have
occasionally had them washed and drained before they were used,
without any injurious effects. Jam boiled down in the usual manner
with this fruit is often very dry. It may be greatly improved by taking
out nearly half the currants when it is ready to be potted, pressing
them well against the side of the preserving-pan to extract the juice:
this leaves the remainder far more liquid and refreshing than when
the skins are all retained. Another mode of making fine black currant
jam—as well as that of any other fruit—is to add one pound at least
of juice, extracted as for jelly, to two pounds of the berries, and to
allow sugar for it in the same proportion as directed for each pound
of them.
For marmalade or paste, which is most useful in affections of the
throat and chest, the currants must be stewed tender in their own
juice, and then rubbed through a sieve. After ten minutes’ boiling,
sugar in fine powder must be stirred gradually to the pulp, off the fire,
until it is dissolved: a few minutes more of boiling will then suffice to
render the preserve thick, and it will become quite firm when cold.
More or less sugar can be added to the taste, but it is not generally
liked very sweet.
Best black currant jam.—Currants, 4 lbs.; juice of currants, 2 lbs.:
15 to 20 minutes’ gentle boiling. Sugar, 3 to 4 lbs.: 10 minutes.
Marmalade, or paste of black currants.—Fruit, 4 lbs.: stewed in its
own juice 15 minutes, or until quite soft. Pulp boiled 10 minutes.
Sugar, from 7 to 9 oz. to the lb.: 10 to 14 minutes.
Obs.—The following are the receipts originally inserted in this
work, and which we leave unaltered.
To six pounds of the fruit, stripped carefully from the stalks, add
four pounds and a half of sugar. Let them heat gently, but as soon as
the sugar is dissolved boil the preserve rapidly for fifteen minutes. A
more common kind of jam may be made by boiling the fruit by itself
from ten to fifteen minutes, and for ten minutes after half its weight of
sugar has been added to it.
Black currants, 6 lbs.; sugar, 4-1/2 lbs.: 15 minutes. Or: fruit, 6 lbs.:
10 to 15 minutes. Sugar, 3 lbs.: 10 minutes.
Obs.—There are few preparations of fruit so refreshing and so
useful in illness as those of black currants, and it is therefore
advisable always to have a store of them, and to have them well and
carefully made.
 NURSERY PRESERVE.

Take the stones from a couple of pounds of Kentish cherries, and

boil them twenty minutes; then add to them a pound and a half of
raspberries, and an equal quantity of red and of white currants, all
weighed after they have been cleared from their stems. Boil these
together quickly for twenty minutes; mix with them three pounds and
a quarter of common sugar, and give the preserve fifteen minutes
more of quick boiling. A pound and a half of gooseberries may be
substituted for the cherries; but they will not require any stewing
before they are added to the other fruits. The jam must be well
stirred from the beginning, or it will burn to the pan.
Kentish cherries, 2 lbs.: 20 minutes. Raspberries, red currants,
and white currants, of each 1-1/2 lb.: 20 minutes. Sugar, 3-1/4 lbs.:
15 minutes.
 ANOTHER GOOD COMMON PRESERVE.

Boil together, in equal or unequal portions (for this is immaterial),

any kinds of early fruit, until they can be pressed through a sieve;
weigh, and then boil the pulp over a brisk fire for half an hour; add
half a pound of sugar for each pound of fruit, and again boil the
preserve quickly, keeping it well stirred and skimmed, from fifteen to
twenty minutes. Cherries, unless they be morellas, must first be
stewed tender apart, as they will require a much longer time to make
them so than any other of the first summer fruits.
 A GOOD MÉLANGE, OR MIXED PRESERVE.

Boil for three-quarters of an hour in two pounds of clear red

gooseberry juice, one pound of very ripe greengages, weighed after
they have been pared and stoned; then stir to them one pound and a
half of good sugar, and boil them quickly again for twenty minutes. If
the quantity of preserve be much increased, the time of boiling it
must be so likewise: this is always better done before the sugar is
added.
Juice of ripe gooseberries, 2 lbs.; greengages, pared and stoned,
1 lb.: 3/4 hour. Sugar, 1-1/2 lb.: 20 minutes.
 GROSEILLÉE.

(Another good preserve.)

Cut the tops and stalks from a gallon or more of well-flavoured ripe
gooseberries, throw them into a large preserving-pan, boil them for
ten minutes, and stir them often with a wooden spoon; then pass
both the juice and pulp through a fine sieve, and to every three
pounds’ weight of these add half a pint of raspberry-juice, and boil
the whole briskly for three-quarters of an hour; draw the pan aside,
stir in for the above portion of fruit, two pounds of sugar, and when it
is dissolved renew the boiling for fifteen minutes longer. Ripe
gooseberries, boiled 10 minutes. Pulp and juice of gooseberries, 6
lbs.; raspberry-juice, 1 pint: 3/4 hour. Sugar, 4 lbs.: 15 minutes.
Obs.—When more convenient, a portion of raspberries can be
boiled with the gooseberries at first.
 SUPERIOR PINE-APPLE MARMALADE.

(A New Receipt.)
The market-price of our English pines is generally too high to
permit their being very commonly used for preserve; and though
some of those imported from the West Indies are sufficiently well-
flavoured to make excellent jam, they must be selected with
judgment for the purpose, or they will possibly not answer for it. They
should be fully ripe, but perfectly sound: should the stalk end appear
mouldy or discoloured, the fruit should be rejected. The degree of
flavour which it possesses may be ascertained with tolerable
accuracy by its odour; for if of good quality, and fit for use, it will be
very fragrant. After the rinds have been pared off, and every dark
speck taken from the flesh, the pines may be rasped on a fine and
delicately clean grater, or sliced thin, cut up quickly into dice, and
pounded in a stone or marble mortar; or a portion may be grated,
and the remainder reduced to pulp in the mortar. Weigh, and then
heat and boil it gently for ten minutes; draw it from the fire, and stir to
it by degrees fourteen ounces of sugar to the pound of fruit; boil it
until it thickens and becomes very transparent, which it will be in
about fifteen minutes, should the quantity be small: it will require a
rather longer time if it be large. The sugar ought to be of the best
quality and beaten quite to powder; and for this, as well as for every
other kind of preserve, it should be dry. A remarkably fine
marmalade may be compounded of English pines only, or even with
one English pine of superior growth, and two or three of the West
Indian mixed with it; but all when used should be fully ripe, without at
all verging on decay; for in no other state will their delicious flavour
be in its perfection.
In making the jam always avoid placing the preserving-pan flat
upon the fire, as this of itself will often convert what would otherwise
be excellent preserve, into a strange sort of compound, for which it is
difficult to find a name, and which results from the sugar being
subjected—when in combination with the acid of the fruit—to a
degree of heat which converts it into caramel or highly-boiled barley-
sugar. When there is no regular preserving-stove, a flat trivet should
be securely placed across the fire of the kitchen-range to raise the
pan from immediate contact with the burning coals, or charcoal. It is
better to grate down, than to pound the fruit for the present receipt
should any parts of it be ever so slightly tough; and it should then be
slowly stewed until quite tender before any sugar is added to it; or
with only a very small quantity stirred in should it become too dry. A
superior marmalade even to this, might probably be made by adding
to the rasped pines a little juice drawn by a gentle heat, or expressed
cold, from inferior portions of the fruit; but this is only supposition.
 A FINE PRESERVE OF THE GREEN ORANGE PLUM.

(Sometimes called the Stonewood plum.)

This fruit, which is very insipid when ripe, makes an excellent
preserve if used when at its full growth, but while it is still quite hard
and green. Take off the stalks, weigh the plums, then gash them well
(with a silver knife, if convenient) as they are thrown into the
preserving-pan, and keep them gently stirred without ceasing over a
moderate fire, until they have yielded sufficient juice to prevent their
burning; after this, boil them quickly until the stones are entirely
detached from the flesh of the fruit. Take them out as they appear on
the surface, and when the preserve looks quite smooth and is well
reduced, stir in three-quarters of a pound of sugar beaten to a
powder, for each pound of the plums, and boil the whole very quickly
for half an hour or more. Put it, when done, into small moulds or
pans, and it will be sufficiently firm when cold to turn out well: it will
also be transparent, of a fine green colour, and very agreeable in
flavour.
Orange plums, when green, 6 lbs.: 40 to 60 minutes. Sugar, 4-1/2
lbs.: 30 to 50 minutes.
Obs.—The blanched kernels of part of the fruit should be added to
this preserve a few minutes before it is poured out: if too long boiled
in it they will become tough. They should always be wiped very dry
after they are blanched.
 GREENGAGE JAM, OR MARMALADE.

When the plums are thoroughly ripe, take off the skins, stone,
weigh, and boil them quickly without sugar for fifty minutes, keeping
them well stirred; then to every four pounds add three of good sugar
reduced quite to powder, boil the preserve from five to eight minutes
longer, and clear off the scum perfectly before it is poured into the
jars. When the flesh of the fruit will not separate easily from the
stones, weigh and throw the plums whole into the preserving-pan,
boil them to a pulp, pass them through a sieve, and deduct the
weight of the stones from them when apportioning the sugar to the
jam. The Orleans plum may be substituted for greengages in this
receipt.
Greengages, stoned and skinned, 6 lbs.: 50 minutes. Sugar, 4-1/2
lbs.: 5 to 8 minutes.
 PRESERVE OF THE MAGNUM BONUM, OR MOGUL PLUM.

Prepare, weigh, and boil the plums for forty minutes; stir to them
half their weight of good sugar beaten fine, and when it is dissolved
continue the boiling for ten additional minutes, and skim the preserve
carefully during the time. This is an excellent marmalade, but it may
be rendered richer by increasing the proportion of sugar. The
blanched kernels of a portion of the fruit stones will much improve its
flavour, but they should be mixed with it only two or three minutes
before it is taken from the fire. When the plums are not entirely ripe,
it is difficult to free them from the stones and skins: they should then
be boiled down and pressed through a sieve, as directed for
greengages, in the receipt above.
Mogul plums, skinned and stoned, 6 lbs.: 40 minutes. Sugar, 3
lbs.: 5 to 8 minutes.
 TO DRY OR PRESERVE MOGUL PLUMS IN SYRUP.

Pare the plums, but do not remove the stalks or stones; take their
weight of dry sifted sugar, lay them into a deep dish or bowl, and
strew it over them; let them remain thus for a night, then pour them
gently into a preserving-pan with all the sugar, heat them slowly, and
let them just simmer for five minutes; in two days repeat the process,
and do so again and again at an interval of two or three days, until
the fruit is tender and very clear; put it then into jars, and keep it in
the syrup, or drain and dry the plums very gradually, as directed for
other fruit. When they are not sufficiently ripe for the skin to part from
them readily, they must be covered with spring water, placed over a
slow fire, and just scalded until it can be stripped from them easily.
They may also be entirely prepared by the receipt for dried apricots
which follows, a page or two from this.
 MUSSEL PLUM CHEESE AND JELLY.

Fill large stone jars with the fruit, which should be ripe, dry, and
sound; set them into an oven from which the bread has been drawn
several hours, and let them remain all night; or, if this cannot
conveniently be done, place them in pans of water, and boil them
gently until the plums are tender, and have yielded their juice to the
utmost. Pour this from them, strain it through a jelly bag, weigh, and
then boil it rapidly for twenty-five minutes. Have ready, broken small,
three pounds of sugar for four of the juice, stir them together until it is
dissolved, and then continue the boiling quickly for ten minutes
longer, and be careful to remove all the scum. Pour the preserve into
small moulds or pans, and turn it out when it is wanted for table: it
will be very fine, both in colour and in flavour.
Juice of plums, 4 lbs.: 25 minutes. Sugar, 3 lbs.: 10 minutes.
The cheese.—Skin and stone the plums from which the juice has
been poured, and after having weighed, boil them an hour and a
quarter over a brisk fire, and stir them constantly; then to three
pounds of fruit add one of sugar, beaten to powder; boil the preserve
for another half hour, and press it into shallow pans or moulds.
Plums, 3 lbs.: 1-1/4 hour. Sugar, 1 lb.: 30 minutes.
 APRICOT MARMALADE.

This may be made either by the receipt for greengage, or Mogul

plum marmalade; or the fruit may first be boiled quite tender, then
rubbed through a sieve, and mixed with three-quarters of a pound of
sugar to the pound of apricots: from twenty to thirty minutes will boil
it in this case. A richer preserve still is produced by taking off the
skins, and dividing the plums in halves or quarters, and leaving them
for some hours with their weight of fine sugar strewed over them
before they are placed on the fire; they are then heated slowly and
gently simmered for about half an hour.
 TO DRY APRICOTS.

(A quick and easy method.)

Wipe gently, split, and stone some fine apricots which are not
over-ripe; weigh, and arrange them evenly in a deep dish or bowl,
and strew in fourteen ounces of sugar in fine powder, to each pound
of fruit; on the following day turn the whole carefully into a
preserving-pan, let the apricots heat slowly, and simmer them very
softly for six minutes, or for an instant longer, should they not in that
time be quite tender. Let them remain in the syrup for a day or two,
then drain and spread them singly on dishes to dry.
To each pound of apricots, 14 oz. of sugar; to stand 1 night, to be
simmered from 6 to 8 minutes, and left in syrup 2 or 3 days.
 DRIED APRICOTS.

(French Receipt.)
Take apricots which have attained their full growth and colour, but
before they begin to soften; weigh, and wipe them lightly; make a
small incision across the top of each plum, pass the point of a knife
through the stalk end, and gently push out the stones without
breaking the fruit; next, put the apricots into a preserving-pan, with
sufficient cold water to float them easily; place it over a moderate
fire, and when it begins to boil, should the apricots be quite tender,
lift them out and throw them into more cold water, but simmer them,
otherwise, until they are so. Take the same weight of sugar that there
was of the fruit before it was stoned, and boil it for ten minutes with a
quart of water to the four pounds; skim the syrup carefully, throw in
the apricots (which should previously be well drained on a soft cloth,
or on a sieve), simmer them for one minute, and set them by in it
until the following day, then drain it from them, boil it for ten minutes,
and pour it on them the instant it is taken from the fire; in forty-eight
hours repeat the process, and when the syrup has boiled ten
minutes, put in the apricots, and simmer them from two to four
minutes, or until they look quite clear. They may be stored in the
syrup until wanted for drying, or drained from it, laid separately on
slates or dishes, and dried very gradually: the blanched kernels may
be put inside the fruit, or added to the syrup.
Apricots, 4 lbs., scalded until tender; sugar 4 lbs.; water, 1 quart:
10 minutes. Apricots, in syrup, 1 minute; left 24 hours. Syrup, boiled
again, 10 minutes, and poured on fruit: stand 2 days. Syrup, boiled
again, 10 minutes, and apricots 2 to 4 minutes, or until clear.
Obs.—The syrup should be quite thick when the apricots are put in
for the last time; but both fruit and sugar vary so much in quality and
in the degree of boiling which they require, that no invariable rule can
be given for the latter. The apricot syrup strained very clear, and
mixed with twice its measure of pale French brandy, makes an
agreeable liqueur, which is much improved by infusing in it for a few
days half an ounce of the fruit-kernels, blanched and bruised, to the
quart of liquor.
We have found that cherries prepared by either of the receipts
which we have given for preserving them with sugar, if thrown into
the apricot syrup when partially dried, just scalded in it, and left for a
fortnight, then drained and dried as usual, become a delicious
sweetmeat. Mussel, imperatrice, or any other plums, when quite ripe,
if simmered in it very gently until they are tender, and left for a few
days to imbibe its flavour, then drained and finished as usual, are
likewise excellent.
 PEACH JAM, OR MARMALADE.

The fruit for this preserve, which is a very delicious one, should be
finely flavoured, and quite ripe, though perfectly sound. Pare, stone,
weigh, and boil it quickly for three-quarters of an hour, and do not fail
to stir it often during the time; draw it from the fire, and mix with it ten
ounces of well-refined sugar, rolled or beaten to powder, for each
pound of the peaches; clear it carefully from scum, and boil it briskly
for five minutes; throw in the strained juice of one or two good
lemons; continue the boiling for three minutes only, and pour out the
marmalade. Two minutes after the sugar is stirred to the fruit, add
the blanched kernels of part of the peaches.
Peaches, stoned and pared, 4 lbs.; 3/4 hour. Sugar, 2-1/2 lbs.: 2
minutes. Blanched peach-kernels: 3 minutes. Juice of 2 small
lemons: 3 minutes.
Obs.—This jam, like most others, is improved by pressing the fruit
through a sieve after it has been partially boiled. Nothing can be finer
than its flavour, which would be injured by adding the sugar at first;
and a larger proportion renders it cloyingly sweet. Nectarines and
peaches mixed, make an admirable preserve.
 TO PRESERVE, OR TO DRY PEACHES OR NECTARINES.

(An easy and excellent Receipt.)

The fruit should be fine, freshly gathered, and fully ripe, but still in
its perfection. Pare, halve, and weigh it after the stones are removed;
lay it into a deep dish, and strew over it an equal weight of highly
refined pounded sugar; let it remain until this is nearly dissolved,
then lift the fruit gently into a preserving-pan, pour the juice and
sugar to it, and heat the whole over a very slow fire; let it just simmer
for ten minutes, then turn it softly into a bowl, and let it remain for two
days; repeat the slow heating and simmering at intervals of two or
three days, until the fruit is quite clear, when it may be potted in the
syrup, or drained from it, and dried upon large clean slates or dishes,
or upon wire-sieves. The flavour will be excellent. The strained juice
of a lemon may be added to the syrup, with good effect, towards the
end of the process, and an additional ounce or two of sugar allowed
for it.
 DAMSON JAM. (VERY GOOD.)

The fruit for this jam should be freshly gathered and quite ripe.
Split, stone, weigh, and boil it quickly for forty minutes; then stir in
half its weight of good sugar roughly powdered, and when it is
dissolved, give the preserve fifteen minutes additional boiling,
keeping it stirred, and thoroughly skimmed.
Damsons, stoned, 6 lbs.: 40 minutes. Sugar, 3 lbs.: 15 minutes.
Obs.—A more refined preserve is made by pressing the fruit
through a sieve after it is boiled tender; but the jam is excellent
without.