How Does One Get Five Very Different Suitors to the Table?

What forces would lead five fiercely independent and competitive teaching hospitals to talk about cooperation?

The answer depends on whom you ask.

Pam E. Lawrence, director of communications for New England Deaconess Hospital, looks at the positive potential of coordination. "People and hospitals working together can assure better access and value in the health care system," Lawrence says.

A joint statement released by the hospitals and Medical School Dean Daniel C. Tosteson '44 puts the emphasis on necessity.

"With our leadership responsibilities in patient care, research and education, our institutions have a special obligation to the community to maintain and improve the quality of what we do, while significantly reducing our costs. We believe this will not be possible in the coming years without closer coordination," the statement says.

Harvard Provost Jerry R. Green, a former chair of the Harvard economics department, frames the issue in economic terms. "Anything which is good for economic efficiency in the delivery of medical care is going to be good for the whole Boston area, not just Harvard," he says. "Maybe we can get some more coordination, and get some aspects of medical service in some hospitals and not others and avoid duplication."

But it is Nancy M. Kane, assistant professor of health policy and management at the Harvard School of Public Health, who is not a party to the discussions and is thus perhaps the most willing to offer an unvarnished view of what motivated them.

"You don't do this unless someone is really burning your toes off"," Kane says.

Kane says the hospital leadership realized they had a choice between continuing to "fight with each other over a shrinking patient care pie," or trying to cooperate. The fighting would be expensive, and some hospitals might close, she says.

Technological advances have meant that patients spend less time overnight in hospitals, Kane says.

Declining birth rates have also adversely affected the obstetrics area, where there is fierce competition between Brigham and Women's Mass. General, and Beth Israel hospitals. And pressure from insurers have, led doctors and patients to move toward less costly outpatient care, she says.

The result is overcapacity--something similar to what would happen if three different developers all built huge shopping mails right next to each other.

In the absence of some sweeping new epidemic, a population boom or a technological leap backward, these pressures are likely to continue.

And while they can make life at the top of a Harvard teaching hospital difficult, they may also be the spur to the kind of value savings that everyone hopes foc.

Marion B. Gammill contributed to the reporting of this story.