Building a healthier community is clearly the job of every person and institution in healthcare. Yet just as clearly, it is not a job that we can do. The community must do it.
Somehow healthcare institutions must become catalysts, provoking changes far beyond our campuses, calling forth energies far greater than our own. To do that we have to find partners throughout our communities, from the other great institutions, companies, and arms of government, to community action groups, service clubs, churches, special interest groups, and even the clients of social service agencies. But the place to start is with each other, making partners out of other people and institutions in the healthcare world.
How do you build those partnerships? How do you effectively call up the energies of the community, of other organizations, even of competing organizations, to build a healthier community? What are the key elements that allow true partnership to work?
We talked to scores of people across the country -- healthcare executives, hospital trustees, public health leaders, and physicians. Sifting through their experiences, we found a surprising coherence in the themes that emerged. They were:
1. A passion for connection
2. A ground-up, informal flow of information
3. A shared vision
4. A specific opportunity
5. The generosity to share or give away both credit and decision-making power.
John Lewin, M.D., Director of Hawaii's Department of Health, insists that building a healthy community is not something any one group can do alone: "Hospitals can't do it. Business can't do it. The schools can't do it. Government can't do it. But together we can." And we will have to: "We are moving into a new paradigm in which we increasingly share the risk, because our funds are capitated. This means we will all do better when we can raise the health of the entire community." This passion for connection is "part of our understanding of what our civilization is becoming."
But the passion for connection is only just beginning to wake up even within the health care industry.
Last year, for instance, John King, president and CEO of Portland's Legacy Health System, sat down to lunch with John Lee, president of the Sisters of Providence. King and Lee each held about one quarter of the managed care market -- in an area in which 75 to 80 percent of the non-Medicare population, and 50 percent of the Medicare population, is in managed care of one kind or another. Out of that lunch came one important idea -- King and Lee would get together with the head of Kaiser (which controlled another quarter of the market), the head of the Oregon State University Medical School, and the head of Oregon Blue Cross.
"We five knew each other pretty well," says King, "and we have a common problem. The public sees the empty beds, and the high-tech wars. We have all this technology and brick and mortar lying around." Over time, working alone as well as with the state healh department and the executive of the county medical society, they worked out a "collaborative/competitive" model. Basically, "We agreed to compete in primary and secondary care, but collaborate on tertiary care, on community health, and on improving the health status of the population." This June, the group incorporated as Oregon Health Systems In Collaboration.
When the group decided that their first project would be improving the state's immunization rate, the state health authorities were "very happy," says King. The state had adopted the "Health 2000" public health goals, and given the state health department the charge of carrying them out -- without increasing their resources to match the task. But two years into the project, they had not called the providers to ask for help. "It had never occurred to them that we would even be interested," says King.
San Diego, California, has some traditions of collaboration that go back for years. Kaiser, for instance, does all of its cardiac catheterization work in Scripps Health System facilities -- and Scripps surgeons do all of Kaiser's cardiac work, under a contract that's a decade old. Similarly, San Diego's widely-admired and highly sophisticated trauma system is a shared asset of all the providers in the area. This is a sharp contrast from the situation in nearby Los Angeles, where one trauma center after another has closed, because hospitals cannot afford individually to shoulder the burden -- and ambulance EMTs must do long, frantic radio searches to find a hospital that can take a critical patient.
So perhaps it is not so strange that Scripps and Sharp HealthCare-- traditionally strong competitors -- have signed an agreement to share facilities. A. Bruce Campbell, Ph.D., M.D., FACP, vice president of medical programs at Scripps, says, "We determined that certain facilities, such as MRI, urgent care facilities, and ambulatory surgery, weren't economically justified for both of us in certain areas. We decided not to be the traditional lemmings running off the cliff of competition." The slate of facilities to be shared is still open. In the future the sharing may spread to more ambitious projects, such as the development of the hardware and software of information infrastructure.
In Manchester, New Hampshire, that passion for connection has taken two hospitals much farther: from bitter rivalry and litigation to cooperation, and finally to the beginnings of merger. When Scott Goodspeed became acting CEO of Elliot Hospital in the fall of 1989, he was only 35. He had been senior vice president and COO for three years already, three years in which the competitive pressures of the 1980s had gotten out of hand between the century-old, top-quality Elliot and its rival, Catholic Medical Center. The rivalry went far beyond marketing slogans ("We're committed to excellence" and "We deliver genuine health care"). The medical arms race was in full swing. Every change in service required a state certificate of need, and each hospital vigorously opposed the other on every CON. In 1987 and 1988 the two systems fell to litigating over who got the CONs for cardiac catheterization and cardiac surgery.
Then something changed. "I know this will sound corny," says Goodspeed, "but it's true. Soon after I became acting CEO I attended a THF forum where they talked about building healthier communities. That stuck in my gut, and I brought it back to my community. I knew, I could feel, that the community recognized that we were very good at optimizing the pieces -- but not at putting the whole together."
At the same moment, a new CEO had taken over at Catholic. Sylvio Dupuis was two decades older than Goodspeed, and very well-connected, as former mayor of Manchester and state commissioner of Health and Human Services. "I felt the pulse of the community," says Dupuis. "They were tired of the fighting and the marketing."
He had identified a serious obstacle to healthier communities: the competitive business atmosphere in which many hospitals find themselves.
Strategies: find areas of cooperation, lower the decibel level, engage in mutual projects, search for larger frameworks which shift the incentives so that the goal of the competition can change from higher income to higher levels of health
Early in 1990, at its annual retreat, the management of Elliot squarely faced its relationship with Catholic, and came to the conclusion that the vicious rivalry was bad for both of them, and bad for the community. So when Goodspeed began planning another set of CON applications (for cardiac recovery rooms and an ambulatory care building), he picked up the phone and called Dupuis: "Why don't you bring your management team over here? We'd like to show you our plans." Dupuis and his team showed up, saw that the plans made sense for Elliot and the community, and decided to support them. It was a first.
Dupuis and Goodspeed next made an interesting and crucial decision: rather than apply to the Kellogg/New York University Hospital Community Benefits Standards Program separately, as rivals, they would file a single application, as partners. The application was accepted.
But they had already begun what became a broad-ranging voluntary cooperation. The two staffs met frequently to work out the HCBSP application, and then to impliment the program. They ended their attempts at duplication. Elliot does most of the obstetrics, gynecology, and pediatrics. Catholic sends the difficult births and neonatal problems to Elliot. Catholic takes the cardiac surgery. Both boards soon adopted new mission statements that included powerful commitments to building the health of the community, reflecting the belief that, as Goodspeed says, "We have to do it ourselves." The hospitals developed joint policies on free care and on living wills. Their executives began attending THF and Estes Park gatherings together.
Together with the a local not-for-profit, Child Health Services, Elliot and Catholic hired a researcher to give them a picture of the health access problems of poor women and children in Manchester. In May of 1993, in response to this research, they opened a new Manchester Community Health Center for the medically underserved, with each hospital kicking in one third of the funding, and the federal government picking up one third. "It was a broad-based community effort," says Dupuis. "We got the foundations involved, some people gave furniture, other people donated space. The medical staffs formed a joint Access to Care committee to identify unmet needs, and find doctors who are willing to help meet them."
Together the two hospitals have become very active in the future of Manchester, through the Chamber of Commerce -- where Dupuis is the chairman, and Goodspeed heads the long-range planning committee. The Chamber has involved itself in education, through the "Education 2000" project, and in creating jobs, through the Greater Manchester Development Corporation. This spring they convened 30 community leaders for a retreat called "The Manchester Agenda." Fifteen public sector leaders, including the board of aldermen and the heads of the city departments, and 15 private sector leaders, including Goodspeed and Dupuis, the heads of the television station and the newspaper, and major local business figures, met with a facilitator to build a vision of a clean, safe, healthy Manchester, to set priorities, and to brainstorm the public/private partnerships that could make that vision real.
In June of 1993, Elliot and Catholic took the big step. The two holding companies, Fidelity Health Alliance and Elliot Health System, signed a letter of intent to formally merge.
The personal relationship between the CEOs shapes the whole interaction. "We have a mutual respect," says Goodspeed, "and we bring complementary skills to the task" -- Dupuis the coalition builder, the outside man, Goodspeed the organization builder, the vision builder, the inside man. Both have a powerful desire to make the connections that will help the community live.
But such willingness to connect is still rare in health care. Public health administrators and hospital executives, especially, often act as if they are in completely different businesses. The cultural distance between public health administrators and hospital executive is a major challenge to anyone who hopes to build healthier communities.
Strategies: involve them in mutual projects, share information, invite them on boards
At Magic Valley Regional Medical Center in Twin Falls, Idaho, administrator John Bingham dealt with the problem directly: he invited the regional director of public health onto his board. In return, the public health agencies invite him and his staff to planning and other meetings. "As I travel around the country," Bingham says, "I find very few organizations doing anything like that. In fact, doctors and hospitals are often at odds with the public health authorities, and have little or no communication with them. Getting together with the public health people brings more `systemness' to health care. For instance, before we got together, they did pre-natal screening and education, but they had no coordination with Ob-Gyn. Now the public health nurses handle Medicaid pre-screening, do all the paperwork, track which doctors could handle another Medicaid case, and actually make the appointments. We're having a lot of fun with this. It's the right thing to do."
Douglas Cook, Director of Health Care Administration for the State of Florida, echoes Bingham: "A few years back, people on the public side would not get much of a hearing from the private side. Now we're involved in intensive discussions, simply because we have to be. For years on the public side we talked about prevention, only to hear the idea poo-pooed, because it `cost more to prevent.' That was simply because the money was in treatment. But now we're starting to break down that cultural gap."
Molly Coye, M.D., M.P.H., director of California's Department of Health Services, paints a similar picture: "We have had two different cultures. There has been a lot of hostility. Public health people have tended to see hospitals as indifferent. The reality is that we have to build bridges."
The first step, says Coye, is "to build trust and friendship, to see each other as people. That's a lot easier than meeting for the first time over a confrontational issue. Most private and public health people have spent very little time in each other's environments. Public health is mostly staffed by people who have not worked in hospitals"
Like many elements of the health care landscape, private and public health can be of great use to each other, if they make the connection. "If `Hillary's thing' is at all successful," says Coye, "health systems in the future will be doing a lot of the stuff that public health does now. That's a great incentive for public health to get allies, and to get the message out."
Strategies: push for changes in the overall system that shift the incentives, negotiate "covered lives" capitated contracts that reward prevention
"The key," says Cook, "is universal coverage. Once we have a common goal, we will have more of a common working relationship."
Hawaii's Lewin likewise points to the need for political change: "We have to divest central governments of assets and return them to local agencies. We have to take significant resources from federal and state legislatures and return them to the community. Here in Hawaii we already have universal coverage, and we have not allowed over-capacity. But that's just the beginning. Even with insurance, people still drink and drive, people still smoke, people still live unhealthy lives. We have to put the resources at the level where people live."
Strategies: offer information freely, ask for it from others, re-examine what information is considered confidential and why, meet and talk at every opportunity
Hawaii's Lewin saw this shift in real time: "After I was in office for three years," he says, "I could see that I needed to reach out more to get things moving." So he began holding monthly meetings, usually a breakfast or lunch, with the state's top healthcare executives, leading doctors and nurses, and insurance executives. "They are informal meetings, and we kick around everything from major legislated health reform to simplified paperwork and reimbursement. Sometimes we invite in the heads of major agencies, business people, or labor leaders." He's been doing this every month now for four years, and the meetings have had a profound effect on the shape of healthcare in Hawaii.
Scott Goodspeed calls this "getting the incoherence into the room -- all the people who don't usually talk to each other."
Hank Walker, CEO of Arizona's Tucson Medical Center, does something similar within the walls: a monthly ad-hoc brainstorming group brings together top management with key trustees, top doctors, and nurses.
A great deal of information goes unused because it's in somebody else's hands. For instance, Molly Coye points out, "Hospital people often have no idea how much information the public health people have about the health status of their communitites. But hospitals have a much greater ability to crunch those numbers, since many public health departments aren't really computerized. The same information that tells the hospitals about marketing and patterns of service are useful to the public health people for their community health assessments." A free flow of information helps everybody involved.
Strategies: develop relationships, repeat a consistent message
Sometimes the information has to flow outward from the healthcare organization. For instance, Sutter Health System in Sacramento, California, met resistance at first when it proposed to the school district that it provide immunization for every child. Why? Not enough information. "People were suspicious," says Kurt Sligar, M.D., who was then Sutter's vice president for medical affairs. "They thought it was part of a corporate marketing effort. And school nurses were concerned that we were doing their jobs. But the need was increasing, and they were unable to fill it. We broke through the resistance by developing relationships, and by being consistent in our message."
The need to get information out can be far more than charitable. "We just signed a contract with a large local employer to cover 6000 lives," says Portland's John King. "It's a capitated, fixed-price, 3-year direct contract with a strong preventive incentive. If we're going to make this kind of thing work, we have to do a much better job delivering information and behavioral change at work places, schools and churches -- where the people are."
But the most neglected information flow is from the bottom up, from the outside in: it's the flow of information from the community to the organization. In Memphis, says Shaw, "Because we are a private hospital with a public mission that includes a high level of Medicare and Medicaid, and some county subsidies for dealing the indigent, we have become very conscious of all the things that can make or break a community. We got engaged very quickly, looking at, for instance, what really drives our emergency room load."
The most powerful source of information for Regional turned out to be very simple: "We went to the neighborhood councils, to the residents' groups in the projects, and we asked: what services did they feel they needed?" The answers were sometimes unexpected. Some elderly groups complained that they often ran out of food by the 20th of the month. They wanted to know how to make their money go further. So Regional started road-show classes on how to shop for more nutritious, less expensive food, followed by classes on how to cook better and more cheaply. "Of course, we weave in a lot more, especially about diet and health," says Shaw.
Other neighborhoods were more concerned about diabetes, or blood pressure, or infant mortality. "We found that many young pregnant women couldn't think of a good reason to come to a clinic. So we took pre-natal classes to the projects. We found a very good way to get them to come to the class: we brought dinner."
Shaw builds the information flow into the structure of the medical center: "We try to pick up community advocates and put them on our boards. We form advisory groups."
Dorothy Mann, a trustee of Group Health Cooperative of Puget Sound, considers GHC's Center for Health Promotion, the Center for Health Studies, and the GHC Foundation (which gives about one third of its funds to community-based organizations) a "structure for listening to the community. That's not available to a lot of boards."
Warren Rustand, a member of the board of Tucson Medical Center, feels that this information flow is, in fact, a basic role of the board: "reflecting the diversity of the community back to the hospital."
If you want to build partnerships, your vision must be shared. And it's easy to fool yourself. It's not enough that people nod politely or clap when you speak. They have to own it -- which usually means that they have to help build it. Even though Magic Valley used focus groups to help develop its "vision statement," Bingham now feels that "it was too top down. If we were to do it again, it would be more truly shared. Now we are back, asking people what we should measure as an index of the health of the community."
The hardest part, Bingham feels, is "staying focused on that vision, not getting side-tracked." He depends on his relationship with Paul Miles, a pediatrician he refers to as "my mentor," and with his board chairman, to keep him on track.
Strategies: strong personal relationships with colleagues who share the vision
The vision is the great magnet of people's energies. "Most people want this problem fixed," says King in Portland, "but they want someone else to fix it. The easy thing is getting people to commit to an idea, and to show up at the meetings. The hard part is the follow-through. We do not yet have a common vision that will carry itself."
The vision that first brought together two hospitals in Omaha, Nebraska was not a grand new vision of a healthier community -- it was the same old vision of making money. Omaha, a town of 600,000 with two medical schools and eight hospitals, is a fiercely competitive market. Immanuel Medical Center owned land in an affluent part of town. It looked like a good place to put an outpatient facility, but Immanuel wanted to share the risk and the costs. They contacted Bergan Mercy Medical Center across town -- like Immanuel, a successful operation with money in the bank. They formed a joint venture, gave it a name (Community Health Vision) and a joint board, and called in a consultant, Gerald McManus of McManus and Associates in Washington, D.C., to help with the planning.
That's when things started to take a new direction. At the first meeting, McManus said something startling. He said, "I can help you build a first-class outpatient facility. But I want to ask you something: what you have ever done for the community?"
The board members were shocked. This fellow was going way out on a limb, discussing things they had not invited him to discuss. Board member Thomas Ruma, M.D., vice president for medical affairs at Immanuel, says, "We all just looked at each other. Then we sort of took a breath and said, `Okay, let's hear more about this.'"
McManus gave them his point of view: "Your primary asset is not your hospital. It is the health of your community." And he started a discussion about how they could improve that asset.
As a result of that discussion, Community Health Vision took on another task, besides the outpatient clinic: a general health assessment of Omaha, which led to an access assessment, focused on the initial access of Medicaid patients, the uninsured, and the homeless. At the same time, the outpatient clinic took on a new shape: the board decided to involve the community in planning the facility, and to focus on wellness and prevention.
But the first place this vision had to be shared was at the hospitals' home boards. "There was some head-scratching," says Ruma. "They said things like, `We have fiduciary responsibilities. The program you've laid out could cost us $200,000 per year. You're not supposed to be bringing us projects that lose money.' We had to do some education."
Strategies: wider understanding of mission, bring in partners to share risk, seek "covered lives" capitated contracts that reward preventive care, seek high-leverage programs
Bingham, at Idaho's Magic Valley, faced a similar problem: the hospital's great success at reducing children's head injuries cost the small institution about $400,000 per year in lost business. It was one of those times when the bottom line and the needs of a healthier community were directly opposed.
The vision -- and the readiness for vision -- has to be shared at least as much by your own employees as by the community at large. Memphis Regional has been taking its staff through "paradigm shift" workshops for five years now. They have made the employee volunteer program a part of the employee's annual evaluation, "but we hardly need to," says Shaw. "We exceed our goal every year."
Building and sharing the vision is a constant task. "I and others from Regional speak to Kiwanis and Rotary and Women's Clubs, to churches and schools -- anyplace we can," says Shaw. "We use every avenue we can to educate people that this problem, whether it's teenage pregnancy, or eldercare, or public safety, is their problem, too. I am not combative, but I speak for the voiceless."
Group Health's Dorothy Mann sees it as an important task of the board: "We have to take responsibility for our stated values, for `walking the talk.' Our board is very active. We work closely with the CEO. We ask questions about particular issues. We ask, `How can we do this better?'"
In fact, Magic Valley's Bingham defines the healthcare executive's primary role as "articulating the vision of what we're attempting to everyone, both in the institution and in the community."
Where do you find these "opportunities?" Just substitute the word "problem," and they are a lot easier to find. According to Hawaii's Lewin, "Our best examples of healthier communities are in the most depressed areas of Oahu -- Waianae and Waimanalo. In each case, their local health center, in partnership with the state Department of Health, have become the stimulus for whole movements that have reached out from medical issues to include things like beautification, crime, safety, and jobs."
In Sacramento, the opportunity for collaboration was the county's move to close a Saturday public clinic for the uninsured. Sure that those same uninsured people would walk into their emergency rooms if there was no clinic, Sutter Health System and Mercy Health System, together, dug into their pockets for the necessary cash to keep it open. The two organizations, together, are also helping an anti-drug program called, "People Reaching Out," not by giving cash, but by helping in their fund-raising, training their people, and giving management assistance
The opportunity that Immanuel and Bergan uncovered in Omaha was once again an underserved part of town. Community Health Vision is opening two primary care offices where they are needed most -- and it has found partners: Project Hope, which provides rudimentary medical care for the homeless, and the Indian/Chicano Health Clinic. CHV is helping both to enlarge their small operations, and will pay the salaries of two doctors and at least two nurse practitioners.
"Then, to fill the gaps," says Immanuel's Ruma, "we went to the medical society and asked for volunteers. We found that people already were volunteering some. What held them back from doing more was not the time, it was that the clinics were not well organized. They wanted to spend their time doctoring, not organizing the place and handling paperwork. Once we told them that we would handle the paperwork, that we would make sure that the clinics were ready to make use of them, we got more volunteers than we could use. We stopped taking names when the list grew to 50. If we can re-create the excitement of the first days of medical school, or the first time they laid hands on a patient, people are happy to help."
Strategies: get an M.D. on your team to talk to them, discover and correct the obstacles to their involvement, find ways to maximize their medical usefulness by minimizing hassle and organizational difficulties
The next project, still in process, was negotiating with the other hospitals in town, convincing them to pitch in and take their share of the uninsured and Medicaid patients.
Omaha, of course, is a hotbed of insurance companies, including Mutual of Omaha, the nation's sixth-largest health insurer. As Ruma says, "Insurance companies get nervous whenever hospitals get together." So CHV board members made the rounds of the insurance companies, explaining what they were doing. "Two days after we visited Mutual of Omaha," says Ruma, "they called us back. They wanted to be part of what we are doing." As a result of that visit, Mutual of Omaha has signed a joint venture -- a first in itself for Mutual -- with Community Health Vision for an at-risk managed care agreement that will include prevention and wellness, and will even bid for Medicaid patients.
A series of "problems" turned into opportunities has led Immanuel into a network of partnerships that it had never contemplated before. "It really snowballed," says Ruma.
Detroit's Henry Ford Mercy Health Network was built on just such an opportunity partnership, combining business imperatives with the passion to do what needs to be done. Southeastern Michigan is another tough competitive market. Henry Ford Health System, a not-for-profit with four hospitals, 33 outpatient centers, one of the nation's largest group practices, and a managed care health plan, needed hospitals in the wealthier suburbs to the north and west of the city. Mercy Health Systems, a major not-for-profit with 23 acute hospitals and six psychiatric facilities scattered across the Midwest, along with continuing care centers, long-term care facilities, ambulatory care centers, and an HMO, is based in those suburbs. Its three hospitals in the Detroit area included Mercy Hospital on Detroit's east side, where the Sisters of Mercy have provided health care for the poor for almost a century. Mercy was hemorrhaging money, and when its patients needed more care than it could provide, it often had trouble placing them with other hospitals. But, as John J. Collins, Jr., M.D., CEO of Henry Ford Mercy Health Network, put it, "Somebody's got to take care of those people."
Mercy couldn't afford to do it alone, but Mercy had some things Henry Ford could use. And Henry Ford had some things that Mercy could use -- its management skill, its vast group practices and its managed care program. And Ed Connors, CEO of Mercy, knew Gail Warden, CEO of Henry Ford.
So, in 1990, Henry Ford and Mercy sketched out the area where they matched, and called it a joint venture. They put two well-off suburban areas together with the east Detroit area in the Henry Ford Mercy Heath Network. Henry Ford took over managing Mercy Hospital, sharing the risks and rewards with Mercy Health System. Together they built a managed care approach that increased quality at the same time that it cut Medicaid costs. They tightened up the operation at Mercy Hospital, and used the savings to stanch the red ink at the same time that they ramped up their work in preventing teen pregnancies, in pre-natal work with the poor, and in providing for the homeless. With Mercy hooked into Henry Ford, Mercy Hospital has an easier time placing its difficult cases. And Henry Ford, as part of its Urban Health Initiative, has started a program in its medical school to train family practice residents for the inner city environment. "We can give them the opportunity to join a system, instead of going out there alone in private practice," says Collins. In the first year, this program has been able to recruit a strong faculty, and has filled all its residency slots.
Strategies: orient residency programs to those parts, link them into larger system
As Collins puts it, "We knew that, in order to do good in the inner city, we had to do well -- we had to expand our collective market share -- in the suburbs."
In healthcare, opportunities to do well by doing good are surprisingly common, if you look carefully. For instance, Memorial Hospital in Broward County, Florida, found that it could actually make money by taking over the public health clinic -- for the simple reason that it could do a better job of catching people before they wandered into Memorial's emergency room.
Problems create the opportunities to build the partnerships that are the links of true community. In Twin Falls, Idaho, Magic Valley got the school system involved in a public safety issue. Pediatrician Paul Miles led an investigation of preventable injuries to children. He discovered that a sizable portion of head injuries seen in the Magic Valley ER were the result of bicycle accidents -- and only one percent of the kids in the area wore helmets while riding. They didn't think it was cool. Working with the school system, Miles got a grant to buy and give away 1200 helmets, and wrote a curriculum on bicycle safety for the schools to use. Now 30 percent of the children wear them, and children's head injuries have dropped by 40 percent.
In Arizona, Tucson Medical Center has also teamed up with the school system -- to help teenagers who can no longer live at home. In the "Helping a Teen" program, the school system identifies older teens who are in danger of running away and dropping out. The medical center helps them find jobs and low-cost housing, so that they can stay in school.
Another community-wide partnership was the brainchild of a TMC board member. The medical center has long teamed with the local food bank, sending it excess or damaged food. But the food bank needed more storage space, and didn't have the capital to pay for it. The board member's idea? A community-wide one-day fast in October to raise both money and awareness: participants will donate whatever they would have spent on food that day to the food bank. According to TMC board member Rustand, the idea is really catching on: "Even the restaurants in Tucson are supporting it."
Similarly, joint projects in trauma care and pediatrics have drawn TMC into regular monthly meetings with the medical center at the University of Arizona, and an ailing county hospital has drawn it into a joint task force of all the providers in town to seek a community-wide solution.
The opportunities can be daunting. Oregon Health Systems In Collaboration looked on immunization as "something easy and simple." They thought it would be a slam-dunk -- until they looked at the statistics. Only half of the state's kids were immunized -- and even among Kaiser members the figure only hit 60 percent. But it was an opportunity to join with the state's public health officials in ways that they never had before. They plunged into the task by (among other things) helping make certain that pediatricians got the right stock, and convincing Blue Cross to promise that it would write no health plans that did not include immunization.
In Memphis, the Regional Medical Center's Political Leadership Group, which includes some board members, carries on a ferocious advocacy of a legislative agenda focused on the needs of women and children. "We get everybody involved," says Shaw. "Our physicians know that they may be asked to go to a church on a Saturday and give a little speech. We work a lot through the churches. We get them to do letter-writing campaigns, or to be ready at the drop of a hat to get on a bus, go to the capitol and act crazy. The more we do, the more we need to do. We run 33 clinics, with over 125,000 visits per year -- and that figure has been growing at 20 percent per year for the last three years now."
In Memphis, as elsewhere, the community's problems can become opportunities to build partnerships -- and the partnerships build connections that can go on to serve other problems, building flexibility and power into the community's attempt to improve its health.
Florida's Doug Cook recently echoed Franklin: "There's no limit to what you can do if you don't mind working together -- and if you don't care who gets credit."
That's not an easy strategy for major healthcare organizations -- or for the people who are ambitious enough and experienced enough to run them. Portland's John King says, "We have to reach out to the schools, the churches, the neighborhoods. Health providers are not the best at that. We tend to want to be in control. We're the big kahunas."
Sometimes, for the job to get done, it can be important that your partners are generous, too.
When one Memphis neighborhood said its highest health priority was getting a traffic light at a dangerous intersection, Regional Medical Center teamed up with another public agency to see what they could do. "But they backed off," says Lucy Shaw, "when they saw that it would mean empowering the local people. They didn't like the consequences of that. So that corner is still without a stoplight.
"Our biggest challenge," she says, "is not the clients, but the city government. It takes patience, manpower, and coordination to work with them. The government tends to be very fearful -- if they really solved the problems, they might not get re-elected, they might not get the credit, it might cost them money. They have a great deal of fear about empowering people."
Strategies: full communications, establishing strong ongoing relationships with other institutions and other parts of the community
"Empowerment is never on my terms," says Shaw. "It's on the clients' terms. Once that clicked for us, we did a lot better."
Giving away credit, sharing the work, the risk, and the kudos, is not easy. But it works.
Sharing is not necessarily the American Way. In fact, the legal phrase for it is "restraint of trade" -- under certain circumstances.
Just what those circumstances are, and how they might apply to healthcare in the turbulent `90s, is not at all clear. As Scripps' Bruce Campbell says, "Some things are essentially impossible" under anti-trust law and the regulations of the Federal Trade Commission. "The rules were invented to promote competition in a free-market environment. More and more people are unconvinced of the virtues of competition in this environment. Where resources are limited, it may not be very appropriate for not-for-profits to compete for them."
Whether the FTC and the Justice Department will share that opinion remains to be seen. As of this writing, Elliot Hospital and Catholic Medical Center in Manchester, New Hampshire, are awaiting federal clearance for their plan to put their two facilities, the only two general hospitals in town, under one holding company. And Scripps is treading carefully in its agreements with Sharp.
Intent is very important in anti-trust law. If two hospitals combined to drive out competition, then fix prices, they would, in theory, be violating anti-trust law and acting in restraint of trade. But if (as is often the case in healthcare) competition between individual institutions actually drives up prices, and institutions are working together to bring them down, to provide more of their services to a wider population for less money, then in theory there should be no problem. In theory. But the fact could turn out quite differently. We will know more when we have seen how the federal government reacts to this new wave of cooperation in healthcare.