"Healthier Communities" and Healthcare

by Joe Flower


International Copyright 1995 Joe Flower All Rights Reserved
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The great goal

Building a healthier community is a great goal for the healthcare industry, and in some ways an obvious one, on moral and philosophical grounds: we are not here only to cut and dose the people who have the right paperwork. We do what we do because we believe in health. But when the time comes for action, healthcare organizations too often do as little as possible, or only enough to preserve their tax status. The reason is two-fold: money, which translates into, "What's in it for us? How will this help our margin?" and inertia, which means, "Wouldn't I be safer just staying where I am?"

Four coming shifts of mind

The answer to the second question is, or soon will be, "No." The safety of inaction is disappearing. Over the next several years, one organization after another is going to go through the same vigorous series of shifts of mind.

Shift one: fee-for-service to covered lives

The first shift springs from changing incentives. Federal reform, various state reforms, business alliances, and the integration of the industry are all driving in the same direction: the economic base of much of the industry is moving from fee-for-service to covered lives.

The 1994 attempt to pass federal reform, and the 1995 reform of Medicare, have both given greater energy to parallel reform efforts at every level. The momentum toward covered lives has gained its own life independent of the legislation, a life with deep roots. In a hundred different ways, healthcare organizations are taking on risk based on the health of enrolled populations. As the country moves closer to full access -- and as HMOs and other managed care organizations saturate their market segments -- healthcare organizations will have less and less ability to "cream off" populations that are young, healthy, educated, and employed. Many institutions, especially large teaching hospitals, will try to survive on the niche markets of "carve-outs" that will be less constrained by price competition. As healthcare futurist Jeff Goldsmith puts it, "A lot of people are making implicit assumptions that they can survive on the remaining fee-for-service business. But that market is not going to be that big."

Shift two: drive out costs, drive up quality

So the first shift -- changed incentives -- will lead directly to the second shift: With most institutions sharing risk on covered lives, competition on both price and quality will move them to a vigorous use of outcomes measurement, matched to TQM and other "new management" techniques, to drive the costs out and drive the quality up.

But this is a game of diminishing returns. The easy stuff will be done early, expertise will be shared, and within a few years all the survivors will be working at a higher level of quality and a much lower level of cost inflation. But they will be in a commodity business, because the other smart players in town will be working at the same level. They will have to be.

Shift three: toward wellness

So the third shift will come as an important realization spreads among boards and management teams: they can no longer survive just curing the sick. In order to earn survival margin, they will have to widen the gap between what they get paid per covered life, and what they spend to care for that life. If they are going to cover people's lives, they will have to learn how to keep those people healthy.

As the National Civic League's Tyler Norris puts it, "Health reform is not going to fundamentally change health outcomes." The hard-to-reach populations won't change their habits when they get insurance. They will continue to show up later and sicker, draining scarce acute resources for conditions that education and changes in behavior could have avoided. National Institutes of Health studies have shown that most disease arises from preventable causes, from behavior and environment. Healthcare organizations, whether progressive or sticks-in-the-mud, will be forced to go "upstream," to deal with the problem closer to the source. The cost differences between, say, neonatal intensive care for a premature, underweight baby, and finding some way of communicating to that mother and getting her good prenatal care -- or between dealing with insulin shock and teaching people to deal with diabetes -- are so great that everyone will be in the business of preventive care and health education. Outreach and education projects, neighborhood clinics and partnerships across public/private lines will proliferate astonishingly. Private healthcare will become public health.

Scores of institutions have already hit this shift. For instance, Magic Valley Regional Medical Center in Twin Falls, Idaho, invited the regional director of public health onto their board, and set out to, among other things, subsidize bicycle helmets in the area and write bike safety curricula for the schools. Last year Portland's Legacy Health System, the Sisters of Providence, and Kaiser Permanente (which together control three quarters of the Portland healthcare market), got together with Oregon State University Medical School, and Oregon Blue Cross and incorporated as Oregon Health Systems In Collaboration. Their first project: to work with the state health authorities to immunize every child in the area.

Hundreds of healthcare organizations have ordered the Voluntary Hospitals of America's new community benefits software published by the since it came out in January 1994. Linda DeWolf, who heads up the VHA's healthy communities effort, calls the response to the software, and a range of other materials the VHA publishes, "a little overwhelming. There is a great increase in interest among hospitals. We get several calls a day from people trying to figure out how to do this."

Shift four: Beyond prevention

But healthcare will rapidly find it has to go well beyond providing more prevention, to changing people's minds. As long as people see health as the mere absence of disease, as the province of doctors and hospitals, as something you buy from someone else rather than build for yourself, healthcare organizations will be playing fool's poker with money they don't have. They will be forced by circumstances into massive efforts to shift the public awareness of health, disease, and responsibility.

In discussing hospitals engaged in healthier communities initiatives across the country, Norris points out that "for many of these institutions, it's still just part of the strategy, an attempt to address the demand side through education and prevention. But for the most part, poor health outcomes don't have to do with configuration of healthcare and social organizations. We have to change the ways people think, the ways people act, the behaviors and practices they choose and condone."

Once financial realities make changing behavior a top priority, healthcare managers will quickly discover the difficulties of changing one behavior at a time, one person at a time, isolated from that person's family, neighborhood, and job.

A recent World Bank study identified the two things that could do the most to improve the health of the world: educate girls, and give opportunities to women. We in the United States have done a much better job at these than many countries have, but the underlying message of the study remains true here: the principal vectors of health are not rooted in medicine, or even in individual behaviors, but in the structure of our communities, in our relationships.

Dr. David Felten's work at the University of Rochester, New York, (which has brought him a number of awards, including a MacArthur "genius" grant) has shown the direct connections between the nervous system, the immune system, and the hormone system. His experiments (and those of many other researchers) have repeatedly shown the direct causative correlation between psychological stress and depressed immune response -- you can consistently kill a lab mouse by driving it crazy. His experiments have gone further, to show the most prominent stressor leading to depressed immune reponse, both in laboratory mice and Harvard medical students: loneliness, helplessness, lack of connection -- lack of community.

People's behaviors have causes and contexts. They are not random. When people smoke, or drive drunk, or beat their children, or take crack, it's not because they are stupid. It's because the behavior answers some question in their lives. Until they find another answer to that question, they will continue the behavior.

The final shift: Beyond healthcare

So what happens next -- the final shift -- is even more interesting. As these pressures come to bear on healthcare, and the search for ways to keep people healthy grows fiercer, it will emerge in stark clarity that most of the real vectors of health are not in the traditional realm of healthcare at all. Rather, they are things like education, the environment, domestic violence, despair, unemployment -- that huge knot of problems that we as a society have been pushing from one hand to another, too often looking for the easy, one-shot solutions.

Healthcare will face a huge dilemma. In order to survive, it will have to do something about these problems, because its margins will depend more and more on improving the health of the population. Will healthcare be able to solve these problems? Of course not. These problems are bigger than any one industry, sector or professional group. Can healthcare provide leadership? Can it be a catalyst? Absolutely. It is still the largest industry in America. In almost all local economies it is one of the largest employers. Hospitals alone directly employ five percent of all Americans. In many local economies the single largest employer is a hospital. Healthcare boards are typically community-based, and crammed with local expertise and contacts. The industry touches people's lives with a scope and intimacy that no other industry does. And people still trust it more than any other industry -- you don't find volunteers parking cars or staffing the gift shop at a silicon chip factory or a brokerage.

Healthcare, as an industry, will be forced into the search for ways of bringing people together to deal with the problems facing their communities, to help communities re-knit themselves.

Some healthcare institutions have already begun this final shift. "Increasing numbers of institutions are getting involved in things that are not medically-based," says VHA's DeWolf. Seattle's Group Health Cooperative, for instance, is providing expertise and dollars to a local anti-violence initiative. Memphis' Regional Medical Center teaches money management and smart shopping in the projects -- as a weapon against malnutrition. It also gets right up to its elbows in political organizing, when it comes to legislative issues affecting women and children. "We get everybody involved," says CEO Lucy 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."

In Waianae and Waimanalo, the most depressed areas of Oahu, local health centers teamed with the Hawaii 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 Arizona, Tucson Medical Center has teamed up with the school system to help teenagers who can no longer live at home find jobs and low-cost housing, so that they can stay in school. It has also drawn the community, including restaturants, into greater support and cooperation with the local food bank.

As an industry we have begun to say to ourselves, "We can't do this, but it has to be done if we are to survive. Maybe it can't all be done, but some parts of it can be -- if we get enough people together, committed to learning how to do it."

When healthcare as a whole hits that wall -- and it may take a few years yet before everyone goes through all these shifts of mind -- those organizations that are most adapted to change, and those organizations farthest along in this process, will not only survive, they will prosper. Those who remain stuck in the old role will find themselves increasingly saddled with patients who are medically illiterate, living in unhealthy, violent environments, operating at a survival level -- and who are capitated at levels that simply do not allow for adequate margin. At that point, the move toward building healthy communities will become the most powerful single force re-shaping healthcare in America, and the healthcare industry will become an equally powerful force in helping America re-shape itself.

Odd, isn't it -- in the midst of the turbulent Nineties, this revolutionary force is turning us back to the vision that drew us into healthcare in the first place. It's calling us home.

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