This article was published as part of the Healthcare Forum's Healthy Communities Action Kits, Module 3, in 1994
Building a healthier community takes everything from a philosophic and economic rationale to the nuts and bolts: the community meetings, the flows of money, the alliances. For this article, Joe Flower sampled the country's best thought by talking in depth with a score of involved experts, including not only healthcare CEOs and CFOs, futurists, and doctors, but also foundation heads, government officials, economists, and business representatives.
In this section, we will discuss:
Under their own headings, we will also explore:
Similarly, Tom Chapman, who has just left his post as CEO of Greater Southeast in Washington, D.C., to take over George Washington University Medical Center, calls for "a pure and thorough recognition that it is not healthcare delivery that fundamentally drives health. Other major determinants -- such as good housing, jobs, a strong economic base, good nutrition, responsible behavior, genetic makeup, and education -- dwarf healthcare. One of our frustrations as providers is that the harder we work to provide health, the further we get behind, because we have no influence over these other determinants. It doesn't work to use `healthy community' in a narrow parochial sense. If everybody gets immunized, then kids get blown away in gang warfare, that's not a healthy community."
We found wide agreement with this -- and with the idea that at a deep and practical level, the health of a community depends on its inter-connectedness. Bergthold's healthy commmunity would be "dense with empowering organizations at the local level, a community that has identified its own priorities and set out to build them." For "anti-economist" Hazel Henderson, "this means shifting our value system away from compulsive individualism toward re-balancing the needs of communities." In the same vein, Tom Chapman said that the people of a healthy community would have a "collective understanding of their interdependency." Health futurist Clem Bezold calls a healthy community "one in which the community has a shared vision, and is able to make that a significant part not only of public policy, but of healthcare and commerce."
Sean Sullivan, executive vice president of the National Business Coalition, points out that things like housing, education, crime, or the community's vision of itself "are not things that usually show up in conversations of healthcare reformers about ways of reducing healthcare costs -- or that managed competition will have much impact on."
Some consider the economy the most fundamental aspect of community building. Drew Altman, president of the Kaiser Family Foundation, says, "A good job and a strong family is the best health and human services program. You've got a shot at educating the upper middle class about their diet, for instance, but you don't have a chance with people who are just surviving."
But others look through a different lens. Clem Bezold, for instance, says, "For me, development -- creating new jobs and attracting more industry -- is not necessarily a viable direction to go. I see a steady increase in the ratio of people who desire to work, relative to opportunities. In other words, we'll see a steady rise in unemployment. So the task becomes: how do you create communities that do more with less, that can live in more sustainable ways in face of adverse economic development?"
But whether the economy is primary, as Altman would have it, or is inseparable from deeper questions of the nature of strength in a community, as Bezold and Henderson would say, the exercise of bringing people together to build a stronger community, done correctly, tends to work on all aspects of the problem at once. Health futurist Leland Kaiser calls building healthy communities "a resource generation strategy" that "makes sense because a society depends for its well being on a full utilization of all its resources, especially people."
In the broadest sense, the things we can do to help the individuals in a community live healthier lives -- safer lives in stronger families with less stress, better nutrition, more information, and greater wisdom -- are the same things we can do to help make a community more democratic, wealthier, more interconnected, better educated, and even happier. You can't build healthy individuals in a sick community. If you want to fight disease, you have to build healthy communities.
Implication You can't truly effect the health of the people you serve until you get beyond the walls of your institution, and even of healthcare itself.
Action Re-frame your mission from "curing disease" to "creating health," and then one step further, to "building a healthy community."
"Every institution in the community has an obligation to put something back into the community," says David Lawrence, M.D., CEO of Kaiser Permanente, "whether it's your dollars, the work you do, or the talent you make available." As Linda Bergthold puts it, "Things won't change unless you get involved. If you stand back you will have no effect, so either accept what's going on out there, or get involved."
Traditionally, healthcare's obligation for public service is expressed in tax legislation, and met by totting up the uncompensated care and public education programs that every hospital does. "There is increasing pressure for people to demonstrate the value of their tax-exempt status," says Phil Newbold, CEO of Memorial Hospital and Health System in South Bend, Indiana. "People will figure out the allocation of hours necessary to do keep the status, and that's exactly how much they'll do. They'll keep time-sheets on every hour of it. The difference is whether you are doing it defensively, or prospectively to serve the community"
"The question," says Phil Nudelman, CEO of Group Health Cooperative of Puget Sound, "is `What's your real bottom line?' There are those that provide healthcare services so that they can have a bottom line, and there are those that have a bottom line so that they can provide the healthcare services."
The very volume of uncompensated care we provide shows that providing it is no longer sufficient public service, either for healthcare institutions or the communities in which they live. We have been providing the very best head-trauma work without ever asking what we can do to keep people from getting shot, clubbed, and run over. Our involvement has to go beyond our the business fo giving people high-quality healthcare. "For instance," says Lee Kaiser, "I'm doing some work for a hospital in LA, ostensibly to improve their medical outreach. But out on the streets medical outreach is the last thing they need. Unless you go in and re-juvenate the neighborhood, the lines just get longer in the ER."
Implication We must recognize explicitly that a healthy bottom line is not an end, but a means to a larger goal: health. Then we must mold our every action to that goal.
Action Change the essential question from, "What will cure this case?" or "what will give the best return on investment" to "What builds health?"
The economic imperative is simple: risk. No-fault healthcare management is dead. Your capacity to choose your level of exposure is diminishing. In the relatively short term, the majority of your business will come to you in shared-risk packages, because of state and federal legislative reform, business alliances, and the integration of the industry. Your capacity to survive and grow will be tied directly not only to the health of the population you serve, but to the true vectors of their health: their economic success, the safety of their environment, their level of education, and the strength of their families.
Nudelman points out that "not assessing and acting on the health needs of community will have higher economic costs in the long run." The social pathology of our communities threaten to drown even the best-run institutions, at the same moment that cost pressures and reforms give them less and less room to maneuver.
Luckily, you can spend a lot on community building -- or you can do it on a shoestring. "Everyone assumes that money is the rate-controlling step," says David Lawrence of Kaiser Permanente. "I don't think so. I think it's the definition of the problem, the galvanizing of interest around it. Often the resources are already there in the community, but they are fragmented, disconnected, and replicative. The schools, for instance, already spend a lot of money on this kind of thing. There are a lot of exciting ways to finance housing rehabs that don't require extra funds."
Washington, D.C.'s Greater Southeast has done more community-building work than almost anybody -- on the thinnest of shoestrings, during a major financial turnaround. According to former CEO Tom Chapman, "People tend to say, `this costs too much,' or `I'm not going to be reimbursed for it.' These are not only shallow reactions, they may not even be accurate. Many things can be done that cost little or no money. What they take is leadership, and energy." At the other extreme, Phil Newbold's Memorial Hospital in South Bend now puts 10 percent of each year's margin into a pot for new community-building projects, in addition to all the uncompensated care, community education and outreach work the institution was doing before (as established by careful audit). This is a sizable chunk of change, yet Newbold emphatically agrees that big cash is not a prerequisite: "There's a lot of sweat equity available, a lot of volunteers. We haven't even begun to tap the volunteer power in this country. We could do 7 out of 10 projects with volunteers alone. What's necessary is the will and the vision to do it."
Linda Bergthold says, "The costs are just your time as an organization or individual. There's always time to do the things you believe are important."
You already are involved, because the social pathology outside your doors is already costing you money, and it's not small change. "Our physicians helped us move along on this," says Newbold. "It shows up in the ER night after night after night. It shows up in neonatal intensive care, in the low birth-weight crack babies. You're going to get into it anyway if you're a pretty large community-based system. There just aren't enough resources available to fix these problems this far down the chain. The national movement is to get as far up the line as possible. It's the same perspective that you get from CQI."
Kaiser Permanente's Lawrence says, "You begin to push the limits of what medical care can do to raise people's health status. That drives you back into the community, because a lot of what you're spending money trying to fix comes from what happens in the community."
From the narrow view of a particular healthcare institution with a business based largely on fee-for-service, the immediate financial incentives can run directly counter to building a healthier community. As Altman puts it, "The biggest obstacle is that, though it's always in the overall interests of the greater community, it's not in the interest of those who would be doing it." Under the present system, he points out, "You still get more money when people get sicker." Indeed, there are cases on the record, usually from small rural hospitals, in which the institution has been so successful in solving some local health problem that it cut into its revenue significantly.
But those incentives are already changing -- and that change is likely to occur, sooner or later, no matter what legislation comes out of Washington. We are approaching a time when, as Bezold puts it, "healthcare organizations will be held accountable for the health of the community."
For one thing, that future is one in which, one way or another, everyone is likely to have a health card, and providers will find themselves serving a market segment that they are used to encountering only as uncompensated care in the ER. "Even the best and most responsive of the HMOs," says Tom Chapman, "have very little experience in reaching those underserved populations."
Beyond that, few healthcare institutions seem to have really absorbed how profoundly the flipped incentives will change the business they are in. "All providers, especially hospitals," says Chapman, "are going to have to learn a lot about how to keep people healthy. Most people can't yet digest the fact that the great incentive of the future will be to keep people out of the institution. Once the economic rules really change, once they understand that the hospital has become simply a cost center, not a revenue producer, then the institutions' behavior will change."
"You've got to marry the community," says Group Health's Nudelman. "If you don't, then you fall into a camp that I don't think is going to make it in the long run. If the community is just there to make a profit for you, you won't have their cooperation. When the competition is about who can develop the best mousetrap to keep people well, who can figure out better ways to enhance health of the community, the people that will survive are those who have made that their business already."
Lee Kaiser puts the argument succinctly: "As we move into capitated, managed care the individual healthcare organization is going to lose. After three or four rounds of managed care, the cost and quality competition among the survivors will reduce to zero -- anybody who can't make the cut will have dropped out. Building a healthier community will be the only competition left. There will be only one strategy for winning -- keeping people healthy. Those who do that will make a pile of money. It's the only effective long-term strategy."
Finally, there is something more subtle, also, something beyond money: healthcare is intensely local. Growing deep roots in the community, making strong connections at all levels, going through the changes that people in your organization will have to go through to make those connections, gives your organization the flexibility and alertness to deal with the changes that we will all face over the next decade. Community work is a boot camp for dealing with change.
Implication In order to survive and prosper, you must increase the health of the people you serve. To do that effectively, you must go beyond clinical matters and even preventive medicine and health education, and use all your wit and resources to effect the social bonds that create healthy communities
Action Commit your organization wholly to the task of building healthy communities, not as a marketing edge, but as a fundamental strategy
It is not clear now, and will not be for some time, whether health care reform will free up resources that can be used in this fight. As Bergthold says, "Capitation gives health plans an incentive to keep people healthy." Yet Bezold points out, "none of these bills looks hard enough at the broader causes of health, and how healthcare can be used to leverage cross-sector efforts against such health factors as poverty, homelessness, poor nutrition, poor self-esteem, and a lack of meaningful roles."
Yet vast resources are there already in the system. "A better organized system," says insurance commissioner Dupuis, "will free up significant financial resources. For instance, Manchester, New Hampshire, with 100,000 people, generates 70,000 ER visits per year, most of them $200 ER visits for non-emergency matters that could have been dealt with in a $40 or $50 doctor's office visit. There are enough resources in the system now, but they need redistribution."
We cannot tell at this point whether the reform legislation will encourage such re-distribution or not, nor whether its cost pressures will actually free up resources or strangle them. Yet if the resources are not there, our task becomes only more urgent. Legislation is not a cause, but a symptom of deeper forces pushing healthcare in new directions.
Implication Since the legislation is not a fundamental cause, if we wait for the details and practices of the legislation to settle out, we will get caught behind the curve of change.
Action Anticipate reform by focusing on the fundamental social and cost vectors that are driving it.
Sylvio Dupuis, insurance commisioner of New Hampshire and a former healthcare executive, says, "getting the other guy to do it never works." It has to be done in partnership both between competitors and across sectors.
The community argument is at least partly economic, the sense that "social illness and a productive economy," as Chapman puts it, cannot co-exist.
"If the community is going to prosper," says Dupuis, "you have to build a solid foundation. You can have all the fancy brochures and high-priced consultants that you want, but when business looks at a community, they want to know about everything from education and the arts to public safety, transportation, and the social structure. We compete with states and localities that understand these things."
Sullivan, of the National Business Coalition, concurs: "More businesses are starting to realize, as one corporate board member told me recently, `Healthy companies like to be in healthy communities.' A healthy community is a better place to do business, and it has a better labor force. That goes right to your productivity figures and your bottom line. It reduces overall burden of social costs that business has to bear. And there are opportunity costs of not doing something, in healthcare costs that could be avoided, in absenteeism, in lower productivity in the workplace."
So all the threads that make up a healthy community have to come together -- and all the people and institutions that can effect change have to work together. We will not be able to significantly effect the physical health of the people who come to us by ourselves, or without effecting their economic, emotional and spiritual health. And for that we need good partners.
The essence of that urgent work is fostering the inter-connectedness of the web that is community. At the core of community building is what Bergthold calls "getting people to feel they have some control over their lives." Involving people is not just a way of spreading the work around and cutting our costs. It's not a tactic. It's the essence of what we are doing. "Holism is an organizing principle for healthier communities," says Lee Kaiser, "not just a concept. In concrete terms, that means you must have ongoing relationships with the police, with the schools, with the churches, and with businesses." Community is built out of real bonds between real people. If you want to get a CEO involved in something, says Bergthold, "take him out to a school, and have him work with a kid. Give him or her an experience."
Second, says Bergthold, "make the goal something achievable, something you can see happen." Chapman agrees: "Find a small area to start with." It's important that, among the chosen goals are a few that can be done quickly, visibly, with some assurance of success -- some early victories will keep the momentum going.
When asking where to start, keep in mind the goal: getting people more interconnected. So pick a problem that by its nature cuts across sectors and calls on the talents of all sorts of people. David Lawrence says, "It's instructive to look at Minneapolis/St. Paul; Portland, Oregon; and other communities that have had some success at this. Their common denominator is this: different groups coalesce around an issue that is multi-sectoral. The health sector (for-profit and not-for-profit), the business sector, and the public sector all get together to focus on a particular issue that is locally important. That becomes the entry wedge."
For other, tactical reasons, it is important to bring in not just a few big partners, but people at all levels. Sean Sullivan, of the National Business Coalition, points out that "for larger companies, it's always an option to re-locate their facilities, though it's expensive and difficult. Smaller businesses and hometown companies, like Boeing in Seattle, can't avoid involvement in their communities. The key is to get different types and sizes of businesses to combine their efforts. Business is probably the institution best situated to try to get the community to think of a community health improvement budget." Sullivan calls this "a communitarian approach."
Implication To succeed at this task, you must give up ownership and seek conection. As John McKnight would put it, you must seek out the gifts and capacities of everyone in the community.
Action Seek partners and information at all levels in the community. Look for structures and methods that include others equally or more than equally. Avoid taking charge or taking credit.
"When you get into building a healthier community," says Lee Kaiser, "you'll have one of two emotions, either, `I'm paralyzed, it's too big.' Or, `Isn't this fun, let's go out and do something.' I see both of these in hospital executives. The fact is, its not a big deal to change the world. You don't have to do big things. You just have to do little things. The world is built in such a way that synergism is an operating principal. If I do one program it establishes a conversation, it puts things in motion, it's a ripple on the pond. Build it and they will come."
Eventually, the goal is not just new programs but new minds. As Lee Kaiser puts it, in healthcare reform "we are stretching the old mind as far as possible, but the circle still doesn't meet. Building healthier communities is not an add-on, it's a whole new movement. A lot of people add on a class for unwed mothers or throw in an exercise class. Building a healthier community is far more than that, it's a whole new way of occupying the Earth. It's a gateway to reinventing America and eventually the planet."