First Seed Grant Dinner Meeting
Thursday, October 6th

Rough transcript
CD #1

Table of Contents:
Orientation
Vision Discussion

Group Discussions:
Group One: PREVENTIVE broadly defined
First Question
Second Question
Next Questions
Fifth Question
Sixth Question

Group Two: DATA PROJECT

Summary of Whole Group

INTRO: Feel free to keep eating but we really appreciate the fact that you're all giving up evening time for this meeting at the end of a long day of doing something else so we're trying to be very respectful of the time and get everybody out of here as close to when we promised as possible. I'm Adele Amadeo and I'm the co-facilitator for the evening, and here's Rhonda Sarnoff, my other half. And everybody here knows Skip Robinson....

(Attendees identify themselves.)

ORIENTATION

I just want to take a couple of minutes to go over this recording business and what we intend to do with it. What we're hoping is that we will have an edited transcript that won't be identifying people's names that will be posted on the password-protect portion of the Web site. Skip sent out a notice about that today. I hope you're all OK with that. It's not for general distribution. We're going to be using the notes that will be coming off of the flip charts to capture the highlights of what's going on, supplemented by what the actual task was. So any questions about that? Great.

You've got the agenda in your packets. If you want to just look through the items that are in there, pretty self-explanatory. There's a roster, there's a listing of what to do locally that was culled from previous attempts by a larger version of this group who came together around the health care crisis. There's a set of questions that are going to help focus the discussion as we go through trying to narrow what comes next out of all the work that's gone before.

VISION STATEMENT DRAFT

But the first thing that we want to do is look at the vision statement. And this had been circulated about a year ago. It's been slightly modified since then based on some suggestions from Skip and others who are looking at it. I just want to spend a few minutes going over it with you because it's really - people hate spending time on vision statements. They go - oh, we just want to get right to the problem. But I've been doing enough strategic plan design and other things to know that if we don't all agree that we're going to the same place, some of us will wind up in Australia and others in New Zealand and maybe even in Austria and then we'll be very surprised - how did that happen? So although this whole effort was prompted by the collapse of Health Plan of the Redwoods and the immediacy of the health care coverage crisis, there was acknowledgment that to really improve health status in Sonoma County, to mediate growing costs associated with increased health care utilization, that developing a vision that would be for a healthy Sonoma County is something that would help guide the work of this group and others that we might bring into the process.

So I don't know how many of you had a chance to look at it. It was sent out ahead of time. But we got just a few minutes to work on it now. If you've got some immediate reactions about whether this speaks to you in terms of agreement in general principles, some concerns about particular statements or how they're ordered, this would be the time to begin the discussion. I've been in other situations where it takes three meetings to develop a vision statement so I can understand if this will require more than the few minutes that we allocated to it tonight. But I would really like some sense from especially the people who have been involved in this for the last 2-3 years or so, to see whether this expansion of the vision of what started out as a response from the immediate problem, but understanding that the components to address that problem are larger than just health services financing, no matter how important that is, or health services organization no matter how important that is. And for some of you this may be a new concept, for some of you it might feel right at home. We just want to have a little bit of taking the temperature of the group as to whether this looks like the outlines of the journey that we're going to be taking together. Questions, comments?

I like this. What seems to be missing in this for me is a recognition of what is sort of the blindingly obvious problem, which is that health care costs way to much. It comes out to the question that Skip heavily reinforced at the last meeting, which is why does health care in the United States cost three times as much as health care in Europe per capita and yet the results are no better? And it's partly obvious why that is and that's the problem we have to deal with. The ridiculous overutilization of psychology is the problem. I think that's a really important question to address. I think that answer is not sufficient. So let's add to the list of characteristics that we want to look at specific language about identifying the particular causes of the relevant overcosts of health care in the United States vs. elsewhere. Got that? Do you want to restate for them?

The problem is how much the overcost is the word that __ used. It's way too expensive. Our health care system is way too expensive. We need to figure out why.

In terms of the actual vision, which I'm assuming starts toward the bottom of the page, there really isn't anything about people having access to basic health care, which I think ought to be part of the vision - part of our goal. And then the second piece is, on the second page, health coverage is available for all. Let me read you what I thought was the vision statement we were working from. I guess the first page is the same - on the bottom it says ÒWe envision a healthy Sonoma County.Ó

No, in the pre - thing you sent out there were 3 pages, the one you just gave us has only 2.

I'm sorry - so if any of you printed out what was sent ahead of time, the second page talks about public and private providers of health care are adequately paid and offer comprehensive, accessible and culturally competent services. Health coverage is available for all including those who are traditionally uninsured. Mental health coverage is equivalent to that for other services. Basic public health infrastructure is maintained at levels sufficient to meet everyday needs and those required in extraordinary circumstances such as natural disasters and bio-terrorism events. Permanent coalitions of health service providers, public health agencies, community residents, health plans, academia, labor, business and other sectors work collaboratively to plan, implement and monitor strategies for enhancing health care delivery and otherwise improving community health. Schools are places where healthy habits are taught and practiced, including meals and snacks that are made available, and physical education is a regular part of the day. Responsible economic development offers economic security. Seniors, the disabled and children are special populations whose needs are consciously addressed in every aspect of planning. Cities and counties plan for regional green spaces, community gardens, public transportation, farmers markets, bicycle trails, affordable housing, etc. while working to eradicate environmental stresses and toxins; and annual report cards of the health of Sonoma County are issued and made public so that people can be made aware of which areas require more focus for the near- and long-term future.

It would be nice to see a statement about business. I see the economic development one but I think it would be good to have a statement about businesses assuming some sense of responsibility for the health of their employees and their community.

Is that a yes?

It's obviously a critical, one of the critical choices of about how the funds are paid. It's not the only one, like single payer. So I'm not sure why -

Not just to fund the health care services, but to make it - to have employment practices that don't work in opposition to employee health to create healthy work set environments, to not pollute the environment - there are lots of things, not selling alcohol to minors - whatever it is.

That makes sense. Anything else? So this is obviously not written in stone. But is there sense in the room that this feels pretty okay for right now with the amendments? I have one more - just because I'm from the Health Department and we might be the most likely folks to need to create a report card. I would be more comfortable with Òmake data available to the community.Ó Because we're moving towards an online age here and it may be more efficient for people to be able to look at health data.

It could be a report card on line.

Sometimes it's nice to have an event where people target their interest and say, this is what we have right now and that's where the scorecard came up, was that people have their own affairs and have their own things all year round but if they understand that this is a compilation of what we know now, and a year or two years later this is what we know now and perhaps what we've accomplished. Maybe there have been certain things that have happened in the last couple of years. Admittedly there is a lot of data that is available and that's kind of the issue. There is a lot of data available that sits on shelves in a lot of places, not just county health departments or state health departments but in a lot of places. And I've seen in some communities where there's a conscious attempt to actually accumulate and assemble something as an opportunity to say - ah - okay, I kind of knew that and now it's being verified.

There's a sample of something Santa Cruz County has done in your packets.

Just a suggestion for some clarity in your language. In some places you're referring to a health care crisis and in some - the first sentence you talk about a health coverage crisis and it's not the same. And then you talk about a remedy being creating a healthy Sonoma County, which is also different from the other two statements. And I think that it's important, although I believe there's a train of thought in here, it's really important to be clear in your language, that you have these dots connected. What does it mean - health care crisis, what does it mean - health coverage crisis, and what does it mean to have a remedy that really is about healthy place to live, healthy environment, healthy behavior, civic institutions that are thinking about health and decision-making in addition to insurance coverage.

You said health care vs. health coverage.

You want to be as clear and as coherent as possible from one dot to the next. I'm concerned that the language that you're using in your __ and in your logic is without explanation.

As we said, this is a work in progress. And it's not my vision - this is something that hopefully will belong to all of you. So the statements that need to be modified, the logic stuff that need to be made clearer, you are not only invited but encouraged and hoped that you will help provide the clarity that increases your level of comfort. And because everybody outside of here has to understand where this whole project is going. Thank you. So we'll work on that.

I think you're right in what you're saying. And in finding the proper language for it, perhaps what we need in accounting is not only the one, not only the second, but all three or all four, and that's really what we're working towards. A large vision of the county and things working at that level. Everybody being included in coverage at that level and then more effective ways of working with health care. So all of the above, and then how do we find the language to say that?

As I said at the beginning, it's hard to do a vision statement in 10 minutes and we've spent more than that already. So I invite you to when we send out another iteration of this to try and incorporate the comments we've heard so far. Please feel free to make other suggestions because this is really going to help the guideposts, the map that we're going to follow. And if the map is taking detours we're not going to get to where we hoped we were going to go. So the next part of the evening was going to be dividing into two groups. The majority of the people have indicated they wanted to work on the health promotion prevention part and a smaller group that has had more experience working on specifically the data project. The smaller group is going to be back there so I'm going to ask those people to get up and move.

And then I'd add, early on in the development of our plans, we were talking about a third sector which was increasing the quality and breadth of stakeholder dialogue, finding ways to really get more talking done that really worked. And that we decided really belonged to the second meeting rather than the first. We've got a better idea of what we're interested in working on, if anything. That's the time to talk about dissemination and group connections. So if those of you who are really most interested in the stakeholder dialogue will simply hold that as a frame in your mind in one of the two other groups tonight, then we'll get more to it next time.

So we've got a minute -get up.

GROUP DISCUSSIONS
(NOTE: THE 2 GROUPS WERE RECORDED SIMULTANEOUSLY. THERE MAY BE SOME OVERLAP AS IT WAS DIFFICULT AT TIMES TO DISTINGUISH BETWEEN THE TWO GROUPS. ALSO SOME PARTS WERE INAUDIBLE BECAUSE OF BACKGROUND NOISE.)

GROUP 1:

We've got about an hour for this discussion. And so what I hoped we'd be able to do is look at the questions, spend a little time on each one. Rhonda is going to be helping us be focused on timekeeping and when we're spending a lot of time on question 1B and there are 5 more questions to go, Rhonda is going to remind us. If the discussion is really rich and we don't want to move off that question, that's great but it's going to be the group decision. We'll just remind you what time is past and we'll just decide whether it's something we really want to spend time or save for the next meeting.

First Question

So the first question and it's written in more shorthand. People have spent a lot of time already talking about this - so we want to make sure that the first thing that we talk about is the nature of the health care access crisis. Here are the key points.

Piecemeal - It's disjointed. We don't have universal health care.

Disproportionate impact of coverage from certain populations.

We can always add to this as we go along. From all of the discussions and we are the ones who live here, a sense of what's critical here. Some of things are going to be true anyplace, but thinking of Sonoma County particularly.

There's a lot of specialty care for a lot ___.

There's a lack of education about health at all levels. What is a healthy lifestyle? That's something that could start through schools.

Education - you get advertising from MacDonald's. Big difference. So poverty is an issue.

Disproportionate ____

This is what makes it a little bit __ than access crisis, and the next part of the question, which is barriers to creating ___. Obviously they're tied together and any discussion is going to have that. So let's switch to focus more on barriers. We'll leave this up, still question 1 but part B - what are the barriers to creating health in Sonoma County. Some of you are [referring to] lack of specialty care, lack of good health education in the schools, in general?

Pharmaceutical industry - people can't afford their drugs.

Let's put that back on part A. Access to drugs.

Cost of living is a huge one.

The hospital health care system isn't structured to make the population healthier. It just isn't and it's going to go further and further away from that. The shorter answer is capitalism isn't working in the hospital system. They're designed - they're trying to make money and they're all losing money, and the way to make money is to not have all the poor people who don't have health care coverage come in your hospital. So move your hospital to a place where there isn't any.

So economic interests of hospitals.

Survival. They have to try and make money. Survival of the hospital so we're not going to cause the system to come together with the way we run it. The other one that I would say is to better Medicare or MediCal - the broader payment and regulation systems can inhibit an individual county from __

Categorical funding restrictions?

What are the MediCal payment rates, what are the Medicare payment rates, what are the insurance... - we can't pretend it with the world.

There's a special issue which is Medicare reimbursal rates in this county are very small. Because it's considered rural. It's half -

That's my point, in order for us to make Sonoma County healthy, we have to look outside.

That would be one of the problems we have to address on a national level.

There's no coherent integral __ or intentions to create a healthy Sonoma County. There are a lot of organizations or lobbies doing __ to come up with what you're saying - not just a business model. There is no decision or planning structure with the ability to do that.

Most sectors of the world who are selling popular deals or selling life insurance or whatever is, capitalism works very, very efficiently. However, with health care, all the people who can't get health care have to be treated ____. ______ There's the assumption that somebody is taking care of it. There are hospitals, there are government providers -

When we were talking earlier about the vision statement and came to the part about economic development and economic security, I was thinking about the importance of living wage. And your comment about economic factors, it seems to me ____ about having a third of the cost, they also have more reasonable workloads - 30- to 35-hour work weeks in France as compared to increasing workload here. I find that the stress on people, the downsizing, the work speedup, that we're seeing in all sectors that we're funding I think impact one's health. So living wage and kind of a healthy working conditions is really key. Beyond Sonoma County, [as well as within].

___________ the full sense of that lack of extended family ____ Among Latinos and Asians ____ If you could find a decent one. We're going to be leaving all these up here so let's move onto the next question.

Second Question

Let's move on to question 2. There's a lot of effort over the last couple of years to ___ and so forth but there was a feeling that the picture wasn't complete and there's still pieces of information here that we needed to make a decision about how to go forward with particular aspects - giving us the biggest bang for the buck. Which kinds of groups are already _____ So this question is actually looking at a data hole. And those of you are here and know what kind of information is available ___ that's kind of what this question is about.

Two kinds of data hole.

We ought to be able to untangle why it costs three times as much.

[Who is doing what?]

Shareholder return?

What I'd really like to know is broken down into the most minute detail so that you can compare how we spend money in Sonoma County and how they spend money in France, and see where are we spending all this extra money.

What would you do with that information - in Sonoma County?

I would target, again, and I would want to verify the claim that I believe is true, that by and large the health care systems in France are about the same as in Sonoma County. So then I'd want to see what are they spending? We're spending 10 times as much on some things and then we're probably spending about the same on other things. But where are we spending all this extra money and do we get better results from that? Well, no. Well then that's where we've got to start, by ratcheting it down. ____ I've seen this figure over and over again. It's not just France, it's England, it's twice as high [as] in Canada, it's three times [as] in France, it's five times [that of] Japan, it's 10 times [that of] China. So I don't think that's hard, but where is the __? Is it this drug, is it this surgical procedure, is it primary care? Where is it going? Where's the money going and then okay, we're spending 10 times more on, I would argue, on stents and surgery. Well, what are the results? Are our results any better, a little better, no better?

I still get this urge about how we're going to make a change in the level of Sonoma County to make this a healthy __?

If I could say with the data behind me that we're doing all these bypass procedures and angioplasties and stents in Sonoma County, but the death rate from coronary disease, the functional status of the person ... is no better than in France where they do a tenth as much. Then __ your doctor, you shouldn't be doing this - don't go there. Are you smoking?

In other countries they're dealing with the lower income people better. They don't spend money on the high-end procedures, the CABGs [?] and all that stuff and we don't do much for __

Now the lower income people are living less long as the wealthier live longer, which offsets the median where they spread it out more equally in other countries.

So there's a disparity issue that should be tracked as well. It's not only absence of ___

If we just reduced the high-end procedures then we would go lower than other countries.

Let's hope there would be more money to spend on - we're spending less on this, and this is the good social cause.

I'm curious if the fact that we're not treating the people in the lower income level also doesn't increase costs in some way or another.

Would you tend to draw a __ in an emergency level they will get a bypass, when in international access for a primary care physician or a cardiologist they might not progress to where they're in extremis when they get there.

I think it can't just be a dollars and cents thing. Because in their __ paper a few years ago they said that getting people to smoke costs you less than health care because they die younger and they use fewer procedures. That was like silly but - some of it's just a human __

It seems like we're kind of getting up higher and higher and higher where it may be changing our policy, changing government, changing insurances. Trying to figure out what makes Sonoma Co. health better. There isn't a day that will go by, you'll read an article that our children, we'll probably outlive them because of their unhealthy lifestyles. So it's like maybe we need to really look at what is very simple - food, smoking, stress, travel - I don't know but it seems like you asked this question, one or two things that would make Sonoma Co. really healthy. Sometimes it's the haves and the have nots, and the have nots struggle and watch at the haves, and I wonder how many people really say yes, they think if they could end the health care crisis they'd put away tobacco. ___ So you need to raise the awareness of the county - here are the stats, here are the figures. Instead of a long article that comes out in some news story on American health care that says our kids probably have a shorter lifespan than their parents. So I don't know, my personal opinion is we're getting so far up. ____________

There's no survey - so a longer term ___

Are there companies in Sonoma County that have kind of employee health support programs. My sister works for Hewlett-Packard and they have a major program where they _____ - so if there's anything like that in the county.

Next Questions

Let's move on. Who's missing from this discussion? Who's not here? Which voices need to be heard? Who else needs to be part of a playing effort? Representation from different racial __.

Actually in your packets there was a list of groups that are already working on teen issues. _____ There were also issues of businesses - small business represented on the list. We'd like to see even larger employers, public institutions, Kaiser - so those are the kinds of things that are needed on the list.

I think teachers too from elementary or secondary because they interact with all kinds of students from all kinds of family situations. There are after-school programs that would be particularly good to help reinforce ideas about ____

___ social economic status. We need to help people who have lower incomes who are struggling to survive. Are there neighborhood community-based organizations that represent these folks?

_____

Issues of cultural contents in developing solutions depend on having representation. Churches -

Any suggestions about that that occur to you after the meeting - we hope that we can do more outreach to make sure that looking at it in a timely way ____

Most people figure out that they can't change everything in the world and they focus on ___. And if this group doesn't have a focus you're going to have trouble attracting people who are ___ and try to make a healthier county ___ and nutritional opportunities for poor kids.

This group is going to have to choose priorities. Nothing is __ success if you take a relatively small slice and you have the larger picture in mind and you succeed that does for people. And then once you do that it's easier to answer your data question and it's also easier to answer who should be ___.

You know where you're going.

Yes. And if this group decides for example that it wants to work on teen issues then that would be the logical next bunch of folks to go seek out. Since you don't want to duplicate what's going on, you want to enhance what's going on, you want the wisdom of people who are already doing that.

Even if all those people aren't at the table, I would love to see ___ paint a picture of all the concerns of the groups and what they're doing and the connections between them, but then you become a resource. Because often I think there's people that are working on support issues and we don't even know it.

A kind of central data exchange for all of the health-related stuff, even if it doesn't appear to be health-related. A lot of the school stuff is really health-related, but they don't identify with being part of the health -

Have you found in the Health Department that there is a little collaboration among groups that maybe have shared interests? Or do you find that the collaboration in the county is pretty _?

I think it's pretty good but as I said, it's been centered around particular issues.

_____?

Oh yeah, I don't think on every issue but I've been on 4 or 5 issue process ___ looking at issues related to __ nutrition, injury prevention - there are many, many - The next question has to do with (inaudible) ___making the vision come to life. So we talked about groups that already are dealing with issues __ so that's clearly something to build upon.

Also you've been spending - folks here have been spending the last couple of years building some relationships that __ with these issues. I think that's an asset to building -

It does seem like ___ that we did in the past that there are already collaborations. In the school system there is the school garden movement and the farming school movement which is bringing locally grown produce into the school lunches, and I think the community is ___

So creating a list of those kinds of assets might be something that again, like you said, that puts all the information in one place.

(something about people from Mexico)

community-based clinics that are serving and they're doing a pretty good job of serving them but they always don't have enough money and enough resources

There are some organizations that are using the Òpromotora de saludÓ model where they're actually supporting peer leaders to provide incentives __ health education to their neighbors.

_____ program and facilities for major health care providers - I'm thinking of the Sutter Breast Care Center and I'm thinking of all the building Kaiser has done recently, the pediatrics building. So it seems like there's some real advancement and growth there of some special services that they didn't have before.

With the health care environment in a lot of communities too. Just healthier, cleaner air.

Fifth Question

Next question - 5. There were issue steps that I pulled from the prior work that had been done. What I thought we would try and look at is for each of these steps which would be free access to quality care, moderated health care costs, improving countywide health __ for population-based prevention services. Starting to think about what kinds of strategies we need to apply to collaboration, special studies, data reporting analyses, using ADCD __ development ... So just spend half a minute - what kinds of strategies, given the fact that a lot of it is national, the fact that employers think health care is not something that is ____. Nevertheless -

Take the Children's Health Initiative, that provides insurance for ___

Get involved, raise money for it, give money to it, talk about it -

It sounds silly but a lot of these access issues are really about __. If you're a senior without a touch-tone phone and you can't access the health care system - you get lost.

Things that are simplified, minor technological -

Is there any kind of Paratransit?

It's very, very limited though and people have a hard time getting to doctors' offices, especially near ___

_________ There are a number of agencies and groups and individuals who have __ to go on about the problem-solving. Even among this group, I think we're saying to each that the only way - because we have a lot of specialized people but it isn't widely shared in the county. The average person.... I'm wondering if it's possible to develop strategies that make much more publicly available either from information about the status of non-health problems including progress, because I think they seem to just repress everybody and that's not healthy in itself. ________ the nature of the problems, the nature of the ____ and the assets or resources that are in the ___. That would give a precondition for people that are self-organizing around connecting with each other and communicating with each other.

That's kind of what the Santa Cruz [work] is trying to do and there are several counties across the state [which are] creating those kinds of reports. They're designed to be widely disseminated, they're designed to be put into context what it means when the high school graduation rate's going up or down, what impact does that have on health? And that's kind of what the discussion of the January report card related to. It wasn't an epidemiological journal that 5 people would read.

_____programs for progress. It becomes part of ___ specialized reports or even a Web site that people who are Googling something might find.

Making it part of the conversation. Any other comments about that?

Sixth Question

Let's try and get to the last question -

I was just going to say health care work toward development ____

Last question - as you were thinking about coming to this meeting, I am hoping that your specific expectations about what brought us to this meeting would be measured. This kind of process is helping to get there. And also thinking a little of what kinds of recommendations would you make to move this particular part of the process forward in our next scheduled meeting. And what other kinds of recommendations - series of projects to seek funding under whose auspices. What you would like specifically to come out of this meeting, what you need to help prepare for the next meeting, and then what we need to __ get beyond.

I think ___ earlier was really totally on target. This is just too big. So we've got to prioritize. It seems me the most important thing is we've got to prioritize. This is just too big.

What would you suggest to do that?

Well, group dynamics or whatever, there's various kinds of processes that you can use. One last suggestion, at least it breaks the problem in half - which two lights are better than one. You call it health care but really mostly, most of all the money we're spending is on illness care, taking care of illness. And then building health is a whole different picture, really different. Illness care has actually relatively little to do with health. So we should decide - maybe it helps to sort of put those two -

Great suggestion. ____ What we hope is that when we all report back on what we've separately been discussing that the priority study, which we certainly can't write a project description in that time that we're going to do a little bit of everything about everything. Nobody will fund us, we'll all be very frustrated. I think there will be something that has very specifically to do with actuarial issues and cost issues and so forth. And then there will have to be something from all the possible things we do - on youth fitness and obesity, safer places to exercise, fresh fruit and vegetable access and affordability, supporting family farms - there's a variety of things. We have to choose among them because we don't have the resources to tap everything. More specifically, we're going to have to make those choices. I don't think tonight we have enough of an understanding of what all the possibilities are, partially because we need more information about who's doing what, there are other people who aren't here who might weigh the priorities differently. So for right now, what would you like to see in your packets at the next meeting? What will help us move to make those decisions?

In the best case, one scenario would be three specific topics for the group to pick one.

So we can prioritize.

Down-select - not prioritize, drop two of the three specific topics. I've been in so many different committees like this. Depending on the subject - if we don't move this toward action in a second meeting, you won't get anybody. It's done. I don't care what it is. If the drop-off rate is __zero in terms of people coming here. It's got to be a meeting that gets ___ take all the short-cuts and say get a small subset together of three people or four people and say the top three ideas that are actionable are - that's what would make them come to the next meeting.

We actually are going to spend a little time at the end of this meeting attempting a first attempt at that.

______ actionable. Because a lot of the things we discussed are very admirable but actually at a county level the criteria ___

The three words I like to use and this is what I use about the Children's Health Initiative all the time - timely, compelling and solvable. And to your point about well gee, we don't have all the information on board - we're never going to have all the information, we're never going to have all the people here. I chair the Sonoma Health Alliance, which is all the hospital CEOs today and the head of the clinics, and believe me, we could have 18 meetings and never have enough data and never have enough resources and never have enough __. There's a lot of smart people in here, a lot of people have data, a lot of people have opinions. Paddle up three things and let's pick one that's timely, compelling and relatively solvable. If we go to work on this we could knock this down by 80 or 90% in the next 3 years. And that's how it will keep people coming back.

That's why I agree with your sense of people are not going to come to sit and jawbone at each other they do that enough in other settings.

There are lots of opportunities. I've already had this discussion 150 times in the last 3 years.

Do you have any suggestions for things that you see in action groups?

We talk about this in Sonoma Health Alliance - doctrine of action. This whole notion around a county 5-year wellness campaign could have a powerful effect. So let's get at it from a prevention standpoint. Another is - and the Sonoma Health Alliance is looking at this right now - something focused on children's health. For example, let's tackle childhood obesity. Come up with a game plan that we reduce the incidence of childhood obesity on ____. Things that I hear about and I say if we got the whole community on these things and Children's Health Initiative could help cover it, I believe that we could take those 8,000 kids who do not have health care coverage and get 90% of them covered in the next 3 years. I believe that this one is solvable. And I think that the other thing that would happen is that we could pick something that the ball would really start to move, that would then lead you to - you don't start out as Motorola. You start out as some little garage in Rohnert Park. We're trying to build a clinic right now in San Diego(?), working on a surgery center for kids is a big, big deal in this community. ___ so they're in so much pain but there's no other way. It's staggering. If there's one problem that this group can say -

And in both those cases, I think those are both things that I think would be really __ that we're going to do, there are groups that are already working very hard on them. So the second phase is after you identify some things where you can get an actionable work done, then the question is what is the true and valuable role for this group? Where can we provide leverage for work that is already being done? If there's none of course, then we develop it. But I think we need to be really smarter in applying anything ___ stuff that's already happening.

It creates a special point of leverage and I think the group could figure that out. And it would be something.

It's 8:20 - and we have 5 minutes to finish up. Five-minute warning.

Following up on our chart to the group. We did want to attempt to get to priorities so that we know how to structure the next meeting. Are there other things? Other comments, suggestions? So the three areas were the Children's Initiative - dental services for children.

Dental surgery for children - total wellness campaign like San Diego and some of those places. Kaiser - they're the best in the world today, their whole system is actually ___ we have a single word vision ____

The message of those ads is an antidote - because really what the problem is because of all the MacDonald's ads -

There might be something that you'd want to launch in Sonoma County, whether you've got it publicly funded by doing something like that or you sought outside sources. Businesses could be convinced their health care costs would go down - universal wellness.

One of the focuses on that could be I mean we are so ill-prepared for the aging of America, let alone our county. We're going to have twice as many seniors 10 years from now and we are all in denial about aging. We need some type of focus and some education on how do you age in a healthy way? With reasonable expectations.

We've got a suggestion for focusing at least 3 different ways on children, another suggestion focusing on healthy aging. So we've got four areas that we've identified as being worthy of attention. Are there other ideas?

This is broad but I just think that parents need help. _____

Give yourself a hand, you got through the whole list. Who wants to be the report back?

GROUP 2:

This is basically what's in the packet.

There are some questions that help us work in a large framework. I would suggest that we save those for a while and get ourselves going on the initial ideas that each person is bringing in or thoughts that people want to start with. I know there's a time in the summer - I'll start with a 30-second piece - there was a time in the summer of 2004 after the spring conference had asked there to be a working group during the summer to develop recommendations [from all that had taken place at the Conference]. We were sitting in one of the early meetings and Tom and Gil and Art were at that, and Michael. And Gil said - ÒWe've got to do a Data Project.Ó ___ And it...just grew like electricity in the room right from there. And I think it would be good for you to start up if you just want to start with the initial idea that you're coming in with this morning and if we can each hold it to about a minute we can zip right around the room and we're off and running.

I was motivated last summer having been in health planning in what sort or another over various incarnations over the last 30 years, naturally we have to take a look at what is really happening. And what kind of available data - I don't mean the data that's been culled itself but there are other - there's a lot of data that's culled less. Actually ___ and then there's health plans that operate in the county. There's Kaiser that always is really good at knowing what it's doing with its - they know it's something like 30-35% of the plan coverage in this county is Kaiser. So the sense is to have profile as a team marker for this group that comes out at some point, in let's say six months in Sonoma County. That not only drives the efforts of this group and impacted on this group, it also recognizes the fact that there's a lot of things happening in the county. There are clinics that are very active right now, there's the coalition that's trying to build healthy kids, a program here that has some money, I believe out of the Endowment, to help drive a program similar to what's happening in 10-12 other counties in the state. So something where this entity will provide an asset, a range of health care of this coalition ___ and presumably do this in concert with the county __ in the past had a lot of responsibilities and it has generated reports...

Sonoma County health profiles is put out every 3 years and ___ status on population on diseases around mortality, deaths, but mostly it's disease-oriented and also there's some serious orientation when it comes to mental health services. It also has demographic data about poverty status and about FSE per capita, data that helps equate ____. Where it's missing and where this project might grow is in resource data. There really isn't here or anywhere else real good data about the way resources around there ___ such as corporate resource that is given to us, not just health insurance coverage but health COBRA they have for employees, how much do colleges put in towards ____. Resources related to workers compensation packages, retirement. What are the costs for resources that they're putting towards them? It's a comprehensive health approach __. Another look further into this sort of resource is health impact surrogates that would be considered resources like school absenteeism, because every time a kid is home sick from school, the school doesn't get reimbursed by the state for attendance. So if you're impacting that - so having healthy kids makes a difference in terms of attendance, makes a difference in terms of school income. So there are a lot of the first responder data - police, fire going out and responding to health calls. We haven't really used that data but sick people, especially chronically, indigent, chronically ill people ___ and law enforcement. (inaudible) __ to the community as a whole so that you can in turn reinvest that in making a healthier population. ___ so look at resources, look at county health surrogates, look at public schools. In terms of health information or data, that data that does not appear very clearly and it speaks to Gil's question about what's happening now ___ about insurance coverage and my premium costs going up and ___ People are thinking, how much am I willing to pay for health care and it's a question of Sonoma County consumers, how much are you willing to contribute in perhaps a different kind of levy. It may be something like a can and soda tax - something that contributes to poor health outcomes. Tobacco does. That would be not only a benefit of a deterrent from using unhealthy products, but it would have some revenue that you could work with in turning it into a system to create health improvement. How __ is the public for that kind of fee? How much are they willing to tolerate in terms of regulation? Maybe it's regulation coherence practices, running advertising in schools about healthy climates regulation in terms of having certain healthy __. How much is the public willing to tolerate of the ideas that you're raising here? You want to have some premonition of whether you're loading something that has no way of getting in the popular support.

So as imagined, a poll.

That would be a poll.

We can look at if there are polls that have been done that are really excellent, take a look at that and develop something and get it out as part of this. So a poll really fits, very carefully done. Coming around and starting comments around the room.

In the past I have tended a little bit as Gil has, to look at the data project as the beginning of funding. What it would essentially be is a platform for planning, for developing strategies. My main interest has been for a long time evidence of the post- health care costs and much of our delivery system malfunction is supply-side driven. While I give great respect to the importance of taking the __ away from the kids and having healthier diets and better lifestyle, the really aggravating grinding costs that are killing us are coming from an industry that is revenue-driven and profit-driven and is stacking services in a way to maximize patient populations as sources of revenue. I brought with me - I didn't finish it until almost the time to leave - I want to give you an example from a report prepared by the Public Health Institute that I worked on that has some numbers that will give you an idea of the range of variation in Sonoma County in 2002. This was true for 2 or 3 years to 2002. Very high cost specialty services, specialty surgeries especially, that account for a large part of the per capita costs in this county. The good news, I'll start with - should I do this now?

I would suggest that you might do the brief version. It would be good for us to hear the good news but then be aware that we're doing an initial round for everybody. We'll come back to this.

I'll give you just a couple of examples. The good news is that if compared statewide with the populations after adjusting for age, gender and severity, on certain ambulatory care sensitive admissions, Sonoma doesn't do badly. That is to say, that typically the ambulatory care system is one conspicuous category that's really bad, and that's diabetic kids admission rates in the hospitals are soaring. It's 12% higher than the state average for the under-35 population and most of that's going to be young adults and kids. But compared for example, Stanislaus County and other counties of comparable size, although very different demographics and different environment, Sonoma County doesn't sound too bad. To give you some idea of what the picture looks like, is your cardiac vascular admissions without complications were 38% higher than expected although most other cardiovascular admissions were just at or a little below the expected rate. Surgical admissions for digestive tract disorders had admission rates ranging from 33% - 40% higher than the expected. Orthopedic and musculoskeletal surgical admission rates were well above the expected, and procedures related to breast cancers. The admissions for those 35 and older were half the expected rate and under 35 were hospitalized at a rate 12% higher. Admissions for full-term neonates with major problems were 19% above the expected. Postoperative - this is really bad news - postoperative and posttraumatic infection admission rates were 17% above the expected. This is above expected means is it's above the state average. The state average in these categories is sad. The state average is a disgrace, and yet this county is consistently above that. I haven't calculated it out but I can tell you that by the time we calculate out the questionable rates and their charges as listed from OSH__, it's going to be in the hundreds of millions of dollars. That's not the total of cost of hospital care, that's just the cost of the questionable admissions, for one year. So we're looking at something that needs to be addressed, but I think fundamentally in all of our review of the question of quality of care and quality of life, and that is how much is the supply part of this health industry here driving unnecessary or questionable hospital admissions? And especially from the high expensive scale.

I think organized labor is here because not only does organized labor negotiate with employers for health care, but also unions have messed up a lot of trust companies that provide health care. And I think what would be very useful to us is we need to know what our total inputs into the system, in terms of dollars, and total outputs - kind of like what George was saying, except I'd say it a little bit broader in terms of to look at, remember which way, what is the total amount of dollars that are going into the health care system on all different levels as holistically as they can do it, vs. output as so basically get handle on how much total money is being spent with benefits they're receiving, and to then be able to parse the data in such a way as we can figure out public policy, health policy initiatives that we can recommend. Because the data should have implications, and then I think that the idea that you __ is excellent is that once we have those initiatives then we have to do polling and shaping of the data to find out where the public is, where public opinion is, and then look for stakeholders and partners. I'll give you a perfect example. It wasn't until local people were able to figure out that they had to get a big tent for transportation in this county. With transportation you're able to go anywhere. It's the same thing for health care. We're going to have to find a way to bring everybody together. And to me as a practitioner, it drives me crazy - it's like a big black box running now. You pour money and money and money into the system and as consumers and our members, we feel like we're getting less and less and less.

I see a data analysis putting a number of really good systems of data in and analyzing the data and cross-referencing it is a way of ___

_______

The Future of Family Medicine Project that you're involved in, and the train is just leaving the station - it sounds like a very important initiative for us to learn more about.

The last task force was on finance __ because again, I bet you don't deal with that and it's pie in the sky. Let's hope that there would be more money to spend.

We're spending less on this and this is the quality.

In terms of where I take it in terms of my interests, I have kind of a general interest in how and what's going on in the health care sector interfaces with what's going on in other economic sectors and I think that's an important question. And then I'm also involved with a group who is trying to get a number of faculty from various departments at Sonoma State, specifically involved in development of a __ in Santa Rosa. And obviously an area that was ripe for development and a lot of attention going into it, and it seems like a good place to try to do a bunch of interdisciplinary power projects ____ education, a whole bunch of stuff. It all kind of has to work together.

I admittedly have a little bit of myopic point of view because I work with a specific population, the educators in Sonoma County, about 10,000 of them. And I think as I listen to many of you that are professional to some degree or other in the field, I think that the challenge that I would be faced with representing some of the same people Michael just talked about is to number one, develop an interest in the data. I think there's so much focus in what I do in just what it's going to cost you next year and how am I going to make those payments that that creates all kinds of stresses that don't even allow you to get to some of the things that you've talked about here. And I think if you could develop data in a way that it's palatable and not threatening to the ultimate consumer, it's a small group in my case but where we can look at this and not immediately jump to executive costs more or less and what's the cheapest way to do it. Because that may not be the best way to do it. So I would like to see an approach that simplifies it and makes it of interest to all of the consumers that eventually determine what the utilization is going to be - back to your issue. They hear some of that, they don't really want to hear that right now. And I'm not talking about management or teachers or any group. I'm talking about everybody except for maybe those of us that are involved on a daily basis with purchasing health care. So I like the idea of polls, I like the idea of data. I just think about how it is right now, you get on the internet and you punch in something and you can spend more time than most of us have and unless somebody can synthesize that in a way that is meaningful to the average person who just really wants to be able to afford health care and have access to health care.

One thing very high on my mind is the potential we have for collaboration among us. I just feel like things are so bad and things are so complicated that two minds are better than one and larger numbers in minds can be even more so. And so I'm sort of hanging on to that bird to see if it can fly. I really think it can. And then to add to the data project, the needs that have been brought up so far, another high priority that we talked about before is a set of master calculations that need to take place, or at least given a lot of assumptions - what would it take and how would it work to find health care resources, access resources, for people who are now shut out? And what would it take financially, and how much would there be in offsets from existing programs that could be configured in different ways. And although it's talked about a lot, I don't see it being calculated, that I'm hearing about anyway, and especially not in Sonoma County. So I think that would be super to raise some foundation money for mathematicians and health analysts to help us figure out an overall model, how we could be doing it more right in Sonoma County so that we don't throw anybody off the ship. It's a big leap but I'm not convinced it's impossible at this time. And we're not going to get the feds to solve it for us, we're not going to get the state to solve it for us. I really think the theme is what can we do locally? And I think this is something we can do. We can get some foundation help for calculations and setting up the problems.

There's a foundation sponsored by organized labor in Santa Clara County who has actually drawn up a cost model for what it would take to cover public finance toward the ____

So part of this planning process could be contact that county, get information, formulate it in a way -

It's not the county, it's in the county.

Working partnership.

You talk to a girl - she was once my baby-sitter - a young woman named Sara Muller. Sara Muller does the work.

This kind of brings to mind, one of the things that we're looking for here is also to identify things that are happening in other counties because many other counties are doing the same damn thing we're doing here. And what the heck can we do to fix - where do we start? And some counties have chosen to start in terms of Healthy Kids. Let's at least deal with the children. Others have tried to deal with ___ coverage. What we're trying to do is to not only explore our best way, but also identify some few good ideas, maybe the best ideas, from other counties that are also in this dilemma. That's one of the things that motivates me to do it.

One of the aspects of what we try to get money for is to do a statewide, countywide county-by-county, community-by-community scan, who's doing the best work, and then try to incorporate it into what we're thinking about in Sonoma County. I just want to add one more thing.

The program is funded ___

Well - let me have some applause for Gil. The one more thing I wanted to bring up at this point is that I had a set of experiences back in the Ô80s and early '90s where Adele and another partner and I had a consulting firm working on health care crises among large public jurisdictions. And we got into working with renewals very aggressively with the health plans so that there would be 8 or 10 unions plus management would come to conclusions about what they wanted to do and then we would go at it with the actuaries and financial vice presidents of health plans, and to me the key was we brought in one of the best independent health actuaries in the state, a guy named Marty Miller of TBF&C, who sat with us and just cracked the egg and looked at every line in the potential renewal to see whether or not it was fair. Guess what? It was almost always padded with certain things that they wanted for their bottom line but that didn't have to do either with the health or the financial stability of our plan. So I would love for us to have at least one in the year's round of labor management negotiations, broad scale or within the educational community or the public jurisdiction community, where we have the services of an independent actuary or an independent actuary's mathematicians, to work line by line on the renewals that are being considered for plans, and not have them renew higher than they need to renew, and that idea is buttressed by having more sophisticated data coming in where we can understand more what's going on and what some possibilities are, so we can negotiate the way certain things are handled as well as call negotiators from health plans on their profit-driven assumptions that are beyond reasonable.

I have a question for you, Gil, and that is how complicated is the task of getting this information that you were suggesting was going on in other parts of the state, where things are working when they're looking at a piece of the puzzle?

How complicated is the task? We funded a study a couple of years back and took a look at the Healthy Kids programs and what they're doing and how effective they've been. And that was a project where there was a lead investigator, an associate researcher and a graduated student. We did that project in about 6 months and it cost us - we paid them maybe $30-35,000 to do that project. I know that the consultant groups - high-price groups - do that for $200,000. In a heartbeat. So it depends. It depends on how deep you want to get into it, what are your key questions. You start off by knowing that there already are probably 15 or 20 counties that are leading actively engaged in kind of exploration and experimentation, and you probably key in those particular counties, and you talk to the right people, the opinion leaders, the movers and shakers. And you can get something out of that. You have a couple of graduate students and a good supervisor, faculty member, you can get something done in a matter of 3 months.

Skip, in terms of your idea about collective bargaining, I'd like to see all this data develop, it would be quite a bit of analysis because right now with health care it seems like a shift. For a while the insurance companies had the whip hand, now the hospitals - it shifted to the hospitals for a while. And it just seems to me that I know just speaking for the Labor Council and the labor unions and employers, I think we're looking for some good data and some public policy initiatives before we even want to head back to the bargaining table because when you go to most counties, one of the things that's most perplexing at the bargaining table is the lack of data, the lack of understanding where the money is going. For what.

He just drew me up - why don't you say it again -

I'll start you out. Before you've come back to the bargaining table, you really want to look at deeper data that you can - we want to look at the structural issues. We've been bargaining for benefits and getting the hell beat out of us. All we do is pick over the bones while the industry run amok with profits and enhanced political strength because of consolidation. We've really got to bargain outside - we've got to get past benefit bargaining, as important as that is, because it's not __. The health plan -

Beyond benefit bargaining to direct bargaining with the providers -in terms of the delivery system cost and quality there can't be any substitutes for direct bargaining with providers. I don't care what health plan you're talking about -

That is to say, the buyers, the purchasers negotiating directly with the health plan.

One of the factoids that came out in the process was that ___ had generated $400 million cash in California that it sent up to the parent corporation.

Assets out the door.

Out the door, out of California, not into the health plan, not into providing reimbursement or benefits for the plan.

You waste your time bargaining with the health plans.

___ generated 500 million last year?

It has to be more than that because CP&C sends $100 million a year out of San Francisco for one campus alone to Sacramento on an assets transfer. That's nothing, no pay per fees, no payment for services. That's just the margin that they lift and take out. And this is after they pay $3-to-4 million a year for the top executive staff. And substandard wages on the floor.

I'd like to just raise for a moment, and then we'll just go ahead with what we're doing, the fact that this is the first of two meetings. What we're doing is beginning to put out on the line a number of ideas that we want to explore with the idea of developing priorities by the end of the second meeting of what we really want to go after. There'll be a Web site operational as of 3 this afternoon to toss your ideas up there. We'll be putting the notes from the discussions and the week after this meeting there will be a transcription up there of what's been talked about. But thank goodness we have not only tonight, but we have 3 weeks from now. I just wanted to put that out, not to change the tenor of discussion but just to help us remember that we're helping ourselves by having a second round.

Just for my clarity, I know that we've been trying for the last year to have to raise some seed money, some grant money. We've raised some. What do the people who are giving us the money believe we're going to be doing with that money? What have we told them? Just curious. I had to ask -

You had to ask - quick, turn off the lights!

It's very simple, very pointed. There are small costs involved in getting everybody together and having communication facilities between times and all, but the primary and almost exclusive cost is two excellent healthcare fundraisers who are going to be interfacing with us. They have already started to, they're interfacing with us, to get our ideas and it's our responsibility to generate ideas, to set priorities and to really be passionate. It's their job, then, to write foundation grant or grants to go get us the money so that we can carry through the visions that we've got. Does that make sense?

That helps a lot. It gives a context of what we're doing.

Do you agree with that method?

I know that with economy working solutions, our group, we do a lot of fundraising so we do research.

Every time I've gone to those meetings I've come away with the notion of getting the data that will enable them to be the kind of negotiation between consumers and providers without all of the expense of these fancy middle persons we have - that's really a fairly fundamental __.

At one point you were talking about a virtual universal health care system by having the data be transparent rather than by having everybody sign up for something. That seems to me supported by this kind of data that is structured __.

Well, you're clearly agitated -

I have to go - just something that I remembered and I wanted to be sure to bring up tonight because we have three people missing, all of whom are going as leaders to a Latino health care forum tonight, I think is very important. And their not being here means that one theme is not going to be reverberating as loud as it would otherwise. But I want to tell you the story that I just found out. You know the Southwest Clinic is such a blessing for us all, a handle of the large part of Latino health care people who are without homes and the like.

But [someone] told me at the beginning of the week, guess what - you got a 3-month wait to be seen. Now again, I think that's unconscionable but whatever it is, it's a fact. And so when we're talking about data, data gathering, data analysis, and putting data to work to make change, this is a place where - okay, clearly the very low-income people, homeless people, are getting the short end of the stick. Okay. So what is the cost to bring the Southwest Clinic forward to be able to have the capacity to have a one-day wait? And before we dismiss it as an unrealistic proposition, we ought to do the calculations. We ought to know that data. We ought to know the factors and see if we could creatively come up with something, and that then, to me, Southwest Clinic and it's 90-day wait is emblematic of a larger set of problems we've got in that domain. That's why... I just thought -

You're lucky there because they have a budget and they certainly have a budget that shows what they need that they don't have. And the Southwest Clinic sends a truck to San Francisco periodically to pick up free supplies from the warehouse for the organization ... called Operation USA. The clinics don't have any cash to buy gloves. They don't have basic materials for seeing patients because the budgets are so constrained. The information is out there except that at a certain level you're blocked from it without bringing terrible, terrific economic pressure on the providers.

The deals between health plans and the hospitals are kept secret. Of all the things in our society, the most critical information about cost is a secret protected by confidentiality agreements and enforced by threat of lawsuit between health plans and the providers. So we have a lot of work to do to open those subjects up.

That reminds me of another thing that was in the process of being secret but it just happened to fall out the back door and that is the reimbursement, the ratio of reimbursement between that given in the large hospitals for a piece of work, and that given for the same piece of work within the small public hospitals. And the ratio is obscene. So there's a question of how to develop and how to stand on what the dynamics are, the data elements that are available, the political elements, and bring pressure to bear.

District hospitals for instance last year were the same to me - Blue Cross 50% less for services. Each of the district hospitals were negotiating directly with Blue Cross and they were not ____. And as those of us who have been in the ___ needs, done negotiations, we know of course that's going to be the end result. And so they don't have the data, they don't have political position to organize themselves as a single network. I'm not sure what that speaks to, mostly purchase of interest __ going around the table here. That's just one covered factor, that data does drive a lot of the success both on the provider side as well as on the purchaser side.

I've been listening to this a little bit and I don't pretend to know much about it, but the focus, at least in the last few minutes, seems to have been trying to get the information from the (setup guys?). And I'm not saying insurance companies aren't, but what we hear from the providers is technology -

It's a lie.

I'm just telling you what we're hearing.

Five fictions are technology, aging population, the industry dominating pharmaceuticals. The industry dominates the debate. They tell the story and unfortunately most of us have bought it for too long.

But it seems like we have a physician in our midst. I mean you must have a sense of what's happening those three areas, probably, and maybe - I'm not saying that what you're saying isn't correct. I'm just as suspicious as you are. But my point is if you're going to collect this data to just go after the insurance companies that's one thing. That's one goal but that doesn't get at all at the mission statement. So I'm getting a little bit confused here as to what you're really trying to do.

You know there's a difference between the prevention group and the data groups in that the data group has actually been working for a couple of years - a lot of bridging and abstraction in the early days and we kept pounding ourselves down towards touching ground. Now we're getting down close the ground and it's hard for me working with the group.

I was just looking at the list of vision elements and questions to be asking, and I kind of know what most people's answers are, just I'm more of a structuralist so I'm not emphasizing that. But also I hear these folks talking about not just focusing on the docs, not just focusing on the hospitals, but trying to develop data that will help us look at the whole system, the whole thing from left to right and be able to see how the pieces go together. And that incorporates the larger vision of what we ___ so don't let me pull you off -

That's good, I hadn't heard that before. What are you doing in ___?

Part of the thing, political background I guess ____ the vision is that you go out the door. And all of us, 200 of us, could sit and try to address that vision for a long, long time. The question is, where do we find a series of projects that are kind of doable, and lay the framework in order to implement that vision. There was a big tent concept that I think - the idea of being is that is there one or two big tent issues that draw the kind of - everybody says aha! That's something that is both doable and that we all want to address and want to solve. And that's part I think of what we're trying to do, both in this meeting and in the next meeting.

I have no problem with saying our objective is to find out what the chairs aren't telling us. I think that's a __ goal. Why not just focus on that piece of it and figure out how to get their information.

I'm hearing a couple of things. One is about creating models with the kind of data that we need. Another is kind of strategizing the politics to get that information. And it sounds to me that a lot of thinking to ___ a kind of information that's going to strengthen the position of consumers. I'd be curious, since we have a doc here, if you have some sense of what needs the providers have, what kind of information would providers like to have that they're not getting about the relationship between the providers and the purchasers.

Look at that Web site.

___ population that doesn't have any access to care, it has no coverage. The care we're giving - people who come to our office are getting ___ have to wait on hold for a half an hour - the whole system is broken. We have to come up with the resources to fix it. And to me ____ there is no value to the outcome (inaudible) ___ if there is a way for us to develop a model of direct partnership between the health care providers and the employer, and have some way to cover catastrophic, and they only way you can do that is the kind of analysis of where is the money being spent now? What are the risks of that? ______ so that's one area is to eliminate your profit-making bureaucracy that's taking hundreds of millions of dollars and pulling them out of the system.

The other area is to improve the efficiency [effectiveness] of the delivery system. Get rid of errors and kind of have a more sane approach to end-of-life care. I don't think it's a lie that people are living longer and I don't think it's a lie that there's a lot more technology now that allows people to charge more money. And the fact is that in another hundred years, average life expectancy is going to be __ and that's huge. So I think those two areas. Trying to figure out is it possible to develop - I think there's a growing __ of non-Kaiser providers who are trying to do that, they realize that the whole thing - including the hospitals, we work __ more of them. So [a hospital] I think [may be] very interested. They recognize that their physician staff is [in difficulty]. And they realize that the health plans are putting the screws there. Why couldn't we set up a primary care system ___ to great quality primary care with an electronic platform ___ so we could really compile the data and say, this is how ___ now. We could do that if we didn't have to spend _______

[Participant said:] What we did is we took in data as to how you put together green building practices, affordability, and social equity and how do you make that work.

And what I did is that I didn't go in and just say - is there something - I brought in Oakland, I brought in what they did at the Staples Center, I brought in the La Brea project in L.A. We brought in all projects all around the country in California, but all these things were brought together and they're actually working. It's kind of hard to believe, organized labor in the neighborhoods actually brought Rupert Murdoch to the table and got him to do something like a community benefit. And so __ other counties ___ public policy that helps the decision makers, it gives them the fig leaf they need at times to say I've gone elsewhere and this works. And so to me this gathering is just really essential because I can't tell you how much easier it was to lobby these people when I could show case study after case study of it actually being working as opposed to __ it's going.

___ in this case for primary care, but if there's not enough money for the investors can ask the modernization of information systems or the support structure that you need to make your plan more productive. Arnie Millstein in a meeting a week ago went through the things that are in this delivery system that are the waste, the medical error costs, the frauds, the administration costs that are nonproductive relating to patient care, the APS that's 50% of the health dollars. That's off the top - that's why our costs are twice ___

Get him to write it down.

It's actually transcribed. It's Arnie Millstein's cost pyramid.

Get it to us by e-mail and we'll put it on the Web site and it will be really easy for everyone to read it.

It may be on the PGH Website. He's the medical ___

A question that I see is the possibility of more productive negotiations between the consumers and the providers coming out of the development, out of the database __ . And a number of ___ that the state get out of trying to be the universal provider and ____ catastrophic insurance ___

I think I can imagine it, not their getting out but rather their seeing the real basis for getting involved in reinsuring catastrophic costs. They're becoming part of a consortium for reinsuring us.

You may be settling a problem that doesn't exist. Have the __ hospitals __ in California are being paid by Medicare. That's not the same. Half the babies born in this state are paid for by Medicare. You're not going to get rid of that that easily because without that, even the hospitals are in bad enough trouble, they're only get paid for ___

I don't know if you should get rid of any of that stuff. I'm talking more about politics particularly at the state level where there's room for certain kinds of creativity ___. Of course it's not much, but it seems to me that educating ___ compared to what? ___ In some sense, by creating this kind of more sophisticated system at the local level we could encourage political constituencies that are trying to operate at higher levels to simplify their lives by asking them to focus on the things that they actually can do something [locally] rather than trying to mastermind the whole system.

I just want to underscore one thing. A multiple of you are talking about catastrophic reinsurance from a higher level and that's something we should [consider].

(Five-minute notice for both groups to finish up)

Okay, 5 minutes. A combination of whatever you've got that you really want to put out and what you know you want us to concentrate on when we next get together.

Developing this data that we're talking. I spent two hours with __ and he has this crazy plan to make it mandatory that employees would get health insurance and they pay it themselves. I asked him, where did you get all this data? He got all this data from insurance companies. He's a __ graduate. I said where did you get this input? He said the insurance industries. The point I'm trying to make is someplace, somewhere, we're developing this data, we're encouraging others to develop the data and the more we have the more we can convince policy makers to do rational things. But we don't have that data.

Conflict resolution __ we could really develop high line data that's consistent and really makes sense and speaks to the needs, this is a big step forward. The need of our coalition is - [Northern California county) ...we don't have enough data to profile. We can profile the hospitals for public data, we cannot profile the doctors and medical groups. _______

Last three minutes

What are the priority things we think we want to work on next time we get together? Last 3 minutes now - either high priority that we do next time we get together or something else that just feels like it hasn't been said the way it needs to be said.

One thing I'd like to say just based on the discussion, I would like to get another ratio of what a data project __, what are the elements to include - not just data but information.

How fast could we get it out to people?

I'm going to get transcripts of this discussion - she can get me something by Wednesday of next week. These notes will be put together in some kind of rational __ by Wednesday of next week and based on that I can generate ___ a synthesis of what the new constructs of data information projects.

A great tool.

The elements and the sources.

Other closing comments? We've done our job. A lot of good ideas.

SUMMARY - WHOLE GROUP

I take it from the general level of conversation in the room that people had a lot to say to each other so that's really good. What we're going to try and do for the next part of our meeting is ask for a short summary of the salient points of discussion from each group. So why don't we start with the group in back. Do you know who your reporter is going to be?

Rather than assigning a reporter, I just suggest to the group that those in the group who would like to make a comment about what they think is of primary importance going in to next meeting and that they want to see moved forward with could do so.

I would like you to make an initial comment.

I'll make a quick initial comment. There were a number of different ways that the group was finding the data, the gathering of data, the analyzing of data can be crucially important in developing the agendas that we're talking about. Even if you're talking about prevention in community public health there's a critical data element and now without a moment's hesitation I'm going to toss it back to you...and you take the next shot.

You're talking not just about data here but information; and health care is driven by good information. And it's not only the data that's collected by the county, or even the data that's collected by health plans. There's a concept of polling that's done on a periodic basis to really find out where people are at, what are people willing to pay for, what are people currently doing and how are they willing to change their lives in terms of different ways. And we talked about certain problem areas that are important to the health care relationships here in Sonoma County. We talked about the importance of primary care physicians. In fact, physician groups that we know are having a considerable amount of problems in this county. And is it a legitimate project for a group of citizens and purchasers to really do something about the level that physicians are dealing with right now. And there was a lot said in the group about working directly between purchasers and providers. But do we have information and the data to drive that kind of relationship? We just weren't sure. So what we agreed to do at the end of the meeting is that we'll pull together the transcripts, the notes, and we'll put together a new kind of data profile as to what kind of information gathering is necessary to drive a series of kind of private projects of significant activity.

Comments?

He's going to do the work, he gets to say it.

And they're recording here.

That'll do for us.

We spent a lot of time at the beginning also talking about information and if you just look up at our wonderful recording up there, we talked about what kinds of information people were really interested in having. And it was with the eye towards making a better decision. And after a lot of discussion about data, the kinds of imperatives that people were expressing about making a difference in the health of Sonoma County. There was some discussion about there's a lot of data, we don't need a lot more data, everybody has data. There are things that can be done with information that can create a conversation so that everyone in the county is aware of something along the lines of what [he] was talking about before, also a media campaign. The data has to have context and the context has to be improved health. And I invite any member of the group to jump right in. I'm just going to bounce around a little bit but please jump right in if there's something you want to amend or say -what are you talking about? I'm perfectly willing to be corrected. We talked a lot about issues of who's not at the table, what other kinds of voices would need to be heard if you were really going to affect all of Sonoma County, that the population's different ethnic and economic groups that are disproportionately affected by disparities in access, in income and so forth, need to be part of a broader discussion. That the faith community wasn't represented, the small business community.

And there was discussion about lots of groups that are already doing issue-focused work and that many people aren't even aware that there are people who are already doing things in areas that they are most concerned about. And that's a part of an information gathering and sharing possibility would be to bring all of this information together and make it easily accessible for people to identify, who's doing what, find areas where they can be part of it.

We also talked about the assets that exist in Sonoma County that could be used to build whatever directions we want to pursue, and those include the fact that there are groups already working and that people have been talking to each other in terms of the health care crisis, that there are community clinics that are providing great services, there are progressive people in this county, that our politics tend to be more progressive than they are elsewhere. The university is hosting this effort. There are a lot of assets that can make a difference in moving forward.

When we talked more specifically about what kinds of issues and strategies to be used for different clusters of issues that had been previously identified, which included access to health care, access to quality health care, and community-wide health prevention intervention, there were very strong feelings expressed about single-payer systems and other things that may or may not be amenable to change at a county level.

And we wound up with the last part of the discussion, when we talked about trying to set priorities in outcomes of this meeting and getting ready for the next meeting, what is it that will bring people back? What is it that we need to do? And we were challenged by somebody who left, that quite a few people sit around and talk about these issues a lot. We've been in other forums where people have talked about these things ad nauseam, and that what really will make a difference is finding doable slices of the pie, and figuring out what we need value-added, what leverage this group can bring - even if another group is already working on an issue, to make a real difference. And that the time horizon that we'd be looking at is not 5 minutes, it's maybe 3-5 years, and there were several major suggestions that came out as priority areas. Three having to do with children, supporting the Children's Health Initiative, supporting dental services especially dental surgery for children, and family wellness for obesity prevention for kids. A fourth area was focusing on the elderly - that healthy aging in a county where the demographics are particularly skewed to the older side, there are so many retirement communities located here. That might be another arena that we could really get people identifying with and active about.

I didn't mean the elderly - have you talked to my daughter? We're the elderly.

Healthy aging at whatever age - with that modification. And so that by the next meeting, especially if we can't get to it tonight, that we be charged with coming up with those areas and actually having people make a choice and a commitment to move forward. And that whatever the community wellness intervention was that we chose, that it would be complemented by the appropriate kind of information that we discussed here and in the other group.

I'd like to amend that phrase of giving us an opportunity to think a little bit more about what that issue might be instead of having to pick between those three, all of which are great, but it might be worth going away and having a little time to really think about it.

So that's the invitation, that I think there was general agreement that people felt that we had to commit ourselves to some reasonable action or there was no particular reason for the group to continue if other groups are already -

I think ... said it - which is whatever it is we do should be compelling, timely and doable.

I guess I'm going from the understanding too that what's special about this round in the work is that we're having two intense meetings to talk about doable and high-priority matters that are really needed in the county, and that that is done with excellent fundraisers in the room, with the intention that when we finish our second meeting, and any followup telephone calls that go on, that they're then going to take a good crack at doing those wide spectrum foundation grant or grants that can carry that forward, that we're looking for are there places where we can work collaboratively, as well as places to work alone, and places of high priority that we could work collaboratively - are there places we need money to really move that forward? And if so, then we'll give it a shot.

Do you mean collaboratively internal to this group or collaboratively with things that are happening in the community already?

I would think potentially both-and. The idea being that not that this is an ongoing group beyond the next meeting, but rather that ideas that this group brings up, and that really crackled with the electricity, go into the fundraising process as a collaborative expression of what multiple institutions here might like to try to do together. Multiple individuals and institutions. And that at the same time, we may identify things that are happening in the county of high priority that while not going out to raise funds for them necessarily, that we could as multiple institutions get back and help push that wagon up the hill. So that we could be helpful even where we're not raising money.

That makes perfect sense. I guess what I don't want us to do is to form yet another group that's going to end up competing against a group that's already halfway down the road on a particular issue.

Actually I think one of the highlights of the Spring '04 conference was a panel of speakers that talked about the highly successful coalitions going on in this county. It's a real tribute to the people in the county that they've done so much already together, and they're still doing it right now.

It seems like a really key role would be to enhance the synergy between those kinds of things, rather than competing.

Any other questions or comments?

Just in hearing the two conversations, because I sat where I could hear both of them, it seems like this group is very broadly cast. You're contemplating both supply-side and demand-side problems and challenges. And you might say a good solution solves many problems. Following up on what [they] are talking about, perhaps there's a future in this group thinking of itself [or imagining an emergent group] as a health promotion policy institute for Sonoma County, and this kind of institute might be one that calls for all organizations and entities in the county to count health as a priority in their mission statement and in what they do in their line of business, whatever business that is. Whether it's a private business or government business.

And your work would be about calling for accountability and fulfilling that mission so that there would be healthy workplaces and healthy schools and healthy environments and healthy policies. And it would be up to this group to gather the information and the data and then call for the accountability both in public forums, info medias, and particularly maybe connecting consumers to these issues - why organizing advocacy and consumers so that people would know what they are or are not getting out of the health system for the health dollar investment. Or what they may not be doing to protect their own health, to be healthy as possible. The conditions may not exist for them to be as healthy as they can, or maybe their own behavior is what needs to change. And pointing that out in terms of dollars and cents or other opportunities with some of the work this group does.

But I agree completely with the points you made about not replicating what other groups are doing but giving all of your support to helping other groups that have a policy agenda, or a system change agenda, and you would be there to support them with the data, with the advocacy groups, with the efforts that you have organized.

You put that behind asthma prevention, obesity or insurability.

And you could think of yourself as maybe an ongoing health grand jury for the County of Sonoma __ adopted by the Board of Supervisors as such or city councils everywhere, and be there when it counts.

How about the posse commitatus instead?

You can write that report.

I think that's a fabulous idea. I just have to say that - I think it's a wonderful idea.

What you've done is just described in new terms the objectives of the old planning accountability process, and it needs a new language so that will freshen it up a bit. That's what planning set out to do before Ronald Reagan in his wisdom wiped it out in the '80s.

So we are going to create transcripts of these discussions, we are going to cull the highlights from all the flip chart recording, we're going to do a quick review and then send it out to you for your comments on accuracy [and your reflection], and that [may] spur your thinking - what rises to the top. This issue, the related issue, looking for the ways in which this group can best leverage the talent that people are bringing to the table, and that's what we should be prepared to make decisions about at our next meeting.

I know that [about 3-4 of] you are not going to be able to join us at the next meeting so if you have any comments that you want to leave with the group for us to be thinking about in between, now is the time.

I think it would be very helpful if we could get any insight from those of you who can't be here.

I have a question. Is there any one simple place where we have a listing of all the groups or organizations that have health care initiatives going on or health care related in the county? I mean we know they exist in a few but is there anywhere that data exists?

That's one of the suggestions we actually talked about creating.

Any one place that shows where all the trust funds are?

This would be a very useful task.

I want to thank you all very much. It's just amazing when you get a bunch of people together even if they're tired, the light bulbs go on and the energy that's shared and it's really been a delight seeing some of you again and meeting most of you for the first time.

So we'll be in touch. Please feel free to send any ideas posted to the Web site and thank you, thank you, thank you. Spread the word.

END OF TRANSCRIPT