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What We Can Do Locally — A Brief Case Study on a More Systemic Approach
to the Health Care Crisis in Sonoma County
by Skip Robinson, Ph.D. • Introduction In late summer 2002, after a series of local medical bankruptcies and the collapse of the second largest HMO in Sonoma County (leaving 80,000 subscribers stranded), Sonoma State University began the SSU Community-Campus Initiative on the Health Care Crisis in Sonoma County, which came to include a dozen SSU Schools and Departments as well as a number of community institutions and most recently the California Program on Access to Care, University of California Office of the President. In an atmosphere where health care failings were often being treated one-by-one, itself a valuable method, the Initiative took a more systematic approach. Here is the Initiative's website: www.sonoma.edu/programs/healthcrisis/ • Identification of local health care stakeholders, in "clusters" (22 main stakeholder clusters identified so far) It is fundamental to analyzing and solving problems that the problem's main stakeholders must be identified, communicated with, and brought into the work. Thus, one of the first Initiative tasks was to identify main stakeholders in the health care crisis. It immediately became evident that, in addition to a large number of stakeholders, each stakeholder was actually a "cluster" of organizations and key individuals, often between 10 and 250. http://www.sonoma.edu/programs/healthcrisis/images/shareholders2.jpg • Primary communication and response methods With such a complex group of stakeholders and knowing that there were many aspects to the crisis, the Initiative developed a set of response methods that it has used regularly since the inception of the Initiative - such methods as an Initiative website, stakeholder conference dialogue, etc. http://www.sonoma.edu/programs/healthcrisis/images/healthcaremethods.jpg • "Humane cost containment" potential actions The Initiative has held a series of meetings and conferences to identify the key problems the County is encountering and to consider ways of fighting back systematically and with interdisciplinary approaches. About 50 potential ameliorations have been identified so far, many of which work synergistically. (The link below is to an Acrobat file. It may open automatically. If not, save it to your desktop and open it as an Acrobat file there.) • Current: "Seed Grant" priority setting and action At the Spring 2004 Initiative Conference, at which dozens of ideas were suggested, the Conference asked that a subgroup meet during the summer, set priority goals for review, and host a fall meeting. That subgroup met successfully, set priority recommendations, and called the fall meeting of Spring Conference attendees. That fall meeting ratified those priorities, which called for fundraising to leverage limited funds to create foundation grant applications on identified priority needs. Over a few months, the Initiative raised the needed funds. Foundation fundraising and advising has begun. This phase kicked off in October 2005 with two dinner meetings held for 20 of the most important Sonoma County health care leaders (chosen across stakeholder boundaries). These meetings reviewed dozens of ideas and identified five top priority tasks for which to raise funds. The first grant application has been submitted, a partnership between the SSU Initiative and the California Program on Access to Care, University of California Office of the President. Foundation grant consulting has begun on several other priority projects. http://www.sonoma.edu/programs/healthcrisis/5priorities.html • Summary By a variety of systematic interdisciplinary approaches, the Initiative has sought to broaden and deepen the health care amelioration dialogue and action going on at the university and in the local community. The end of this "Seed Grant" period will lead to dissemination activities, including expanded use of the website, educational e-mail, meetings, and media communications to local stakeholders, other California counties working on similar matters, and CSU campuses with health crisis programs. Initiative funders so far have identified the project as not only pertinent to Sonoma County but also as a possible model to stimulate other local initiatives elsewhere. The paper • First thought by Gil Ojeda, Director, California Program on Access to Care, California Policy Research Center, University of California Office of the President "When I describe Sonoma County as 'ground zero' for the changes that are coming into play in California's health care industry, I mean this primarily in relationship to three significant factors: 1) physician group practices in Sonoma County which were already under considerable financial pressures (e.g., physicians were already leaving the county) prior to the Health Plan of the Redwoods bankruptcy, 2) the falling apart of Health Plan of the Redwood and the "free for all" it started among area employers and individuals and the related juxtapositions among other plans (which still appears to be somewhat "fluid"), and 3) the capacity and interest of institutional players and prominent consumer/patient advocates to build and continue a dialogue which can lead to the creation of some solutions which are local and also to better define those problems which are inevitably outside of the limits of the county. Sonoma County has become a model for the types of problems which the California health care industry is going to continue to encounter over the coming years and also for the types of strategies and solutions that can be developed through dialogue and cooperation. In a sense, Sonoma County becomes a laboratory for action for other counties which will be going through similar circumstances but which may not yet have a common forum for dialoguing and working problems out." • Introduction In late summer 2002, after a series of local medical bankruptcies and the collapse of the second largest HMO in Sonoma County (leaving 80,000 subscribers stranded), Sonoma State University began the SSU Community-Campus Initiative on the Health Care Crisis in Sonoma County, which, over time, came to include a dozen SSU Schools and Departments as well as a number of important community institutions (such as The California Endowment, the Northern California Labor Council, Kaiser, the Community Foundation, and the Sonoma County Office of Education, and most recently the California Program on Access to Care, University of California Office of the President. • Crisis elements identified Before one can begin to explore potential ameliorations, it is essential to explore and find the key aspects of the problem, especially since this health care crisis is so complex and daunting. Here is what the Initiative and others have found to be many critical elements of the crisis. The Initiative began in late summer 2002 right after the bankruptcy of Sonoma County's second largest HMO, which had followed the bankruptcies of five large medical groups in the County. A series of Initiative conferences and studies, plus work by a number of other local organizations, identified serious current and projected shortages of local doctors, nurses, and other allied health professionals. (In the midst of this, the local medical association has announced that poll findings show that fully half of Sonoma County physicians intend to retire or move elsewhere within the next five years. Current and impending major nursing shortages here are well-known.) The County's Medicare designation as a "rural" county (which is no longer accurate) has meant that services reimbursement rates are significantly lower than for other counties, putting our health care services at a distinct competitive disadvantage for professional services. This competitive disadvantage is added to by the extremely high cost of housing and living here. Further, one of the best doctor recruitment tools here for decades, the physician training program now managed by Sutter, has announced that it is likely to close. The fast inflation of premium rates for employers and individuals has become shocking and increasingly unaffordable. Public care for indigents has been going down. Public outpatient mental health care for indigents has been cut back into the bone with impacts flowing in all directions, from personal and family safety, to public safety, to increasing and inappropriate police burdens. Small hospitals here are saddled with unsustainably low reimbursement rates in the light of unfairly much higher large hospital reimbursement rates. In the midst of this, Federal, California, County, and local governments have all been rocked by financial crises of their own, which have substantially limited their capacity to be of help. • Identification of local health care stakeholders It is fundamental to analyzing problems that their main stakeholders must be identified, communicated with, and brought into the work. Thus, one of the first Initiative tasks was to identify main stakeholders in this local health care crisis. It immediately became evident that, in addition to a large number of stakeholders, each stakeholder "group" was actually a "cluster" of organizations and key individuals, often between 10 and 250. A surprisingly wide variety of local institutions and people have a deep "stake" in what takes place or doesn't take place, from cost-overburdened employers and individuals to underreimbursed providers and their networks, from public health care programs to efforts to recruit and train new health care professionals to take the place of those leaving or retiring. The clusters clarified into dozens of independent clinics, hundreds of employers, multiple studies led by a number of local leading institutions. By using a clustering method, the Initiative identified at least 22 main stakeholder clusters - and began with communications and conferences to increase the cross-cultural dialogue.
• Primary communication and response methods With such a complex group of stakeholders and knowing that there were many aspects to the crisis, the Initiative developed a variety of communication and response methods that it has used regularly and interactively since its inception. Stakeholder dialogue As is so often the case with complex community crises, key stakeholders are not necessarily talking and reflecting with each other. Since Day 1 of the Initiative, gathering community leaders, providers, and academics for study and dialogue has been a key method. (On could even make the case that it was THE key method.) SSU Initiative website This educational website went on-line soon after the Initiative began:
http://www.sonoma.edu/programs/healthcrisis/ When the California Program on Access to Care, University of California Office of the President decided to audiotape and transcribe all the speakers at the critical SSU Initiative conference in Spring 2004, "What We Can Do Locally", which was focused on a wide variety of answers, techniques, and actions which could make a difference, the transcripts were quickly put up on the website and began to crystalize as a set of crisis working papers for wider distribution. Meetings and Conferences Monthly meetings of on-campus academics began the first month of the Initiative and continued for three years. The first conference took place the first fall, focusing on the predicament of labor and management negotiators in the County's approximately forty school districts. It was imperative that neither side get lost in recriminations about the other, in this atmosphere where the health care system itself appeared to be coming apart and employee-family-retiree health care premium costs were leaping upward. The next spring, the Initiative held it first broad-based community conference looking at how the crisis had gotten here, precisely where the crisis now stood, and what possibilities were appearing for where the community stakeholders could direct their energies. The following spring was the "big step forward": the "What We Can Do Locally" Conference, which enumerated dozens of actions which the community could consider for working more closely together. This led to a summer subcommittee charged by the conference with proposing priorities from the dozens of ideas and hosting a fall 2004 meeting of spring conference attendees to consider recommendations. This, in turn, led to critical focusing and fundraising work as "seed grant" activities to encourage and back-up priority community endeavors. This was further focused with a series of dinner meetings with 20 community healthy care leaders in October 2005. (Central material emanating from each of the Initiative's steps is available for study on the Initiative website.) Systems plan and design Through the time since the Initiative's beginning, community leaders, providers, consultants, and academics have continued to explore alternate ways of operating the health care system elements which are in serious disarray. Dozens of ideas can be found on the Initiative website. Those discussions continue. At the same time, alternative ideas are developing statewide and in other states. The "Massachusetts Plan", the Kuhl plan in Sacramento, a point-of-service approach in the County envisioning Kaiser at the center of a collaborating set of IPAHMOs and PPOs, the "building up from managed care Medicare" approach in the County, the Blue Shield universal proposal, and others give community and academe lots to discuss. Financing and fundraising Costs of the conferences, communications, and dissemination of what is found - all have costs. The Initiative has raised approximately $50,000 since 2002 to cover its expenses. Research Given that the Initiative has been based at a university, study and research has been a necessary starting point. The action research conducted has produced the ideas which now are available for the community to respond to. On-campus development SSU (and most recently SSU with its partnership with the California Program on Access to Care at UC) has held a series of conferences based on campus. UC has taped a substantial variety of observations and recommendations for use on the website, in dissemination, and to generally enrich the discussions. Ten SSU Departments and five SSU Schools periodically sent faculty and staff for discussions together. A core of university students sometimes involved themselves. The monthly meetings generated a wide variety of ideas. Tantalizingly, sometimes discussions focused in on how different sectors of the university community could work better together both for study and action in the community and for potentially building in the future an even more formidable and interdisciplinary health care studies curriculum.
• Potential actions in "humane cost containment" Particularly through the series of meetings and conferences, the Initiative has further helped to identify key problems the County is encountering. It then has facilitated consideration of dozens of ways to fight back in ways both systematic and interdisciplinary. Over 50 potential ameliorations have been enumerated so far, many of which can work synergistically. Generally, these fall under several headings: Coordinating primary and secondary prevention; coalition-building; integrating quantitative studies and data analysis; dealing with prescription drug programs and prices; redesigning health plans, health systems, and operations; reducing ecological/environmental poisoning dangers; addressing issues of education, training, and allocation of scarce resources to work with critical shortages of health professions personnel; further broadening the systematic study of the crisis and its amelioration; fund-raising - and, most importantly, continuing to communicate and explore together. (The link below is to an acrobat file which organizes and lists dozens of potential helps. It may open automatically. If not, save it to your desktop and open it as an Acrobat file there.) • Current: "Seed Grant" priority setting and action At the Spring 2004 Initiative Conference, at which dozens of ideas were suggested, the stakeholders dialogue at the end of the Conference asked that a subgroup meet during the summer, set priority goals for review, and host a fall meeting. That subgroup met successfully, set priority recommendations, and called the fall meeting of Spring Conference attendees. That fall meeting ratified those priorities recommended, which called for fundraising to leverage limited funds to create foundation grant applications on identified priority needs. Over a few months, the Initiative raised needed funds. This phase kicked off in October 2005 with two dinner meetings held for 20 of the most important Sonoma County health care leaders (chosen across stakeholder boundaries). These meetings reviewed dozens of ideas and identified five top priority tasks for which to raise funds and carry out support. Foundation grant consulting has begun on several priority projects, specially on developing a data analysis project; supporting the local Healthy Children initiative, to provide protection for poor and uninsured children; exploring increasing financial stability for the primary care community; helping capacity-building for community clinics; and exploring formulation of a local multi-employer or "single payer" system. • Dissemination of findings By a variety of systematic interdisciplinary approaches, the Initiative has sought to help broaden and deepen the health care dialogue and action going on at the university and in the local community. The end of this "Seed Grant" period will lead to widespread dissemination activities, including expanded use of the website, educational e-mail, meetings, and media communications. Materials and the Initiative funders so far have identified the project as not only pertinent to Sonoma County but also as a potential model to stimulate other local initiatives elsewhere. |
