The winner of the 1997 MODERN HEALTHCARE and Governance Institute Governance Fellowship Award has determined that public-private healthcare coalitions encounter a variety of obstacles on the road to providing effective services.
According to Bryan Weiner, assistant professor at Tulane University's School of Public Health and Tropical Medicine in New Orleans, coalition boards are under great pressure to actually define the community they aspire to serve, then take pains to include it in the coalition's plans.
The community-care partnerships the boards govern are a diverse lot. They may include hospitals, clinics, physician groups, businesses, schools, churches, public health departments, social service agencies and community interest groups.
Weiner's interim report on governing the coalitions studied four such efforts over the summer: the Solano Coalition for Better Health in Solano County, Calif.; Healthcare 1999 in Pembroke, N.C.; the Itasca Partnership for Quality Healthcare in Grand Rapids, Mich.; and the Somerbridge Community Health Partnership in Cambridge, Mass. The $2,500 award from MODERN HEALTHCARE and La Jolla, Calif.-based Governance Institute helped pay for his research.
Community boundaries. Weiner writes in his report that the coalitions sometimes rely on "geopolitical boundaries, markets, enrolled populations and catchment areas (as) convenient operational definitions. . . . They rarely correspond to the natural boundaries of communities. As a result, efforts to create community engagement and feelings of ownership often fall flat."
When coalitions can put those boundaries aside, they often are met by other daunting tasks, such as navigating the tricky waters of racial diversity and the willingness to share power with "grass-roots" community groups rather than just politely listen to their suggestions.
"The problem is that once you become sensitive to the issue of cultural diversity, you have to bear a lot of anger, resentment and suspicion, and you get into very weird linguistic forms about what and who is actually the community," Weiner says. "That's something (your typical) board can argue about over lunch. But with these groups, the issue of power and control is immediately at the forefront. And when they make a reference to community, it may be in an exclusive way, something that pertains only to their own socioeconomic group."
Moreover, Weiner observes that coalition boards often are taken by surprise when outsiders want some of their power. "These (coalitions) often grow out of a community benefit program the local hospital is running, something that is fairly containerized from the real business of the hospital. The boards are well-intentioned, and they may have some initial success, and they're willing to listen to outsiders. But those groups often don't come in neat packaging. Lo and behold, (the board) is facing demands as to how to allocate money."
Economic questions. But resolving power-sharing issues are not the means to an end: Economic models for community coalitions are just as critical, Weiner says. He recommends such organizations rely mainly on a capitated revenue stream.
"Sharing risk aligns economic incentives with good intentions. It forces the group to think upstream, a situation where an ounce of prevention is going to become much more important," he says.
One coalition Weiner studied had economic incentives so perversely misaligned that success could actually translate to disaster: "They have a lot of small county hospitals in this particular partnership, and they are so dependent on (Medicaid) dollars that if the teen-age pregnancy problems were solved as intended, half of the hospitals would fail overnight," he says.
And whether or not coalitions can achieve their goals is a matter of speculation. Weiner observes that only one of the four coalitions he studied employed methods that could effectively track its progress.
"Aside from the fact that it's just darn hard to measure progress, these efforts are governed by people -- CEOs and the like -- who really want to do interesting things. Starting initiatives is a lot more interesting and fun than planning and assessing them," he says. "They tend to be highly action-oriented people, and reflective thinking is normally not part of their personal style."
Weiner added that highly successful people may not be well-keyed into the healthcare realities faced by poorer populations -- the portion of the community their coalitions are intended to help.
Stretching. Weiner concludes that these challenges may require coalitions to stretch governance structures beyond the normal models. He suggests boards should be constructed with a more inclusive, "top-to-bottom" structure.
"The traditional philanthropic model of governance is based on the community's social and economic belief that the biggest contributors have the requisite knowledge and credibility. The assumption is just not tenable in those cases," he says. "In that model, you simply can't walk into a housing project and say, `I'm here to help.' "