Richard de Filippi says it won’t be easy and it won’t happen quickly, but with the help and collaborative leadership of key partners—including the hospital trustee community—health care reform will happen. The new chair-elect of the American Hospital Association, a trustee himself and a former hospital board chairman, is very optimistic.(www.hospitalconnect.com)
My interest in health care began during an early career managing a biomedical engineering activity in a new-technology startup, working hands-on with some of Boston’s leading physician researchers in developing new medical devices and instrumentation. Around that time, the city of Cambridge was searching for board members for its newly formed Department of Health and Hospitals, which combined the Cambridge City Hospital with the Department of Health.
I joined the board along with 15 other people who knew little about hospitals or health care, and I became chair largely because no one else wanted it. I realized that I needed to learn fast, so I went out and talked with everyone I could find both inside and outside the hospital community. That early education still serves me well.
The merged city department became the core of what is now the Cambridge Health Alliance, (www.cha.harvard.edu) an safety-net academic health care system operating in a seven-city catchment area north of Boston. Under truly visionary management and medical-staff leadership spearheaded by then-CEO John O’Brien, a former AHA trustee, the Alliance became what I believe to be a model health care system of the future. Our focus is on wellness, prevention, community health and primary care, emphasizing outreach and improved access for underserved populations. With some of the best tertiary hospitals in the world only 15 minutes away in Boston, we play an essential role in an informal regional collaboration that serves our patient base well.
Some of our proudest moments have come from AHA recognition: In the mid-’90s we received the Foster G. McGaw Prize for our community-based programs, and two years ago we won an AHA NOVA Award for our community outreach efforts in chronic disease care.
My tenure as a hospital trustee is an experience of learning the needs and interests of a wide range of stakeholders: patients and their families, physicians and nurses, other health care and social service providers, business, labor, insurers and public officials. Health care issues touch everyone, and constant communication with and sensitivity to key stakeholders is in fact a central job of the hospital board of trustees. In order to do the job well, you must develop and maintain a significant number of trusting relationships.
AHA’s Health Care Reform Program
Richard de Filippi is currently a trustee and former chairman of the board of the Cambridge Health Alliance, a major Boston-area safety-net academic health care system with three inpatient campuses and more than 20 community health centers. The Alliance includes a managed care organization and a physicians’ organization.
He serves on the AHA Board of Trustees and is a liaison to the Committee on Governance.
He is a managing partner of the Ariano Partnership, a consulting group that largely works with emerging technology-based companies. He was founder and CEO of CF Systems Corp., a chemical technology firm in the environmental field. Prior to that he was a founder and technical vice president of Abcor Inc., a bioengineering and separations technology company.
He earned his bachelor’s degree from Amherst College, and master’s and doctorate in chemical engineering from MIT.
In the effort to promote Health For Life, (http://www.aha.org/aha/issues/Health-for-life/index.html) the AHA’s framework for reforming the health care system, and to build a successful coalition among its many stakeholders, I believe the AHA and the field could benefit by having a hospital trustee in a leadership position to contribute related experience in understanding and managing the diversity of these stakeholders.
Advancing Health for Life and health care reform will require a major collaborative effort. The AHA board has taken a very strong leadership position among its members, and it is gratifying to see that the health care reform principles of so many other groups resemble our own. AARP, physician groups, the Commonwealth Fund and others all have proposals similar to ours, and there is also major support from both the business and labor sectors. It’s clear that the groundwork that has come out of Health for Life will be put to great use going forward.
Health for Life is a comprehensive policy framework—an organized group of strategic goals coupled with a series of policy alternatives that could successfully achieve those goals. Those strategic goals fall into the following categories: focus on wellness; efficient, affordable care; highest quality care; best information about patient health status and provider performance; and health coverage for all, paid for by all. Together, they represent a unified policy response.
Linked to Health for Life is a defined set of actions that hospitals can take on their own initiative and authority, without any need for new legislation or changed regulation. The objective of this step, called “The Pursuit of Excellence,” is to help hospitals organize their own thinking about improvement and, most importantly, to show our partners in this endeavor that those leading the charge must be prepared to get into the thick of the battle themselves. The proposed actions in Pursuit of Excellence are consistent with the “six aims” defined in the Institute of Medicine’s landmark report on the quality chasm in health care
Trustee Support for Health For Life
Hospital trustees need to become involved to help others understand the Health for Life principles and to serve in a major health care reform advocacy role. Trustees tend to have a broader range of experience and thus a broader view than others in health care. Hospital management and physician leadership have exceptional experience that is relevant to advancing our reform agenda but, by necessity, they are also charged by their boards to see to the current well-being of the organization and its stakeholders. So when the hospital hits a major fiscal crisis—and, unfortunately, hospitals are often in crisis—management must become totally focused on solving that fiscal problem. Management properly has a shorter-term and more internal view, often concentrated on overcoming huge obstacles to simply provide the financial and human resources to allow the hospital to function today. Trustees can and must rise above the immediate crises, look into the future and beyond the walls of their institution, and bring their own life experience to bear on a situation.
Applying this vantage point to health care reform, trustees need to pull together and be a persuasive force with policymakers. I take it as part of my AHA leadership responsibilities to help find the strategies to accomplish this. Much of it will be a grassroots movement. There can’t be an expectation that every single trustee has the time, but even if just a fraction of a hospital’s board is willing to become involved, working together to persuade other community leaders and policymakers of the urgency and the shape of reform, that is an enormous force when committed over the long term.
The Prospects for Health Care Reform
There is only one place in the health care system where there is a confluence of an understanding of community needs, knowledge of the blessings and curses of the health care system, and a compassion that recognizes the variety of conflicting interests that must come together in order for us to transform the way we help people in trouble. That place is the hospital boardroom. This is where health improvement and health care reform can generate its strongest force.
In addition, hospital trustees are mandated to be coalition builders. As outsiders by definition, we are constantly balancing different interests. We are drawn from businesses, professional groups, service agencies and the community at large. At the same time, we are responsible for ensuring that the hospital achieves its mission. Much of our work requires the management of split loyalties. What better group is there to facilitate the banding together of disparate interests to bring about the transformation of health care that will produce major improvements in the health of individual Americans?—Excerpted from Trustee magazine, October 2007.
Health care reform will not happen quickly or easily. Some say that 2009-2010 will be the crucial congressional term. I’m prepared for the Health Care Reform Act of 2011, maybe 2012. Just think about the broad scope of the change we are trying to make and the need to move all of the parts of a reform policy together. A comprehensive policy is necessary, but keeping all the pieces together will slow down the process.
Perhaps most important, if we are lucky there will be ambitious and aggressive leadership in Washington to help. The imperative is there—the public will push for change. While some political observers of the last decade or two may be discouraged about the chances for that kind of leadership, let’s not forget that there have been turning points throughout history where very important decisions were made that changed the course of events.
I know it seems that problems can drag on for decades before they are acted upon, and that within the continuity of our conscious political life we read the daily newspaper and become pessimistic about the possibility that something positive will ever happen. But I believe that some combination of collective will and individual leadership plus the pressure that has been building around health care in the last 15 years will tip the scales from inertia to action.
Health Care Reform in Massachusetts
Perhaps the most important lesson learned from the Massachusetts health care reform process was the surprising willingness of powerful partners to come together and to take risks, including commitments that put them at risk with their own membership or constituency. They were driven by a recognition that the end result was needed. It was a successful collaborative effort among extremely disparate groups, but each was able to keep the common goal paramount.
Fortunately, there was strong leadership in many segments of the field: patient advocates, labor, business, hospitals, professional providers, the health plans, elected officials and others. All of these people had the capability to look beyond the immediate interests of their organizations and were willing to actively pull reform together.
Is the heavy lifting over in Massachusetts? No. We are now feeling the aftershocks of the legislation, particularly in the area of funding, and corrections will be necessary. Strong leadership during the aftermath is as important as it is in the formative stages. Similar corrections will be needed when we pass a federal Health Reform Act. Everything will not play out effortlessly, and we can expect to work at adjustments to the legislation for some time.
The important thing in Massachusetts is that it worked. Once the legislation got rolling, the public was behind it. At this date, the best count is that the number of uninsured has been reduced by 75 percent. Among other benefits, the legislation significantly increased access to medical care: Physician visits are up by as much as 20 percent in some parts of the state.
To bring about the change needed for the future, leadership must have the drive to build and sustain relationships both within and outside the field, relationships among hospital management, physician and trustee colleagues around the country, with public-sector policymakers, and with other leaders having a common vision. It is those relationships that will enable us to reach consensus within the critical mass of interests, even apparently disparate interests, which we must unite in order to successfully effect change. I am committed to the effort to make this happen.
Rationing is any public policy allowing essential health care services to be systematically withheld from a broad population because of scarce resources. It is an extreme form of denying health care access, and one that most of us are reluctant to face, even though many, both inside and outside the health care industry, say it is inevitable.
My goal here is to examine rationing, not because I think it is a viable solution to the problem of affordable health care, but because I feel that exposure of the painful issues raised by rationing could help drive much-needed change.
A clear-eyed discussion of rationing might help us face the fact that our health care system is broken. It may help us find the will to implement real reform. If that were to happen, rationing should cease to be an issue.
Rather than focus solely on the specter of rationing, I’m making a plea that we turn our fear of that specter into the resolve we need to fix our broken health care system.
Why are we having difficulty learning the lessons of other industries around us? So much has happened, for example, in the production of automobiles, and we all have graphic evidence of it.
The first car I ever owned was a hand-me-down Studebaker with a deeply troubled oil-consuming existence. It finally died a smoky death at less than 80,000 miles, all the while putting a huge dent in my grad-student budget. Fast-forward to the present: I own a 1988 Toyota 4x4 pickup with close to 200,000 miles, and it survives on fewer maintenance dollars than that Studebaker burned up many years ago.
Sometime in the intervening years, the automobile industry made investments in improving the way it made cars, absorbing new technology with the express purpose of increasing productivity by both reducing costs and improving quality. It took a long time, and the path was far from direct, but it happened. Even more interesting, it appears to be happening again right now in the face of new challenges.
This kind of improvement has not taken place in the nation’s health care industry. As a society and a national culture, we seem unable to find the imperative. Instead, like the automobile industry 50 years ago, we tinker with last year’s model, searching in the same old over-explored corners for solutions.
How can we begin to find the solutions we need? One way is by investing our health care dollars in ways that begin to redress the extreme imbalance between our current allocation of resources and the factors that have an impact on health.
For example, the U.S. Department of Health & Human Services report “Healthy People 2010” attempts to estimate the degree to which various factors influence health: lifestyle constitutes about 50 percent; biology and the environment each have about a 20 percent impact on health. At the bottom of the list is medical care, accounting for only 10 percent.
We spend $2 trillion a year on medical care to attack a small fraction of the cause of ill health. We spend proportionally far less on public health, health education and related basic and applied research—areas that could help address 90 percent of the factors that have an impact on health.
We need our best minds and our best resolve to come up with the kind of changes we must make to reform our health care system. As with all new ventures, the increased investment will be costly at the beginning, but that initial investment will give us positive returns for the future that go far beyond saving money.
If we are able to consider an extreme solution to our health care problems—rationing—why couldn’t we first revisit our national values and priorities and then debate our willingness to sacrifice collectively in other ways to find the investment needed for health care reform?
Political absolutes on tax increases may look very different when a congressional debate on health care rationing appears on C-SPAN.
Indeed, even if that debate is still in our future, it would have an entirely different moral tone after it had been placed properly in the hierarchy of our social responsibilities.—Reprinted from the October issue of Trustee magazine.
This article first appeared in the October 2008 issue of H&HN magazine.