Wye River Group on Healthcare (WRGH) initiated a project in July 2002, called “Communities Shaping a Vision for America’s 21st Century Health and Healthcare.” This report describes Phase I, which was designed to elicit from health care leaders at the community level their thoughts about the values and principles that should be the foundation of health care in this country. The aim of the project was to launch conversations in various communities that could jump-start a national dialogue about the fundamental values and principles that Americans want to guide U.S. health care policy into the future.
During Phase I, WRGH held a series of Healthcare Leadership Roundtables, or “listening sessions,” in 10 diverse communities around the country. During these roundtable discussions, community health care leaders were not asked their views on specific policy issues. Instead, they were asked deeper, more fundamental questions, such as whether there is, or should be, a social contract for health care in this country. Participants proved eager to explore these questions, which are rarely asked in the usual forums on health care policy.
This project is fairly unusual – in fact, unprecedented – in its effort to understand how health care stakeholders and consumers view the values and principles underlying our health care system. We used community-based discussions to explore these issues and asked participants to set aside the politics and sector competition that have shaped so much of our health care policy in this country.
What we discovered was a surprising degree of interest and willingness at the community level to offer honest viewpoints about the values and principles in health care, to bring up frustrations and specific challenges, and to pursue collaborative efforts to address key health care issues in their community. Our findings are described in detail in the section of this report entitled “A Community Based Discussion of Values and Principles for American Healthcare.”
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Healthcare Leadership Roundtables
The Healthcare Leadership Roundtables were held in 10 communities around the country between July 2002 and May 2003. In each community, WRGH assembled a diverse cross-section of public and private stakeholders with detailed knowledge of health and health care. They included physician leaders, hospital and health system executives, community and public health officials, pharmaceutical and pharmacy representatives, business leaders, consumer representatives, and government officials. We also worked to ensure that important constituencies such as the elderly, the uninsured, minorities, and people with chronic illnesses were well represented. We believe that, collectively, these leaders have a solid understanding of the health and health care challenges communities face.
Each of the roundtables was a three-and-a-half-hour meeting focused on the shared values and principles that should provide the foundation for health policy in this country. In these discussions, we explored participants’ views on the social contract for health care – both as it currently exists and what they believe it should be. We challenged them to define the attributes of a well-functioning health care system and the role that each sector would optimally play in creating and maintaining that system. We asked them to reflect on consumers’ expectations of health care. We also tried to raise community leaders’ sense of themselves as catalysts for positive change in health care.
Following each roundtable discussion, a professional writer distilled the comments into a “community profile” highlighting the shared values and principles articulated in each community. Draft versions of the community profiles were shared with roundtable participants for their comments, corrections and additions prior to being finalized. The 10 community profiles are included in this report as Appendix A.
As another result of the roundtable discussions, we have developed a roster of 20-25 leaders in each community. This is a practical list of advisers from different sectors in each community who are willing to help us move closer to addressing issues of common concern in health care. Our intent in Phase II of this project is to collectively engage these leaders in activities designed to bridge the gap between local concerns and national public policy.
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Selection of Sites and Participants
The 10 communities in which roundtable discussions were held were carefully chosen to reflect our nation’s diversity – not only its diversity of peoples, cultures and values, but also its diversity of health care challenges. The selected communities varied by geography and size, ranging from large metropolitan areas to smaller cities and rural communities, and by cultural and ethnic diversity. The communities also represented a range of regulatory environments, from communities in heavily regulated states to those in states with moderate or minimal health care regulations. We also selected communities that represent both ends of the spectrum when it comes to the percentage of uninsured residents.
The final criteria related to health care costs and quality, using data from the Dartmouth Atlas of Healthcare and a Health Care Financing Administration (HCFA) study published in The Journal of the American Medical Association (JAMA) in the summer of 2000. We selected communities where health care costs per enrollee were much higher than national averages as well as communities where costs were several times lower than national averages. Additionally, some communities were located in states that had been rated very high with regard to quality of care, while others were in the lowest bracket, according to the HCFA study.
Roundtable discussion participants were chosen with equal care. In addition to the chief executive officers and senior executives invited by project sponsors, WRGH recruited a broad cross-section of leaders from each community we visited. Our goal was to balance participation across health care sectors and from a public/private perspective, endeavoring to ensure that the “consumer voice,” reflecting the composition of the community, was represented. With the assistance of our supporting organizations, we were able to reach local health care leaders such as public health officials, Medicaid directors, directors of community health centers, representatives from consumer organizations, culturally focused groups and local professional associations, civic thought leaders, and local employers.
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WRGH traveled to each site 4-6 weeks in advance of the Healthcare Leadership Roundtable in order to gain a meaningful understanding of the unique cultural aspects and health care marketplace dynamics in each community. During the site visit, we met with a broad array of community opinion leaders from virtually every health care sector, both public and private, as well as individuals representing key consumer groups. Through a series of one-on-one meetings and interviews, we elicited their concerns and ideas and developed a sense of the local culture, marketplace dynamics, and cross-sector relationships that shape each community’s approach to health care. The one-on-one meetings also helped us identify successful community partnerships that became the basis of our “case studies” in this report, which are intended to provide knowledge transfer among communities and constructive change on the national level.
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Although this project focused primarily on discussions held at the leadership level in these 10 communities, in 6 of the communities we also conducted informal meetings with groups of local citizens. We wanted to elicit their opinions to balance and supplement the views of their community leaders.
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Midway through its 10-city tour, WRGH began to develop a circle of advisers – leaders chosen from different health care sectors and communities – to help us develop recommendations and potential “next steps” in addressing common issues that arose in community discussions. Our intent was to engage these leaders in a process aimed at bridging the gap between local health care issues and a broader agenda with national application.
To organize this aspect of the project, we created “advisory boards” around 6 health care topics – cultural change, access, information infrastructure, incentives, quality, and the role of public health. The advisory board members participated in a series of meetings by telephone that were aimed at identifying opportunities for focused initiatives to be launched in the communities. The boards each developed a topic-specific report describing the crux of their particular issue and suggesting several potential next steps for collaborative action at the community level. The advisory board reports are included in this report.
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"Shared Vision" Retreat
After roundtable discussions were held in all 10 communities and the advisory boards wrapped up their work, WRGH hosted a retreat July 9-11, 2003, at the Aspen Institute Wye River Conference Center in Maryland. Two key participants from each roundtable discussion and representatives from our sponsoring organizations were invited to participate in the “shared vision” retreat, where draft chapters of this report were reviewed, discussed, and edited.
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To announce the “shared vision” that arose from this project, WRGH organized a national summit designed to showcase the findings of the 10-city tour and launch a national dialogue on health care among the American public, policymakers and health care stakeholders. The summit, held in September 2003 in Washington, D.C., provided an opportunity for community and national leaders from all health care sectors to share their insights into our health care future and to articulate their collaborative goals.
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In the second phase of this project, we plan to build on the momentum created in Phase I by working with our sponsors, national leaders, and local community leaders to develop and execute a campaign to raise awareness and engage the public in constructive dialogue on health care challenges; create channels for national health policy leaders to gain insight from communities; and demonstrate local solutions from ten diverse model communities that have the potential to be replicated on a national level.
In addition, Wye River Group on Healthcare (WRGH) has created the Foundation for American Healthcare Leadership (FAHCL) to promote and enable the thoughtful exchange of ideas in a neutral environment, among a broad cross section of senior corporate and public sector executives across America. We will convene healthcare leaders to deliberate on and study national healthcare trends and specific contemporary healthcare issues affecting the nations' health and productivity, and advance the outcome of these discussions before public policy experts, private and public sector leadership, and the general public, through multiple educational outlets
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It is evident from the community roundtables held by WRGH that there is both deep concern about the current direction of health care in this country and a great desire to move forward with constructive changes. One of the fundamental principles that emerged in the roundtable discussions is that the problems in health care today need urgent attention. It is time for elected officials to put health and health care at the top of the nation’s list of priorities.
Community leaders said there is a window of opportunity now to engage health care stakeholders, the public, and policymakers in a dialogue aimed at constructive health system change. They called for a national conversation that starts by asking Americans about the values and principles that should form the basis of their health care system. This kind of conversation about health care – one that really gets at the core of what Americans want from their health care system and what they are willing to support – has not yet taken place in this country.
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The Lack of a Meaningful Social Contract for Health Care
Most community health care leaders agreed that our country has not developed a social contract for health care that is well-articulated and broadly understood. Over the years, our country has developed an effective social contract in other areas of public policy, such as education. But currently, there is no equivalent in health care. As a result, most Americans do not know what they can and should expect from their health care system. Nor do they understand their responsibility to contribute to the health care system.
Instead, what we have is a patchwork of public and private health insurance, a health care safety net under tremendous strain, and millions of Americans who are uninsured and/or medically underserved. We don’t have a clear, shared understanding of health care as a right for all residents. In the absence of a social contract for health care, it is exceedingly difficult to address such fundamental questions as what Americans can expect from their healthcare system, what services should be covered and for whom.
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The Public's Expectations
Community health care leaders identified Americans’ expectations as a key area that needs to be addressed in a national conversation on health care. There is a general consensus among health care leaders that the public’s expectations are often out of line with the reality of what the health care system is able to deliver. There is also recognition that the health care system itself has helped foster these unrealistic expectations, in part by not providing adequate information about the true costs and availability of services.
According to community health care leaders, most Americans expect high-quality care, on demand, and at little or no cost. Americans don’t want to make trade-offs and we don’t want to hear about limits. Because of financial constraints on the health care system, this kind of access to inexpensive services may become increasingly unrealistic. Americans need to revisit the discussion about health care as a social contract and also may need to make tough choices about access and availability of health care services.
There is a need to address the expectations that we have of our health care system by increasing Americans’ sense of collective responsibility about their health and health care. Instead of focusing only on whether we, as individuals, have access to high-quality, affordable health care, we need to begin thinking about health care as a collective resource. The choices we make about our health and our use of the health care system have an impact beyond our own quality of life and our own pocketbook; they affect whether there will be more or less resources available for others. We need to start seeing the connections in how our personal decisions affect other people and how we are affected by the choices that others make.
In addition, while there is broad support for more consumer responsibility, there is also recognition that it should be balanced with much more institutional and organizational accountability. Community leaders have also emphasized that there are limits to the responsibilities that sick or vulnerable people can assume and that individuals should not be blamed for their health conditions.
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Defining and Confronting the Problem
The first step we need to take, as a nation, is to recognize that our health care system is facing enormous challenges that we need to address. In many areas of the country, health care – especially the safety net – is crumbling; employers and consumers are facing skyrocketing health care costs; many patients are not getting the quality health care services they need; and physicians and other health care professionals are facing serious morale problems.
However, many of our elected officials do not seem to grasp the magnitude of these challenges or the urgent need to address them. Therefore, there has to be an effort to educate and engage citizens and policymakers on health care issues. Not much progress can be made without political leadership and public pressure.
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Laying the Groundwork for a National Dialogue
Raising public awareness will require courageous and articulate leadership from all sectors involved in health care, from political leaders to community leaders to health care stakeholders and “the grassroots.” Communities can play a critical role in laying the groundwork for a national dialogue about health and health care.
Community-based discussions can be particularly effective because they are likely to reflect the actual conditions in a community, where people know what works in their area and what does not. There can also be productive collaboration among health care stakeholders in communities, outside of the often-polarizing atmosphere of Washington, D.C. In addition, a community-based discussion is more likely to pull in participation from “the grassroots” and therefore will reflect a community’s own values and principles.
Translating community-based discussions into a national conversation will require a willingness to move beyond the usual political divisions that pit those who support greater government involvement in health care against those who favor less government and a more market-based approach. This dichotomy has often stood in the way of substantive progress in addressing health policy issues such as the problem of the uninsured.
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Transforming the Role of Consumers
Community leaders generally agree that the most important step in moving forward with health system change may be a re-examination of the way that consumers function in the health care system. The traditional consumer role in health care has been relatively passive. But this is changing. The health care market is evolving toward giving consumers more choices, but also more responsibility for the economic consequences of their health care decisions.
Americans need to have the information to be empowered to make good choices that will benefit their own health, and they need to be aware of the finite availability of some health care resources. This will require a shift in the way many of us think about our health. Empowering consumers, and giving them the necessary support and access to appropriate health care services will help them to make good health care choices about their health. It could also improve quality of life and reduce unnecessary costs for the health care system.
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Restoring Confidence and Trust in Health Care
Community health care leaders recognize that health care institutions have lost much of their public credibility, which is a critical aspect of a well-functioning health care system. Skepticism is also prevalent among employers, who are seeing annual double-digit increases in their health care costs.
It is essential that consumers and patients be able to understand and trust their health care providers. Patients must be able to feel confident that their physician is acting in their best interest. Because trust is a two-way street, health care professionals also need to feel confident that their work is valued and supported.
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Spending Money Wisely
The issue of financing is at the heart of our nation’s health care challenges. There is a sense among community leaders that we need to restore balance in how health care resources are allocated and better align incentives in ways that truly support health. The first priority is to recognize that it is well worth the money for the U.S. to make sure that basic health care is available to everyone. Ensuring universal access to health care, through public or private means, is broadly seen as both socially desirable and economically beneficial. Another key consideration should be to emphasize the value proposition, balancing science and measurable outcomes with relative cost.
In all of the roundtable discussions, participants also emphasized the need to better integrate and coordinate health care services. In particular, there should be a greater focus on the areas of health care that are cost-effective ways to improve patients’ quality of care, including primary and preventive care, public health, mental and behavioral health, and care management for patients with chronic illnesses.
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Translating Talk Into Action
Community health care leaders said that a national conversation about health care is important, but it is not, in itself, enough. Discussion, even if it is broad-based and gets to core issues, must lead to action in the end.
For action to be possible, the conversation must move beyond the battleground of special interests that have so often stood in the way of change. There will have to be articulate leadership that generates respect for the process and encourages stakeholders to put aside self-interested agendas that prevent constructive change. There will also have to be broad-based support from the public.
The health care leaders who participated in these roundtable discussions – all of whom clearly recall the failure of the Clinton health care reform plan in the early 1990s – recognize that this type of effort is an enormous undertaking, but they say the effort must be made. Our current circumstances require it and Americans deserve the best health care system we can design.
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The Phase I report of this project, “Communities Shaping a Vision for America’s 21st Century Health and Healthcare,” is comprised of several parts.
First, there is a section titled “A Community-Based Discussion of Values and Principles for American Healthcare”, which describes the values, principles, expectations and preferences that were elicited from the roundtable discussions among community leaders and health care stakeholders. These are concepts that could become a template for national health policy development.
Second, there are the advisory board reports including suggestions of “next steps” to address several key health care challenges – access, quality, information infrastructure, incentives, and the role of public health.
Third, the Appendix includes “community profiles” on each of the ten communities in which WRGH held roundtable discussions and 40 “case studies” showcasing community-based partnerships that have found innovative ways to address key health care challenges at the local level.
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For the full text of the "Guide" in PDF format click here.