BY: JOHN J. BUCKLEY, JR.
Mr. Buckley is president and CEO, Southern Illinois Healthcare, Carbondale, IL.
With managed care sweeping the country, Catholic healthcare organizations are asking how they can remain faithful to their traditional mission and values in light of shrinking resources. A recent study1 confirms that mission-driven providers face thorny challenges. Researchers examined private healthcare providers' role in public health and population-based services in their communities. They surveyed eight facilities (none of which were Catholic) in large urban areas. The research revealed that providers' ability to comprehensively serve their communities may be jeopardized by several factors, including the following:
- Community benefits activities are infrequently related to operational strategy.
- Projects are seldom done in collaboration with other organizations and are narrowly focused on a neighborhood or group.
Motivation for Community Benefits
The researchers used the Institute of Medicine's framework of three core private health functions—assessment, policy development, and assurance—to evaluate the organizations' community benefit programs. They discovered that the majority of these programs were motivated by mission and other altruistic purposes such as addressing root causes of health problems or reducing barriers to access (rather than by business concerns such as increasing revenue).
Where community health services are placed in the organization reflects these altruistic motivations. The responsibility for these services was usually vested in corporate offices or in departments on the periphery of the organization's business strategy, rather than in an operating unit.
The report points out that healthcare organizations—squeezed financially by declining admissions and lengths of stay, changing practice patterns, and new reimbursement structures—are scrutinizing all their activities to see how they contribute to the business strategy. Thus the report predicts that the placement of community benefit activities at the periphery of the organization, without established connections to operations, will be these activities' "undoing."
As the study ironically indicates, managed care and capitated payment may decrease the emphasis on prevention and public health. Respondents said that many of their organizations had been preparing for capitation by becoming leaner and more cost conscious. When projects met opposition, financial officers and administrators were the persons most likely to provide it.
The report adds that the community activities most likely to be dismantled are those with the most potential to support the organization's changing operational strategy: "If indeed the market moves to full-risk capitation, and the organization's interest is in assuming responsibility for the health and health care of covered lives, then the visibility in the community, the network of alternative delivery sites close to the enrollee, and the emphasis on community-wide primary prevention efforts all support a successful strategy."2
Narrow Focus
The study indicates that needs assessments were frequently intense and comprehensive, but they were also often uncoordinated, duplicative, and disconnected from business strategy. Assessments were usually concentrated in one neighborhood, and policies were established for a neighborhood or addressed a specific issue of a particular group. Almost 40 percent of community efforts were undertaken by the organizations acting alone, rather than with other organizations.
Moreover, competition among healthcare facilities and systems impeded successful implementation of projects. A healthcare organization often offered a wide array of services to targeted populations but with little coordination or collaboration inside or outside the organization.
Questions for Providers
These findings pose questions Catholic healthcare organizations must answer. Under managed care's pressures, how will these organizations shape the evolving healthcare system? Will they view population-based services as part of operational strategy or as disconnected from "good" business? Will their mission shape decisions concerning community and institutional services? What spirit will prevail in the managed care environment—competition or collaboration? Will services be delivered in a coordinated fashion? How will ethical issues be resolved—by acquiescence, by confrontation, or by dialogue?
Mission Relates to Margin
People often state that without margin, there is no mission. Although prudent stewardship of human and material resources is essential, decisions about institutional and community care should not be totally business related. They must also be shaped by the organization's mission and values. In our efforts to find security in the bottom line, we must never lose sight of our responsibility to serve the poor, the uninsured, and the people at the margins of society. Remaining faithful to this commitment will require vision and a willingness to change as we discover new ways to serve these persons both inside our facilities and in the community.
Technology and Individualism
Technological advances increase our ability to extend our services beyond the walls of the institution and to minister to persons in the community who were previously unable to obtain services. Financial constraints, however, often militate against the provision of such care and increase the number of ethical questions related to treatment. Our nation's tradition of rugged individualism tends to adversely influence the decisions made about care for the physically disabled, the newborn, the elderly, and other vulnerable persons. But we have the social responsibility in justice to demonstrate concern for the human community by providing basic healthcare and ethical treatment to all persons.
Competition Versus Collaboration
One of the greatest impediments to the delivery of care, especially in communities that are underserved, is destructive competition. Competition was initially encouraged as a means of reducing the cost of care, but it has instead frequently accelerated rising costs. For Catholic healthcare organizations, the challenge is to unite to continue the healing ministry that Jesus bequeathed to his Church, rather than to seek to be the most powerful and profitable leader in the community. If we work together for a common end—the good of those we serve—many of the issues that now separate us will be diminished or resolved and we will accomplish far more than we can imagine.
As healthcare providers, we have the opportunity to create a system that meets the preventive, curative, and palliative needs of the communities we serve. Ultimately, our success will be measured by how well we have done that and how faithful we have been to the words of Jesus: "In so far as you did this to one of the least of these brothers of mine, you did it to me (Mt 25:40)."
NOTES
- "Private Sector Health Care Organizations and Public Health: Potential Effects on the Practice of Local Public Health," report submitted by Macro International Inc. to Public Health Practice Program Office, Centers for Disease Control and Prevention, March 1996.
- Executive Summary, p. ix.