Interview with Samuel L. Ross, MD
Community Engagement Addresses Health Disparities
BY: MARY ANN STEINER
Samuel L. Ross, MD, is the current chief community health officer for Bon Secours Mercy Health, one of the largest health care systems in the nation, with facilities that serve communities in Florida, Kentucky, Maryland, New York, Ohio, South Carolina and Virginia. He is responsible for a large network of community outreach initiatives that focus on housing, education, job skills, behavioral health, substance abuse and rehabilitation, all focused on reducing health disparities and improving access to care for the communities that Bon Secours Mercy serves.
Dr. Ross, you're recognized across the country as strong advocate for reducing health disparities and increasing access to care. Where do you see the momentum for that now and what things do you see changing for the better, or maybe for the worse?
A lot of the momentum was coming from industry accelerators, most of that coming from the revenue side around value-based purchasing. And as managed care — whether that's Medicare, Medicaid or a commercial entity — they put more emphasis on social determinants, using financial incentives, and sometimes penalties, to address screening and then referral of those attributed members to services in the community. These members usually make up a smaller subset of the broader community.
Another form of momentum comes as organizations more deeply embrace their mission and their role as anchors in their communities. That also serves as an accelerator or reminder of institutional commitments made over the years.
More recently, the momentum has come from the heightened awareness and ongoing documentation of health disparities/inequities and social justice issues due to years of structural racism in African Americans as outcomes of the COVID pandemic and the death of George Floyd and other persons of color.
The challenge to that momentum is still whether this heightened awareness will lead to sustainable changes in intentional community engagement and investments.
Samuel L. Ross, MD, MS
A lot has happened in the last ten years that affects racial and ethnic disparities: the ACA and Medicaid expansion; Black Lives Matter; the immigration situation. What can Catholic health care do to help move the needle on racial equity and health care access?
If we are true to our mission, if we are true to the principles of Catholic social teaching, if we are true to our commitment to have prophetic voice, certainly in the form of advocacy, then we will intensify and be more intentional about our efforts in these areas.
When we're not, then we look no different than any other institution, nonprofits or for profits. I think our biggest risk is that people can't distinguish at times between what we say versus what we do in our efforts to address racial equity and access to care.
In this intense period of mergers, acquisitions and divestitures in health care how do topics of disparities and access come up in those conversations?
It probably does not come up enough. Even when it does come up, you have to wonder about the depth and breadth of the discussion, because I would dare say that the amount of time spent on financial analyses and economies of scale around operations far exceeds the amount of time spent on discernments around culture and values that address disparities and access.
Oftentimes the words of the mission statements and vision statements and values are quite consistent, and they're easy enough to say. But what are the actual practices and behaviors that go beyond the words? Are they really being lived in a way that is truly consistent, are organizations truly, biblically, being "equally yoked" in these areas of focus? There is little evidence in published articles or case studies on mergers/acquisitions that the same amount of time, energy and resources are placed on these aspects of a merger that get placed on all the other factors getting scrutinized by boards, rating agencies or regulatory bodies.
Do you think the right people are at the table for those discussions?
When you look at the governance structures of our ministries, one would say the right people are at the table. But if someone were to measure the amount of time spent in discernment at the PJP level and compare it to the time devoted to the financial/operational alignment level, one could question if they would be equal, greater or would there be a significant discrepancy.
To most on the outside, "the deal" seems to hinge primarily on whether the financial, operational and regulatory parts fit well, and often appears driven by the "tyranny of the urgent."
How can health organizations build trust in communities where people's trust in health care institutions isn't very high?
It's about relationships. It starts with relationships and ends with right relationship behaviors. We often talk about community engagement, but we have to look at what is the actual practice around community engagement. Franklin Covey has published much about how things happen at the "speed of trust." If we don't take the time to be intentional about that, then it's not going to happen. We often use the phrase of meeting people where they are, as opposed to where we want them to be or expect them to be. The actual practicing of what we say is often a challenge, and it is what communities point to when our actions don't match our words. Our behavior with community should be a direct reflection of our stated beliefs.
There must be a trusted face of the organization and a consistent presence within communities. Those relationships must be built and earned and that doesn't happen overnight. It's a long-term commitment. And regardless of changes in the organization, we must make sure that those bonds with the community aren't broken. It's only in having those relationships and those bonds that people give you good information about health or their definition of health and their feedback about how your organization is performing or not performing, and whether they trust or don't trust your organization.
If you really want to have that kind of relationship with the community, then you must be much more transparent and you have to have members of the community consistently at the input and decision-making table around issues. "Diversity and inclusion" can't just be words, there has to be evidence of actual practice.
The other thing we do a lot of is go out and hold community forums and community meetings, and we say we're here to hear from you. Then we go away for a period of time, until the next time we come back and have our forums and community meetings to hear from them. It's not really a two-way, mutually beneficial exchange of information and involvement in decision-making. We need to build trust.
Here's an example: We are working with our community leaders in Baltimore, who requested that we convert an old library building that has been closed for over 20 years into a community resource center.
We started to look at challenges around projected capital costs and fundraising challenges. We could have made unilateral organizational decisions about facility changes to reduce costs, but that would violate community trust. Our community health leaders went back to what we call the "anchor group" members of the community, presented the challenges to them, and requested their input and feedback. They said come back to us when you've done more analyses and can present specific options and together we'll figure out the best solution, even if it's not what we all thought we would have from the beginning. There's got to be that kind of mutuality where the people in the community respect and value your opinion and you truly respect and value theirs just as much. There is a phrase, "behavior equals beliefs." If it doesn't work that way, there isn't real engagement or a real community partnership.
How do you lead community engagement in light of that? What programs and approaches work in getting that mutuality that you talked about?
You must have the right people and supports in place. In our markets, we have community health leaders. Depending on the size of the market, it might be a manager, a director or an executive director. Their primary role, in partnership with market leadership, is to lead community benefit tracking, community engagement and partnerships, driven by the community health needs assessment (CHNA), which guides the whole prioritization and implementation process.
In doing that we're not just checking the box for the ACA or the IRS to say we have done the CHNA. We're doing community engagement and prioritizing throughout the year so that there are effective partnerships with nonprofits, churches, schools, etc. We strive to make sure we're not doing what we think is the priority but what they believe is the priority. If we're doing that in the right way, we're building relationships, building trust, building partnerships and bringing other stakeholders to the table, to optimize the likelihood that what we're doing is sustainable. And it's not just something Bon Secours Mercy is doing, but truly something that the community is embracing.
We often use the phrase that these things need to be "community-led and community-driven." Because if that's not the case, you're not going to get the best outcome, you're not going to get the collective wisdom. In the end, they'll leave disappointed that once again somebody brought them to the table and promised them something, and it didn't turn out to be what was originally agreed upon. It's an ongoing process with principles from "Community Oriented Primary Care": you identify and involve community; together, you diagnose what the issues and problems are; you implement solutions together, and then together you continue to evaluate whether or not it works and achieves desired outcomes.
Health care has never seemed more complex and complicated. If you could have just one thing move forward this year, what would it be?
For us, it would be the adoption at all levels — at the ministry level, at the board level, at our senior leadership level — of the framework created by the Healthcare Anchor Network, which is part of the Democracy Collaborative. Currently, there are about 45 health systems that have embraced the Healthcare Anchor Network framework for community engagement, economic development, and health improvement. And under that framework, tied to social determinants, tied to meeting community health needs assessment priorities, you focus on these three areas.
1. If you accept that you're an anchor institution in your geographic community, you determine what your efforts are around local inclusive hiring. You look at what percentage of people you currently hire and then build on projections for the future about what that number needs to increase to and in what disciplines, because you want to move beyond just entry-level positions to positions where there is a living wage. We don't want to have employees living below the federal poverty level.
2. The second area is local inclusive supply chain sourcing. Many of the systems have large group purchasing activities, but we also have discretionary spend for purchasing. So how do we look at services — whether it's electricians or window washers or whatever it is among minority businesses — how can we increase contracts with them, such that they can grow and that they too can become agents of hiring more people from that anchor community. We can also use our expertise and resources to help community members start and grow businesses. There are great examples in place by Healthcare Anchor Network members in Cleveland and New Jersey.
3. The third area is investment, but you can think of this in a couple of ways:
• When we think about our community priorities around social determinants like affordable housing, food insecurity, transportation and education, we are looking to work with partners to invest those dollars in programs and initiatives that address structural issues in our communities that can improve long-standing economic and health inequities. Our commitment has to do with how do we, as a catalyst, convener and in some cases a funder, bring others to the table, whether that's companies or politicians or others. That kind of investment becomes more than a single transaction, but truly a way forward to transformation in communities we serve.
• There is also investment at a much greater scale than just your own organization. Last fall, as members of the Healthcare Anchor Network, each of the 15 health systems committed over time to targeting 1% of the total investment income toward place-based investments that address social determinants of health. So, depending on the size of your organization, that number would vary quite a bit. When you look at that 1% in aggregate across all those organizations, it's a total of about $700 million nationwide that would be committed to these community transforming initiatives.
That's our priority. That's the baseline for moving us forward. Those are the key performance indicators for all leaders throughout our system. Everyone at our organization knows that this is what is important for us. Because, as I said before, it starts with leadership, at the ministry level, at the board level, at the C-suite level. This is what we do according to the principles of Catholic social teaching, and it is our commitment to really make our communities healthier in all the ways we are called to do so.
Do you feel hopeful about that?
Leadership in Catholic healthcare is about hope and inspiration.
"Hope has two beautiful daughters; their names are Anger and Courage. Anger at the way things are, and Courage to see that they do not remain at they are." (Augustine of Hippo)
I am hopeful. It can't be just a feeling. It has to be put in action.