Hurricanes’ Effects on Health Care and What Foundations Are Funding in Louisiana


August 31st, 2010

As the media have been reporting on New Orleans at the fifth anniversary of Hurricane Katrina, it is also an opportune time for the GrantWatch Blog to report on how foundations have been helping in the Crescent City and surrounding area. Foundations have awarded grants to inform the general public about the status of New Orleans, to provide helpful information for local residents, and to provide direct services for people still coping with the aftereffects of the 2005 hurricanes. This is just a sampling of philanthropic efforts.

Recently released survey and blog post:

“New Orleans Five Years after the Levees Broke” is the latest blog post by Drew Altman, president and chief executive officer (CEO) of the Henry J. Kaiser Family Foundation (KFF). (He does a monthly post in his series “Pulling It Together, from Drew Altman.”)

Here, Altman relates some highlights of the KFF’s recent survey of New Orleans residents on how things are going in New Orleans. “New Orleans Five Years after the Storm: A New Disaster amid Recovery” is the third such survey fielded by this operating foundation. Altman says in his August 30, 2010, post that 70 percent of New Orleanians “believe the rest of the country has forgotten them and the difficulties the city still faces in its recovery.” He mentions another surprising survey result: “More residents see the city as divided by ‘class’ (33%) than by ‘race’ (17%).”

Only about a third of this survey focused on health care, by my estimate. An accompanying press release noted, “The picture is mixed on the recovery of the health care system.” For example, 49 percent of residents said “they see ‘a lot’ or ‘some’ improvement in the availability of medical services and facilities,” while an equal share said they see little or no progress in that area. More than half (55 percent) of residents surveyed said their health care needs are being met “very well.” That is an increase from 42 percent in the 2008 survey, and 36 percent in the 2006 survey.

Despite the increased numbers of health clinics in the New Orleans area, 84 percent of respondents said they did not think there were enough health care services for uninsured and low-income people in New Orleans. And 27 percent of respondents said either that their usual place of care is the emergency room or that they have no usual place of care. The survey, which was conducted in May and June 2010, also found “improvement in reported mental health status.”

In his blog post, Altman commented that more respondents chose the BP oil spill than Katrina and the levee breeches (49 percent vs. 40 percent) when they were asked which calamity will ultimately damage the region more.

Hats off to the KFF for continuing to follow this story years later.

Examples of grants awarded:

“GE Foundation Awards $2M Grant to Support New Orleans School-Based Health Centers,” Louisiana Public Health Institute (LPHI) press release, August 24, 2010. This grant to the LPHI will expand access to preventive, primary care, and primary mental health services for adolescents in Orleans Parish (county) and will fund the institute’s School Health Connection program, a regional collaborative. (The collaborative has received funding from the W.K. Kellogg Foundation and the Robert Wood Johnson Foundation.) The LPHI and its partners will “build on previous philanthropic and government investments” received after Hurricane Katrina to continue to provide access to health care in the New Orleans area.

“With 38,000 students across Orleans Parish alone, this grant has the potential to give thousands of students improved access to primary healthcare services,” through school-based health centers, the release said. Such centers allow “easy access to services for youth who frequently delay treatments or commonly seek emergency room care.” School Health Connection and its local and state partners plan to increase health care use “through growing enrollment and increasing use among eligible students, as well as extending services to neighboring schools, family members and nearby residents,” the release noted.

The GE Foundation is the philanthropic arm of the General Electric Company (GE). This grant is part of the foundation’s three-year, $25 million Developing Health program, developed by the foundation and the GE Corporate Diversity Council. Developing Health “aims to improve access to primary care in targeted underserved communities across the United States”; it launched in October 2009. The program partners with nonprofit health centers and offers volunteer support from GE employees and sharing of business best practices. Grantseekers: Please note that the GE Foundation, which is based in Fairfield, Connecticut, does not accept unsolicited proposals.

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Baptist Community Ministries (BCM), a private foundation in New Orleans, has awarded a grant to Catholic Charities, Archdiocese of New Orleans, for the H.O.P.E. Health Promoters Program: Health Outreach, Promotion, and Education. BCM’s web site says that since Hurricane Katrina, the Latino population in Greater New Orleans has increased, and this population has unmet needs. Under this second BCM grant, H.O.P.E. aims to expand to two new areas of need, Medicaid and food stamps, while continuing to help Latinos gain access to health services as it has before. The program uses health promoters (promotoras de salud, or community health workers) to address the needs of Latinos in a culturally competent way.

Web sites:

Check out the Foundation Center’s Focus on Gulf Coast Hurricane Relief web site. This useful site contains news from the center’s Philanthropy News Digest (a weekly electronic digest of foundation news) on efforts by philanthropy to help the Gulf Coast region affected by Hurricanes Katrina and Rita. The site also has links to relevant posts from the center’s PhilanTopic blog, as well as reports that its PubHub site has listed. The Hurricane Relief site also includes an interview with the president and CEO of the Greater New Orleans Foundation; among other topics, this leader discusses the role of foundations in the post-Katrina recovery in New Orleans. Interactive maps show giving for hurricane-related efforts by foundations. (Click here for more information on the maps.)

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Eighty-seven community-based health centers now operate across Orleans, Jefferson, Plaquemines, and St. Bernard Parishes (counties) in Louisiana. GNOCommunity.org is “a service dedicated to helping individuals find a quality healthcare center that fits their needs.” The web site is searchable by zip code or type of health service sought. The centers are open to all people “regardless of their ability to pay” and are funded in part by a $100 million U.S. Department of Health and Human Services Primary Care Access and Stabilization Grant (PCASG), which is set to expire at the end of September 2010. (A few health center grantees would benefit from a pending no-cost extension request under consideration by the Centers for Medicare and Medicaid Services, which will allow those grantees an additional year to spend their federal grant funds, Maria Ludwick, interim director of the PCASG program, explained in an e-mail interview.) The LPHI administers that federal funding. The federal grant and BCM support GNOCommunity.org’s web site and outreach activities.

Ludwick also explained, via e-mail, that there is good news on the funding front. “The State [of Louisiana] has put forth an 1115 Research and Demonstration Waiver that seeks to sustain the clinic network as a bridge to health care reform, which means continued access to primary and behavioral healthcare” for uninsured patients being served “until Medicaid expansion and the State’s [health insurance] exchange in 2014,” she explained. People living in the four-parish area, ages nineteen through sixty-four, with incomes less than 200 percent of the federal poverty level “would be enrolled in the program and offered a limited primary and behavioral health care benefits package through the participating PCASG provider network for phase one of the transition.”

Ludwick said that the demonstration project is expected to “make available up to $30 million per year of the state’s unspent Medicaid Disproportionate Share Hospital (DSH) allotment.” Louisiana has been granted approval by the U.S. Department of Housing and Urban Development “to use the disaster Community Development Block Grant funding as [a] local match required” by DSH draw-down regulations. The waiver is expected to be approved by October 1, 2010, she said.

Related resources:

“Establishing and Refining Hurricane Response Systems for Long-Term Care Facilities,” Kathryn Hyer, Lisa M. Brown, Amy Berman, and LuMarie Polivka-West, Health Affairs (GrantWatch) Web Exclusive, August 29, 2006. Hyer and Brown are with the University of South Florida, Berman is with the John A. Hartford Foundation, and Polivka-West is with the Florida Health Care Association. Look for an update from these authors in an upcoming GrantWatch section of the journal!

“Legacy of Katrina: The Impact of a Flawed Recovery on Vulnerable Children of the Gulf Coast,” Children’s Health Fund and National Center for Disaster Preparedness at the Mailman School of Public Health, Columbia University, White Paper, released August 23, 2010. Among the key findings of this five-year status report is that “children displaced by Katrina were 4.5 times more likely to have symptoms consistent with serious emotional disturbance (SED) than did comparable children surveyed in a 2004 national study.”

“Revisiting ‘Witness to Disaster': First-Person Accounts of Katrina’s Aftermath,” Chris Fleming, Health Affairs Blog post, August 27, 2010. Read about a Narrative Matters section published in Health Affairs in 2006. The section contains vignettes from Fred Cerise (who was then secretary of the Louisiana Department of Health and Hospitals), Ben Springgate (then a Robert Wood Johnson Clinical Scholar), and several more people.

St. Bernard Project’s Center for Wellness and Mental Health, Chalmette, Louisiana. “Opened in January 2009 through an innovative partnership with Louisiana State University’s Health Sciences Center,” the Center for Wellness and Mental Health “provides evaluation, treatment and support for residents of St. Bernard [Parish] and New Orleans suffering from storm- or oil-spill-related mental health problems.” Liz McCartney, cofounder of the St. Bernard Project, said in an e-mail interview that the center has received funding from the Joe W. and Dorothy Dorsett Brown Foundation, located in Metairie, Louisiana, as well as the Gulf Relief Foundation, the United Way for Greater New Orleans, and private donations.

McCartney, who received the 2008 CNN Hero of the Year award, and Zack Rosenburg, the other cofounder, note, “Our goal [at the center] is not to simply solve the problem [in the New Orleans area], but to develop a replicable model that can be taken to other communities impacted by natural and man-made disasters. We must improve the quality of services and the speed at which they are delivered to prevent harm and help people get back to living as quickly as possible.”

The St. Bernard Project is perhaps better known for its efforts at rebuilding homes that were badly damaged by Hurricane Katrina.

“A Tale of Two Recoveries,” Michael A. Fletcher, Washington Post, August 27, 2010.

Recent Foundation Funding in Global Health: Helping Haitians after the Earthquake; HIV/AIDS


August 27th, 2010

It has been more than seven months since the terrible earthquake that hit Haiti on January 12, 2010. GrantWatch Blog mentions here two foundation-related efforts to help people from this poverty-stricken Caribbean nation. We also bring you news of some philanthropic activity related to the ongoing global HIV/AIDS pandemic.

Haiti

New report released:

“Building a More Resilient Haitian State,” Keith Crane and coauthors, released August 13, 2010, by RAND, 179 pp., http://rand.org/pubs/monographs/2010/RAND_MG1039.pdf. In a press release, coauthor James Dobbins, now with RAND and formerly special envoy to Haiti during the Clinton administration, comments, “Haiti will remain vulnerable to natural disasters, political turbulence, and civil unrest until it develops effective institutions.” The authors recommend that Haiti concentrate on several areas, including health, which is the focus of Chapter Nine of their report.

“The Haitian state should focus on monitoring and regulating the delivery of education and health services, not providing those services itself,” according to the release. Specifically, the report itself states that “consideration should be given to shifting the operation of all health centers and hospitals to NGOs [nongovernmental organizations] and other private institutions, allowing the MSPP [Ministère de la Santé Publique et de la Population, or Ministry of Public Health and Population] to concentrate on setting policy and planning for, overseeing, monitoring, and evaluating the operation of Haiti’s public health service–delivery network.” With the “extensive donor involvement” in health care (now and even before the earthquake), however, the government needs “to coordinate, regulate, and oversee” the donors and NGOs. These comments all fall under the recommendation to “Establish Performance-Based Contracting Mechanism for Provision of Services.”

The authors also recommend examining Haiti’s health care financing options for the long term. They acknowledge that “donors will need to continue to pay for the bulk of Haiti’s health-care costs, including the technical and administrative infrastructure required to build a sustainable health system.” However, they say that “steps should be taken now to lay the foundation for a sustainable financing structure for Haiti’s health sector.” With donor support, the ministry should contract for “a study to examine in detail the various options for financing the health-care system and [to] model the implications of those options for access to care, health outcomes, and the continued viability of the system.”

The Carnegie Corporation of New York and the Smith Richardson Foundation, which is located in Westport, Connecticut, funded the study. Note that Carnegie is not a health funder; read about its programs here. Also, Smith Richardson notes on its Web site that only “a small number of unsolicited proposals” that it receives are funded.

Other news from foundations:

“Responding to Haitian Devastation, at Home,” Jim Knickman of the New York State Health (NYSHealth) Foundation, August 16, 2010, on Smart Assets: The Philanthropy New York Blog. Knickman points out that “the devastating earthquake” in Haiti in January 2010 “has lately fallen off many people’s radar,” but it continues to affect “hundreds of thousands of Haitians and their families directly.” Because of NYSHealth’s funding guidelines, it “could not support on-the-ground-efforts in Haiti.” Read, though, about how this foundation, which was determined to help, is funding Haitian communities in the Greater New York area. Its money is being used to “provide needed healthcare and social services for those affected by the earthquake.” NYSHealth aims to provide support to those who lost loved ones in Haiti “or still [have] family members there, and to those newly arrived in New York because they were displaced by the earthquake,” Knickman’s post explains. One example of a gap the foundation could fill, he said, was “access to mental health counseling.”

“Scholars, Alums from Robert Wood Johnson Foundation Programs Heeded the Call for Help in Haiti after Earthquake,” May 11, 2010, Robert Wood Johnson Foundation (RWJF) Web site. Read about what several people affiliated with the Robert Wood Johnson Foundation Clinical Scholars Program and its Harold Amos Medical Faculty Development Program did to help in Haiti.

Related resources:

“Remembering Haiti at the Six-Month Mark: The International Community’s Response to Overwhelming and Long-Term Need,” Heather A. Conley and Johanna Mendelson Forman of the nonpartisan Center for Strategic and International Studies (CSIS), July 12, 2010. This two-pager is part of the “Critical Questions” series of the CSIS. The authors state that “creation of an urban sanitation system” is among the urgent needs in Haiti. Priorities for the immediate future include “providing support in case of an outbreak of epidemic disease.” 

“Volunteers Find Their Pace in Haiti,” Eric Campbell, August 5, 2010, Project HOPE in the Field blog. This post describes just one day spent trying to help people in Haiti who had medical conditions ranging from an infected jaw to excessive earwax to scabies. Military medical personnel and HOPE volunteers together helped 488 patients that day and also filled 642 prescriptions. Project HOPE, an international health education and humanitarian assistance organization, is the publisher of Health Affairs (and the GrantWatch Blog).

HIV/AIDS

New funding just announced:

“Merck Provides New Funding to Fight HIV/AIDS in Botswana: Merck Company Foundation Supports Successful HIV/AIDS Initiative Led by Government,” Merck press release, August 24, 2010. The Merck Company Foundation and the Bill and Melinda Gates Foundation are committing $60 million in additional funding for Botswana’s African Comprehensive HIV/AIDS Partnerships (ACHAP), according to the release. (Each funder is putting in $30 million over the next five years.)

The new funding will continue ACHAP’s “original efforts in treatment and care” but also will support a second phase that “will expand efforts to improve the prevention of HIV, address the link to treatment of TB [tuberculosis] for people with HIV, and create greater sustainability through the transfer of key services to the Government of Botswana and local organizations,” the release explained. “ACHAP has helped demonstrate how public–private partnerships might work to save the lives of the world’s poorest people infected with HIV.”

Merck, a major pharmaceutical company, will continue donation of its antiretroviral drugs for people in Botswana with HIV/AIDS.

Related resources on ACHAP:

Visit the African Comprehensive HIV/AIDS Partnerships web site here.

“Public–Private Partnerships and Antiretroviral Drugs for HIV/AIDS: Lessons from Botswana,” Ilavenil Ramiah and Michael Reich, Health Affairs, GrantWatch section, March/April 2005. This peer-reviewed article is about ACHAP’s early years.

Tutorial

“The Current State of the Global HIV/AIDS Epidemic,” Kim Boortz of the Henry J. Kaiser Family Foundation (KFF), June 2010. This narrated tutorial on the KFF’s KaiserEDU.org web site reports that South Africa had the largest number of people with HIV/AIDS, per 2007 UNAIDS statistics. The slides titled “Critical Challenges” and “Accomplishments” contain important summaries. KaiserEDU.org’s target audience includes students, faculty, and others interested in learning about health policy.

Can Funders Quell a ‘Perfect Storm of Overutilization’?


August 25th, 2010

This month I received a letter from a physician who was dismayed to learn that a colleague was leaving medical practice. He wrote in his letter, “One of my dear friends was nudged into retirement because he didn’t order enough tests on the equipment which his practice had purchased…. His loss [to the field] is immeasurable; he was able to substitute good clinical judgment for a bevy of tests.”

The mantra in health care today is volume, volume, volume. In this highly caffeinated system, many doctors are required to meet productivity targets for diagnostic tests, surgeries, and office visits. As payers ratchet down payment per unit of service, the incentive exists to increase volume, and the cycle perpetuates itself.

Since the 1970s, Dartmouth researchers have brought to light unwarranted variation in health care services. Devotees of the research will remember the compelling finding in the early work of John Wennberg, which revealed that 60 percent of men in some communities in Maine had prostate surgery by the time they were age eighty, while in other communities, 20 percent of men had had the surgery.

Foundations have made major contributions to the Dartmouth research. The early findings from small-area analysis in New England were extended to the whole United States, and the Dartmouth Atlas became a web-based resource for researchers, health care providers, journalists, and policy makers. Over the years the foundations that have supported its research include the John A. Hartford Foundation, Commonwealth Fund, Robert Wood Johnson Foundation (RWJF), and the California HealthCare Foundation, as well as philanthropic arms of some health plans including WellPoint, Aetna, and United Healthcare.

Like a lighthouse warning of rocky shoals, the Dartmouth Atlas shined a light on Redding Hospital in California, which had the highest rate of heart bypass surgery in the country in 2001. After the Federal Bureau of Investigation (FBI) raided the hospital at the instigation of a patient who was concerned about a recommendation for unnecessary heart bypass surgery for nonexistent heart disease, enormous fines and penalties were paid, and the volume of heart bypass surgeries plummeted to a level consistent with the statewide average.

The Dartmouth research shined a light on McAllen, Texas, which has become a household word in the corridors of the White House and among policy wonks. Its enormously high health care costs occur because of across-the-board overuse of medicine, according to Atul Gawande’s account in the New Yorker.

Recently, I read “The Perfect Storm of Overutilization” by Ezekiel (“Zeke”) Emanuel and Victor Fuchs, which was published in 2008 in the Journal of the American Medical Association. The authors identify the factors that contribute to overutilization including physician culture, fee-for-service payment, and direct-to-consumer marketing.

While reading the article, I thought about the Dartmouth Atlas, and wondered whether health care organizations in some communities with a relatively low volume of surgeries see an opportunity to grow the number of procedures they perform to be more in line with the national average, or even higher than the average. There are no data to suggest that this occurs. But in a world where provider organizations may feel pressure to increase volume to meet revenue and productivity targets, it would be interesting to learn the reaction of providers when they realize they are practicing in low-volume communities.

In any event, what can foundations do to quell the perfect storm of overutilization? In the current climate of innovation spurred by health care reform, foundations can fund the development of new payment models as well as new delivery models that help organizations learn how to reduce waste in care delivery processes and curb overuse of tests and treatments that don’t benefit a patient.

One of the lessons from Pursuing Perfection, a national program funded by the RWJF that was conducted at seven participating health care institutions from 2001-2008 and was led by Donald Berwick, new administrator of the Centers for Medicare and Medicaid Services (CMS), is that foundation investments can help clinicians and administrators develop knowledge and skills to dramatically redesign processes of care, remove waste, and spur broader organizational transformation.

Foundations can support research that sheds light on patient experience of overtreatment. A Commonwealth Fund survey published in 2008 found that 32 percent of Americans say they have had medical care they thought was unnecessary or had little benefit. This remarkable finding merits greater understanding.

Finally, foundation funding can accelerate the adoption of shared decision making. When patients are informed of the risks and benefits of treatment options, they tend to shy away from the storm of overutilization. It’s always a good thing to stay out of the path of a storm. Foundations can fund the expansion of shared decision making and lead patients to safe harbors.

On the Philanthropy Blogs Roundup: Health Reform, Dengue, Polling, and More


August 20th, 2010

I have been scanning the blogs listed on our GrantWatch Blogroll to the right and wanted to point out some posts that are worth looking at.

Check out Matt Sundeen’s informative August 5, 2010, post “To Be Seen Whether Other States Follow Missouri’s Vote against Health Reform,” on the Colorado Trust’s Community Connections Blog. Sundeen, who is senior program officer for health policy at the foundation, which is located in Denver, writes about Proposition C, a Missouri ballot proposal, approved by 71 percent of voters in an August primary election, and a petition drive to put a similar proposal on the ballot in Colorado’s general election in November 2010. Prop C “attacks the controversial individual mandate requirement” (contained in the federal health reform law) to buy health insurance. Sundeen makes some insightful points about these efforts.

Have you ever heard the radio ad from Novartis, the pharmaceutical company, about the woman who contracted dengue fever? Well, now you can get more information on this tropical disease in “Where in the World is Dengue?” the title of an August 12, 2010, post by intern Rachael Holmes on google.org blog. She mentions an effort by google.org grantee HealthMap and the U.S. Centers for Disease Control and Prevention (CDC) called DengueMap. Did you know that there have been twenty-eight cases of people catching dengue in Florida since 2009?

Jennifer Chubinski asks in her August 19, 2010, post, “Will the Health Foundation [of Greater Cincinnati] Win Marlboro Researcher of the Year?” This post, on the foundation’s blog that is called simply “The Health Foundation,” talks about this funder’s “belief in sharing openly all of the public opinion polling data collected by [its] Health Issues Polls.” She points out, “We cannot just release the data we like best.” She explains why to foundation-watchers. Chubinski is director, health data improvement, at the Health Foundation, which funds in Cincinnati and twenty surrounding counties in Indiana, Kentucky, and Ohio.

The John A. Hartford Foundation’s Health AGEnda Blog contains a July 22, 2010, post by program officer Amy Berman titled “Visionary Takes the Helm at CMS.” She writes about the appointment of Don Berwick of the Institute for Healthcare Improvement (IHI) as the new administrator of the Centers for Medicare and Medicaid Services. Hartford was an early funder of a project that turned into the institute. Berman writes, “Years ago the Foundation provided the seed money that Berwick and his colleagues used to start” the IHI. And the rest is history, as they say. For more blog fodder on Berwick, read a post by Chris Fleming, social media manager at Health Affairs, called “Berwick to Head CMS without Senate Confirmation (updated),” (posted July 7, 2010).

The Rasmuson Foundation’s Reflect.Share.Blog has an August 16 post about its fourteenth annual Educational Tour of Alaska for Grantmakers. This Anchorage-based foundation each year “invites a small group of grantmakers from the South 48 to visit Alaska.” Rasmuson wants other funders to learn about the state and philanthropic opportunities there, blogger Jordan Marshall says. Among this year’s guests is Luis Urbiñas, president of the Ford Foundation. Read about the health-related organizations the visitors saw. And read a remembrance of former U.S. Senator Ted Stevens (R-AK), including a mention of his role in forming the Denali Commission, a federal agency. (The funeral for Stevens, who died in a plane crash earlier in August, was held this week.) The commission has several programs; read about its health facilities program here.

“A Game-Changing Approach: No New Cases of AIDS in Atlanta” is an August 12, 2010, post published on the Council on Foundations’ Re: Philanthropy blog. In it, Ray Knott of the new Atlanta AIDS Partnership discusses its new campaign called A Community without AIDS: No New Cases. He mentions the roles of the Community Foundation for Greater Atlanta and United Way of Metropolitan Atlanta, as well as those of former U.S. surgeon general David Satcher and Sandy Thurman, a former White House AIDS czar, in establishing No New Cases. Here is some more information, from the community foundation’s Web site, about the Atlanta AIDS Partnership.

Have a good weekend!

Health Reform at the Retail Level: Community by Community, State by State


August 19th, 2010

Our discussions at the recent health funders’ retreat at Brandeis University drove home an important point. The Affordable Care Act is a lot more than a series of provisions to assure access to health care coverage for millions of uninsured Americans. The new health reform law creates opportunities to develop fundamental and complementary payment and delivery system reforms that can reduce costs by raising quality of care.

Even those who had doubts about enacting the Affordable Care Act should be rooting for it to drive major progress on costs and quality of care. If health care costs continue to rise rapidly and quality improvement proceeds at a glacial pace, the fiscal and human consequences will be dire. But cookie-cutter models from Washington, D.C., won’t get the job done. Flexible policies that allow adaptation in light of local delivery systems and market conditions are crucial to successful change.

It’s the Seniors, Stupid!

Except for the access provisions in the legislation, the group that will be most affected by the Affordable Care Act is senior citizens. Seniors are the largest–and fastest growing–population, with complex and expensive health care needs. As we go down the list of problems that drive health care costs, all of them affect elderly patients disproportionately: rising incidence of lifestyle-related chronic conditions; simultaneous existence of physical and behavioral health issues; ineffective chronic disease management; poor coordination of care across health care settings; frequent emergency department visits, hospitalizations, and re-hospitalizations, because of inconsistent transitions of care (from hospital to home or nursing home or rehab facility) and inadequate post-discharge follow-up; recurring, preventable hospital-acquired infections; and medication errors and discrepancies that occur because of lack of systematic medication review and reconciliation. Also, poor support for palliative care or end-of-life decision making adds cost and suffering to our health care system.

The Pittsburgh area has one of the highest proportions of elderly people in the United States. Even before the Affordable Care Act, some national (such as the John A. Hartford Foundation and the Robert Wood Johnson Foundation) and local (such as the Jewish Healthcare Foundation) foundations, leading health care organizations, and private and public payers were already exploring new ways to advance quality of care and efficiency in the above areas. For example, independent community hospitals and small primary care practices are essential parts of our region’s delivery system. A successful readmission reduction project for patients with advanced lung disease at two local hospitals has led to development of accountable care pilots among three other community hospitals and small aligned practices. Also, because it isn’t practical for every small primary care practice to offer comprehensive services and resources, we are exploring the potential for community hospitals and/or federally qualified health centers to serve as primary care support centers (offering, for example, behavioral health services or chronic disease clinics).

Regional Healthcare Improvement Coalitions

In kicking off our discussions at Brandeis, Atul Gawande pointed out the need for community-by-community portfolios of integrated improvements: Any community that presents as a model of value-driven health care, he explained, “will be a model for the rest of the nation.” He stressed that everything hinges on whether this occurs. The importance of a single model community may be up for debate, but the message is clear: communities must be the laboratories for testing health reform strategies.

Local and regional health foundations can bring critical resources to bear, and most of them also have natural local partners in the more than fifty nonprofit regional healthcare improvement coalitions (RHICs). Although often overlooked by national policy experts, RHICs, including the Institute for Clinical Systems Improvement, in Minnesota; Massachusetts Health Quality Partners; Quality Counts, in Maine; Puget Sound Health Alliance, in Seattle; and Pittsburgh Regional Health Initiative (which the Jewish Healthcare Foundation supports), have significant experience in key areas: development of new payment and delivery models, integration of care across settings, patient safety, consumer engagement, and value-based purchasing. They should be encouraged and supported to participate in impending pilots and experiments that have been authorized by the Affordable Care Act, and related state government-sponsored and locally inspired projects.

Strengthening the Community Safety Net

A major topic of discussion at Brandeis was the importance of supporting cash-strapped states and safety-net organizations to enable them to take advantage of the grants and pilots included in the new federal health reform law. Unless you “support your carpenter,” as Michael Doonan, assistant professor at the Heller School for Social Policy and Management at Brandeis University, suggested, your house, or system of health care reform, will not be built.

But what is your state’s or region’s priority? Effective enrollment programs? Safety net expansion? Inclusion of dental and behavioral care? There are many entry points to building your state’s and region’s response to the Affordable Care Act. Models of successful programs to support states and safety-net agencies abound. Look to Blue Cross Blue Shield of Michigan Foundation ($5,000 grants to support large grant applications); Missouri Foundation for Health (Missouri Capture); and the California HealthCare Foundation, which created an office in Sacramento to provide support to policymakers and the media and linkage to experts and resources at the foundation, and made a $550,000 grant to Manatt Phelps and Phillips, LLP “to support the California Health and Human Services Agency by developing and implementing a statewide plan in accordance with the provisions of the Health Information Technology Economic and Clinical Health (HITECH) Act.”

Work Force Development

If health care delivery is local, health care work force development is no less so. Delivery and finance system redesign requires changes to the work force. There are great opportunities in health care to provide not just jobs, but careers and career ladders to those with a high school degree and just some college. Health information technology (HIT) also provides a host of opportunities. Think about it: Where will we get the new HIT professionals to implement and manage electronic health records in every private practice across the country? Also, a number of states around the country restrict the work of physician extenders, especially in primary and behavioral care, even as severe shortages in these fields continue. There is an important informational role for foundations to play with consumers, purchasers, health care professionals, and policy makers.

Where We Go from Here

Every region will have different priorities, but we must start somewhere. I know where we will begin in southwestern Pennsylvania—working to achieve a system of care for seniors in which (1) their care is integrated, (2) there is effective management of chronic disease, (3) consumers and their caregivers are engaged and educated, and (4) end-of-life planning is the norm. Echoing the words of Gawande, the community that is able to put these pieces together will not only be a model, but will save the individuals, families, businesses, and taxpayers billions, if not trillions, of dollars.

Read another GrantWatch Blog post by Karen Feinstein.  

How Foundations Can Help States Implement Health Reform


August 13th, 2010

More from a meeting of foundations, cosponsored by Grantmakers In Health and others and held at Brandeis University, July 2010

How can philanthropies interested in health care delivery assist states in the complex task of implementing health reform? This was the topic that brought philanthropy types together in late July to share visions and to learn from one another. As mentioned in a previous GrantWatch Blog post, Grantmakers In Health (GIH) convened the foundations. Except for the Brandeis faculty who acted as high-level facilitators, this was a philanthropy insiders’ event. The discussions included ways that philanthropies could help with the coverage-expansion tasks of implementation and also how we could help with the systems-reform opportunities that the new law offers.

Confidence in Our Potential Roles

Given the general sense that the new law represents the most significant and complex health care initiative in forty-five years, no one disagreed that foundations could and must play important roles in enabling state-level implementation. State governments have the largest responsibility for implementing health reform, but each and every one of the states is economically stressed and most will be for the foreseeable future.

There is the sense that philanthropy can be more nimble than state government—foundations can fund key players without the long lead times involved with state procurement. Because we “don’t have a dog in the fight,” we can credibly bring together the various actors that need to be involved: consumers, health plans, employers, and state government.

A striking difference in perspectives emerged across foundations at the funders’ meeting, depending on their home state’s views of health reform. In more conservative states, foundations pondered educational roles to ensure that citizens understand the facts about health reform rather than the exaggerations that the “all-news” cable television shows—of both the left and right—perpetuate. Those of us in states where there is more consensus about the importance of expanding insurance coverage focused more on the technical issues of implementation.

Blue Cross Blue Shield Foundation of Massachusetts as a Model

We have much to learn from the role that Blue Cross Blue Shield Foundation of Massachusetts (BCBSMA) played in implementing the Massachusetts version of reform: this funder supported the right research done by the right people, convened the right players, and developed an excellent communications strategy. The foundation sustained a dialogue and sponsored “must-attend” meetings that included decision makers as well as representatives of interest groups from across the state.

Sarah Iselin, president of BCBSMA Foundation, also noted the importance of a monitoring role. For example, after the new health insurance exchange started to sell policies, it was important for the state to understand how changes in revenue flows affect the viability of different types of providers, especially safety-net providers.

Seamlessness of Enrollment Systems Is a Key to Success

One key theme that emerged was the recognition that, as people’s income fluctuates, so does their eligibility for different types of coverage and subsidies. States’ enrollment information systems must be able to handle the transitions from subsidized exchange policies to Medicaid eligibility to ensure that many more people have continuous health care coverage. Some meeting attendees commented that foundations can help by funding the initial stages of designing information systems that will make enrollment in alternative types of insurance policies as seamless as possible.

Great Hopes for Medical Homes and Accountable Care Organizations

As we turned to a discussion of health system improvement, we all acted as if we would soon live in a world of medical homes (health care entities that offer and coordinate comprehensive primary care; meet performance and efficiency standards; and use health information technology) and accountable care organizations (a group of health care providers that assume collective responsibility for the care of a specific group of patients and receive financial incentives to improve health care quality and efficiency).

Personally, I am more skeptical about how quickly these will emerge. My favorite comment, made by a meeting attendee, was that we can all picture unicorns and mermaids in our minds, but they don’t exist in the real world. Who knows? This might be how we will end up categorizing medical homes or accountable care organizations five years from now.

Foundations should work hard to help these movements evolve. But let’s not ignore the more basic first steps of financial systems change: reimbursement reform that encourages good primary care by paying providers more to do primary care and offers clear financial incentives to support good outcomes of care. (Personally, I favor direct financial rewards when a physician achieves the outcomes required, as in the National Committee for Quality Assurance’s (NCQA’s) and Bridges to Excellence’s recognition programs for providers of excellent diabetes care.)

Another initial, doable approach to systems reform is bundling of payments—that is, providing a single payment for a patient’s full episode of care (for example, an entire hospital stay) rather than reimbursing providers for each discrete service or procedure.

States as Experimentation Sites

Because we were at Brandeis University, it was inevitable that Justice Brandeis’s famous quote would come into play: “a single courageous state may…serve as a laboratory, and try novel social and economic experiments without risk to the rest of the country.” As we conduct our experiments at the state level, we state-based philanthropies should take the lead in making sure we work together, plan strategies together, and learn from one another.

Concluding Thoughts

Kudos to the Brandeis faculty for an excellent series of policy briefs prepared for the conference. And kudos to GIH and the three other sponsors of the conference: the Jewish Healthcare Foundation, the California HealthCare Foundation, and the Commonwealth Fund. The meeting should help those of us who work in health philanthropy to help our states with the implementation task ahead.

Helping to Define Health Philanthropy’s Role in the Implementation of Health Reform


August 12th, 2010

Two weeks ago, Grantmakers In Health (GIH) joined with the Jewish Healthcare Foundation, California HealthCare Foundation, and Commonwealth Fund to sponsor a discussion among funders about the roles that state and local health foundations can play in advancing health reform.

The night before the meeting, surgeon and writer Atul Gawande set the stage for the funders’ discussion by laying out the overall goal of health reform—which he framed as getting better results at a lower cost without harming a single person—and reminding the audience of grantmakers that we can make considerable progress if we just systematically apply what we already know. Using anecdotes and insights from his experiences at Brigham and Women’s Hospital, the Dana-Farber Cancer Institute, and the New Yorker magazine, he encouraged philanthropy to provide the platform for stakeholders to set priorities, to help obtain data, and to start working on scalable system innovations.

The next day, Brandeis faculty kicked off a set of conversations about the safety net, delivery system redesign, payment reform, workforce efficiency, and consumer education. Stuart Altman and others were faculty discussants. (For an agenda, click here.) What struck us was that the law will only truly take shape as regulations are issued. Implementation will take place in an extremely contentious political climate. The law’s potential benefits and complexities will need to be communicated to diverse allies, confused consumers, and determined opponents. And the Affordable Care Act is not a cure-all; it has strengths and weaknesses and is silent on several of the issues and populations—such as health care for undocumented immigrants—that funders care most about.

We clearly had the right people in the room and the right topics on the agenda: for eight hours, more than seventy people from nearly sixty foundations across the country discussed their challenges and concerns, asked one another’s advice, and identified potential areas of investment and coordination. Together, the group created an ambitious list of funding opportunities to use in their own states and communities. They also gained a network of potential funding partners with whom they can collaborate—within a state, in neighboring states, or at the national level—to achieve the greatest impact.

Foundations are facing important decisions regarding how their limited resources can best leverage the opportunities created by national reform legislation while continuing to advance broader changes not fully addressed by the Affordable Care Act. The law’s ambitious timeline adds to the field’s sense of urgency. For the funders in the room, the priorities included:

–tackling the enrollment challenge;

–weighing in on the relationship between Medicaid and health insurance exchanges;

–helping state officials access the technical assistance they’ll need;

–supporting convening of diverse stakeholders to develop common goals;

–rethinking ways to provide care to those who will remain uninsured;

–helping to develop the safety net into a coordinated system of care that includes public hospitals, community health centers, free clinics, and community health workers; and

–making sure that state decisions made within the regulatory process are made with public input.

We at GIH have spent years working to connect health grantmakers with each other as well as with those in other fields whose work has important implications for health. What excited us about this discussion was how action-oriented it was. When funders enter into conversations with the explicit intent to share strategies and coordinate, the potential for collaboration is great.

This discussion was part of GIH’s targeted work to advise funders about implementation of health reform and keep them informed about the work of their colleagues as implementation unfolds. Up next will be the release of a report on plans of health funders and advocacy organizations in the wake of the health reform law’s passage. Stay tuned!

Three Most-Read GrantWatch Blog Posts during July 2010


August 9th, 2010

Below, we have tabulated for you a list of which three GrantWatch Blog posts were most read in July 2010. GrantWatch Blog, a fairly recent product of Health Affairs, launched in March 2010. 

At the top of the list was a “roundup” post on foundation-funded efforts in two areas: cardiovascular health and Medicaid. The work of the AstraZeneca Health Care Foundation and the Medtronic Foundation is mentioned in the cardio section. The Medicaid section highlights publications from the Henry J. Kaiser Family Foundation and the Missouri Foundation for Health, and more.

Coming in at number two was a post titled “Reducing Health Care Disparites Affecting People with Diabetes.” This post focused on a Merck Company Foundation program, the Alliance to Reduce Disparities in Diabetes.

Number three on the list was a post about a new GrantWatch paper published in the July 2010 print issue of Health Affairs and online (abstract is free to all). This paper titled “A Philanthropy Tackles Growth in Health Costs at the State Level” was written by David Sandman of the New York State Health Foundation and Anthony Kovner of New York University. (Sandman, you may remember, has also worked for the Commonwealth Fund.) In their article, the authors note that “among the states, New York is faced with particularly staggering health expenses.” 

So here are links to the three most-read posts:

(1) Roundup: Foundation-Funded Efforts in Cardiovascular Health, Medicaid

by Lee-Lee Prina (date of post: June 30, 2010)

(2) Reducing Health Care Disparities Affecting People with Diabetes

by Lee-Lee Prina (date of post: July 17, 2010

(3) New Paper: A Foundation’s Fight to Slow the Rate of State Health Spending

by Lee-Lee Prina and Stephen Langel (who is another senior editor at Health Affairs) (date of post: July 7, 2010)

Have a good week whether you’re at work or lucky enough to be on vacation!

The Relief of Suffering from Serious Illness: How Foundations Can Lessen the Pain


August 6th, 2010

The high cost of end-of-life care in the United States has been a source of hand-wringing among health economists and policy wonks for decades. (See “End-of-Life Savings: A ‘Fool’s Gold’ of Reform” on the Health Affairs Blog.) Nonetheless, a wise man once said, “Every problem has a solution.” This problem has a solution, too, and grantmakers can make it happen. Here’s how.

Earlier this year, I met a former senior Capitol Hill staffer who recalled the anguish of watching his parents suffer during the last weeks and months of their lives while they were patients at a well-known hospital. They received tests and treatments whose purpose was unknown to him and his family, and he felt powerless to intervene. They had “boarded the wrong plane,” it seemed, and couldn’t get off.

The Hill staffer’s story is all too familiar. Fifteen years ago, a landmark study, “A Controlled Trial to Improve Care for Seriously Ill Hospitalized Patients: The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment” (SUPPORT), was published in the Journal of the American Medical Association. Funded by the Robert Wood Johnson Foundation (RWJF), the study chronicled the treatment of more than 9,000 seriously ill adults in five teaching hospitals. Patient preferences were often unknown to the doctors and nurses, and aggressive treatments were the norm. The pain of patients was often unrecognized and untreated.

Since 1996, grantmakers have helped to improve care for seriously ill patients by bringing palliative care into the mainstream of the U.S. health care system. Palliative care enables patients and families to receive care consistent with their preferences. Whereas hospice care is provided to people with a prognosis of less than six months, palliative care seeks to relieve symptoms and suffering for patients with serious illness regardless of prognosis.

At the 2010 American Society of Clinical Oncology meeting, researchers presented findings from a new study showing that when patients with newly diagnosed metastatic lung cancer were provided palliative care, they reported a better quality of life, received less aggressive care, and survived longer compared with similar patients who did not receive palliative care.

Today, about 1,400 hospitals have a palliative care program, a dramatic increase from about ten hospitals in the mid-1990s. While progress has been made, more must be done to ensure access to care for everyone who can benefit from it.

Grantmakers can support the establishment and growth of hospital-based palliative care. The Center to Advance Palliative Care at the Mount Sinai School of Medicine in New York City is the “go-to” place that helps doctors, nurses, and administrators learn how to establish, expand, and sustain such palliative care programs. The center receives funding from foundations.

Also, grant funding would be well spent to support the training of clinicians in palliative care. Without available training, hospitals will not be able to establish and expand their programs and care for more patients. In addition, funding for research is needed to build the knowledge base of what works best for patients. The National Palliative Care Research Center is a hub for such research. More rigorous studies showing the impact of palliative care are needed.

As quality improvement gurus remind us, high-quality health care costs less than what we are paying now. Even better, research shows that when patients are fully informed about their condition and treatment options, they tend to choose less invasive and less costly treatments. It should be little surprise that palliative care has been shown to decrease the length of hospital and intensive care unit (ICU) stays.

Palliative care can be part of a solution to “Letting Go: What Should Medicine Do When It Can’t Save Your Life?”—the challenge that Atul Gawande discusses in his recent (August 2) New Yorker article. By investing in palliative care, grantmakers can help address this challenge. The returns on investment will be satisfying to foundation boards, leadership, and staff, as well as the communities and people they serve.

Related Resource:

Go to www.fundpalcare.org for a toolkit to support grantmakers new to palliative care and those building on work in the field. The Palliative Care Grantmaking Snapshot Report provides funders with an overview of the current state of palliative care grant making. Funder Stories presents a selection of stories that highlight grant-making successes, challenges, and related strategies.

The Palliative Care Grantmaking Snapshot Report, and this Web site, are supported and directed by the Collaborative to Advance Funding for Palliative Care. Its steering committee includes staff from the Altman Foundation, the Emily Davie and Joseph S. Kornfeld Foundation, the Mayday Fund, the Open Society Institute, the Fan Fox and Leslie R. Samuels Foundation, and Grantmakers In Aging.

We Need More Preventive Health Programs, but Let’s Make Sure to Evaluate Them


August 3rd, 2010

I had the good fortune to attend and participate in the Colorado Health Symposium, sponsored by the Colorado Health Foundation on July 28 in beautiful Keystone, Colorado. The symposium brought together 400 health professionals from Colorado, representing a variety of backgrounds, to discuss major health policy issues. This year’s theme was “Value in Health Care,” and the session in which I participated was devoted to prevention. From my perspective as someone who has conducted research on the economics of prevention and the value of preventive services, there were several key take-aways.

First, the session highlighted anew the growing problems of obesity and diabetes and that rapidly rising rates in these conditions reflects societal changes during the past generation. Likely there are multiple causes: our children are not as physically active (for one thing they tend not to walk to school anymore); we eat less locally grown food and eat more processed food (which has become relatively less expensive); we spend more time sitting in front of TVs and computer screens, and so forth.

However, the session also underscored the tremendous amount of efforts occurring—at local, state, and federal levels—to develop, test, and implement new programs designed to produce healthier communities. The other speakers in my session—Judith Bell of PolicyLink, Joe Thompson, the Arkansas Surgeon General (and director of the Robert Wood Johnson Foundation’s Center to Prevent Childhood Obesity), Jodee Kozlak of Target, and Jim Krieger of the Seattle and King County public health department and the University of Washington—highlighted many examples of such efforts, particularly pertaining to “built environment” (that is, the man-made surroundings of a neighborhood), nutrition, and housing.

As several speakers stressed, where you live dictates your health in all sorts of ways. Problems are particularly acute in many urban areas and rural communities, where people are less likely to have access to supermarkets with fresh fruits and vegetables and to parks, and kids are less likely to have safe and convenient ways to walk to school. New programs are targeting the problem from a variety of angles: urban agriculture initiatives; national standards for foods in schools; fewer vending machines offering unhealthy choices in schools; and programs to add or enhance bike paths and to improve mass transit. Jodee Kozlak shared the active commitment at Target to build a healthier workforce at that retailer through wellness fairs, fitness programs, internal publications on nutrition and fitness, free on-site vaccinations, low-calorie options in cafeterias, better choices in vending machines, and availability of fresh fruit at check-out lines at Target employee cafeterias.

Joe Thompson noted that after aggressive action in Arkansas, rates of obesity and diabetes in kids seem to have plateaued and perhaps reversed, and that certain metrics are heading in the right direction (for example, there is less consumption of fast food by children in Arkansas and parents’ awareness about childhood obesity has increased).

The other big take-away for me was the need for more careful analyses about the costs and benefits of these and other community-based programs. All of these initiatives are admirable, but we need to collect data and to evaluate their effectiveness and cost-effectiveness. In my own remarks at the conference, I highlighted the fact that preventive health typically does not “save money,” but I also emphasized that saving money should not be the criterion by which preventive programs are judged. The point of conducting cost-effectiveness analysis is rather to inform decisions about how to best target resources to improve health, whether or not the investments save money. Most community prevention programs have not been scrutinized in this manner and policy makers would be better served if they were.

Editor’s Notes: According to the Colorado Health Foundation’s Web site, “The Colorado Health Symposium, formerly the Dorsey Hughes Symposium, is one of the leading national health policy conferences in the United States.” The conference has been held for twenty-nine years.

Panelists’ slides and presentation materials, including those of Peter Neumann, can be viewed here. A short summary of the “Prevention: A Cure for What Ails American Health Care?” session can be viewed here. Other bloggers’ posts on this session can be read here.

Neumann used the following article that he coauthored as a jumping-off point for his remarks at the symposium: “Does Preventive Care Save Money? Health Economics and the Presidential Candidates,” Joshua T. Cohen, Peter J. Neumann, Milton C. Weinstein, New England Journal of Medicine, February 14, 2008. (free access)

Peter Neumann is a member of Health Affairs’ Editorial Board.

Related resource:

“When Is Evidence Sufficient?” Karl Claxton, Joshua T. Cohen, and Peter J. Neumann, Health Affairs, January/February 2005. (free access)

Also, on Thursday, July 29, Jay Want, the president and chief executive officer of Physician Health Partners LLC, received the John Iglehart Award at the Colorado Health Symposium. In Want’s bio, Physician Health Partners is described as “a management services organization that serves more than 50,000 patients in Colorado.” This award is named after Health Affairs’ Founding Editor John K. Iglehart.

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