Health Affairs

Why did the Duke Endowment decide to select disease prevention as one of its three major funding areas in health care? Why would a private foundation invest in programs and infrastructure to prevent disease when the number of uninsured is growing and there is not enough funding available to treat people burdened with chronic disease? 

The Duke Endowment’s health care program area has always recognized the importance of prevention. Beginning in 1925 the first director of the then-hospital section of the Duke Endowment, Watson S. Rankin, argued that basic medical service must include the “practice of preventive medicine,” according to the book Legacy to the Carolinas.

Over the years, the Duke Endowment, which funds in North and South Carolina, has funded efforts such as Safe Kids (a community education program that focuses on injury prevention) and screening programs for early detection of chronic disease or domestic violence and child abuse. The programs were successful and furthered our efforts around prevention. However, programs aimed at strengthening not-for-profit hospitals and increasing access to high-quality health care were considered priorities for endowment funding.

In 2006 the Duke Endowment’s Committee on Health Care carefully reviewed and discussed the health care environment, the health of residents of the Carolinas, and the endowment’s approach to grant making. Data sources, such as the Robert Wood Johnson Foundation–supported county health rankings and state rankings on obesity compiled by Trust for America’s Health, helped us recognize that even with the best medical treatment, residents of the Carolinas, when compared with other states, are not as healthy.  In addition, the rising costs of health care and the increasing number of the uninsured were identified as areas of concern.

Prevention was viewed as an evolving field, and it was noted that its application in clinical practice, health policy, and community health programs have been shown to improve the public’s health. The committee concluded that implementing effective preventive strategies held much promise in regard to improving health status and ultimately decreasing health care costs and improving quality of life. The recommendation to select prevention as one of the endowment’s three major goals and areas of priority funding in health care was presented to its trustees.

The board approved the recommendation. This action initiated a strategy to promote the importance of prevention in the field and to encourage collaborations on prevention with other health funders, hospitals, and health care organizations. The logic we used was that by seeking strategies to advance prevention and by focusing our funding on evidence-based programs to improve health, we would encourage hospitals and other grantees to become more engaged in effective programs to prevent chronic disease.

Our work in prevention over the past five years has included partnering with other health funders, including the Kate B. Reynolds Charitable Trust, BlueCross BlueShield of North Carolina Foundation, and the North Carolina Health and Wellness Trust Fund, to support the North Carolina Institute of Medicine to develop a statewide prevention plan. The Duke Endowment has also collaborated with the North Carolina Hospital Association, South Carolina Hospital Association, and NC Prevention Partners to create a culture of wellness in our region’s hospitals. We supported the establishment of the North Carolina Center for Hospital Quality and Patient Safety and the South Carolina Institute of Medicine and Public Health. We have also taken a lead role in helping North Carolina develop and implement a program to achieve its Healthy People 2020 goals.

The Duke Endowment believes that if residents of the Carolinas have good health, the costs of health care will decrease and residents’ quality of life will improve. We must work together with public and other private resources to fund effective programs and organizations that address prevention. We must also align resources and goals with the Affordable Care Act of 2010 and national efforts such as Triple Aim and Healthy People 2020. Improving public health and decreasing preventable disease and accidents is everyone’s responsibility.

Editor’s note: Read more about the Duke Endowment’s funding in health care here.

GrantWatch Blog invited staff from the Foundation for a Healthy Kentucky, which is based in Louisville, to report on the forum, which was held earlier this month; the foundation sponsored the event. The authors begin with some background.

The Foundation for a Healthy Kentucky has invested five years of funding and technical assistance in efforts to expand primary care in Kentucky’s medically underserved areas. A twenty-member Rural Health Oversight Committee has guided the work of the foundation in identifying effective approaches and levers for change to reform health service delivery at state and local levels. National experts on emerging models of health service delivery were invited to advise the group; targeted interviews with innovative business leaders, primarily in rural areas, and consumer focus groups further informed our work.

A capstone for this effort was the foundation’s Health Policy Forum (on September 13), which brought local civic leaders together with national, regional, and state experts to explore strategies identified by the Rural Health Oversight Committee.

This one-day event began with a welcome from the secretary of the Kentucky Cabinet for Health and Family Services, Janie Miller, to the group of nearly 200 people gathered at the Center for Rural Development in Somerset, Kentucky. (The Cabinet runs the state’s Medicaid program, Department of Public Health, and much more.) Miller shared details of the state’s new Medicaid Managed Care system, which is scheduled to begin November 1, with a projected savings of $1.3 billion over the initial thirty-three-month contracts with three managed care organizations. The oversight committee identified a new Medicaid managed care system as a possible lever for change because the rollout offers opportunities for better integration of medical and behavioral services and improved care for chronic diseases.

The Foundation for a Healthy Kentucky plans to issue a request for quotations from qualified research organizations to study the rollout of this new system.

Miller also emphasized Kentucky’s commitment to expanded outreach to increase children’s health insurance coverage and state leadership in establishing a health information exchange.

She concluded by honoring the memory of health economist Howard L. Bost, founding board member of the foundation and the Kentucky Health Policy Forum’s namesake.

Keynote speaker Len Nichols of George Mason University spoke about the economic and moral imperatives for health policy change. Nichols pointed out that getting our country’s “fiscal house” in order includes getting our national debt and our Medicare costs under control, which in turn means getting health care costs under control. With the percent of median family income required to purchase family health insurance rising from 7 percent in 1987 to 17 percent in 2006, Nichols stated that “health reform is absolutely necessary to preserve access to health care for the middle class.”

Remembering his own rural childhood in Arkansas and his mother’s approach to triage—summarized as “no bone showing, no blood flowing, we ain’t going”—he brought home the challenges of bringing high-quality care to ruggedly independent communities whose residents are often uninsured and far from health service providers.

The Rural Health Oversight Committee, business and civic leaders, and consumers engaged in the foundation’s year-long effort grappled with similar issues and reached a conclusion similar to that of Len Nichols: the road to fiscal balance is not through cuts in services, but through innovation in delivery of care and realignment of incentives.

The morning plenary panel continued the day’s theme that “business as usual is over” by focusing on providing care differently through using “extenders” (trained care providers other than physicians or dentists) in providing access to high-quality primary care, harnessing health care information technology (IT), and creating and sustaining policy changes that encourage new models of care and reduce barriers to their implementation.

Christie Upshaw Travis, president of the Memphis Business Group on Health, identified ways in which businesses can lead systems change—the Foundation for a Healthy Kentucky’s rural health committee had identified large self-insured employers as an important lever for change. Interestingly, in rural Kentucky, the largest self-insured employer is government.

Trudi Matthews of Healthbridge (a Cincinnati-based Regional Health Information Organization) spoke about the power of IT applications to achieve continuity of care for patients who may seek care from providers both close to home and quite far away—in urban areas. IT applications can eliminate costly duplication of services and bring about better-quality care.

In response to a question about security of online records, Matthews told the story of a physician in her home state of Iowa who was retiring and, thus, placed his old, unshredded patient records in a dumpster—only to have a high wind blow them all over town.

Tork Wade of Community Care of North Carolina (a statewide network of rural health clinics) addressed the need to integrate oral and behavioral health services into primary care settings; barriers in Kentucky law and regulation to receiving such care through a primary care setting were identified in the Foundation for a Healthy Kentucky’s Integrating Mental Health and Medical Services Initiative and Primary Care Initiative.

William Hazel, secretary of Health and Human Services for the Commonwealth of Virginia, spoke compellingly on the need to provide care differently; he described the challenges of scope-of-practice constraints on permitting all health workers to practice as a team and at their highest skill level.

This theme was expanded on in an afternoon breakout session, in which leading Kentucky experts addressed further the roles of physicians, nurses, dental practitioners, and care navigators.

Intended mid-day plenary speaker Kavita Patel of the Brookings Institution, who was to have addressed the triple aims of better-quality care, better population health, and reduced per capita costs, was unable to join us because of a family emergency.

Instead, participants were able to see a preview of Remaking Rural Health, a television special that is in development by Kentucky Educational Television (KET)—and will be aired in early 2012. Funded by the Foundation for a Healthy Kentucky, this special will focus on rural health challenges in Kentucky and innovative strategies in place in the state to address them.

Consistent with the foundation’s commitment to investing in communities and informing health policy, a theme of the day was the need to identify community solutions to community health issues. Len Nichols summarized this well when he advised state legislators and rural Americans to stay calm about health care, focus on what can be measured, and change accordingly. “Forget politics,” he said. “Forget Obama. Don’t watch TV at all. Focus on where you live.” (Read more about the forum in a post by Tara Kaprowy on the Kentucky Health News blog.)

Video of these presentations will be available soon on the foundation’s website, www.healthy-ky.org. For more information, contact Susan Zepeda, president and chief executive officer (CEO) (szepeda@healthy-ky.org)  or senior program officer Amy Watts (awatts@healthy-ky.org).

The author, who is president of the Pfizer Foundation, spoke at a UN meeting this week on noncommunicable diseases.

The United Nations (UN) has been hosting its High-Level Meeting on Non-Communicable Diseases September 16–21 in New York City. This is an important opportunity to highlight the alarming incidence of chronic diseases in developing countries and determine attainable goals to address substantive risk factors, such as tobacco.

As part of the Pfizer Foundation’s participation in the meeting, I spoke at a luncheon symposium called “Women, Girls, and Smoking” on September 19. My presentation focused on a new Pfizer Foundation one-year grants program aimed at reducing the rising rate of female smokers in emerging markets. This blog post is adapted from my presentation earlier this week.

My fellow panelists included Adrianna Blanco from the Pan American Health Organization (PAHO) and Patricia Lambert from the Campaign for Tobacco Free Kids. We saw this as a unique opportunity to share trends in female smoking with an audience of nongovernmental organization (NGO) staff, private-sector leaders, donors, and policy makers.

That smoking kills and that laws and norms need to be arrayed against tobacco use is of little surprise to the public health community. In April a global health ministers meeting in Moscow focused on noncommunicable diseases, of which tobacco is the preeminent contributor. And in the same week, China announced new regulations on indoor smoking—public health professionals welcome this new step for China, because it is still in the early stages of grappling with smoking and tobacco use.

Lost in many of the conversations and initiatives on smoking, however, is a gender perspective. For women, the effects are particularly striking, both because smoking affects their health in a big way and because smoking is an epidemic that is still building. The effects of smoking on women are by now well understood: women who smoke are at a dramatically higher risk for cancers of the lung, mouth, pharynx, esophagus, larynx, bladder, pancreas, kidney, and cervix. In addition to direct organ damage, women who smoke also find it harder to conceive and are at increased risk of pulmonary and coronary diseases.

And because of many women’s roles in their households, they are also more at risk from the dangers of second-hand smoke. In almost every society, women are the primary caregivers and managers of their immediate and extended family units. The result is that women become ill from cigarettes, and their illnesses have wider effects on their families and on society as a whole.

Despite this knowledge, the world is on pace to see an explosion of smoking among women as the developing world becomes wealthier. By some estimates, according to a World Health Organization (WHO) report, about 80 percent of the world’s smokers live in low- and middle-income countries. By 2030, more than eight million people will die annually from smoking-related causes. And a disproportionate number of new smokers are likely to be women if current expectations prove to be accurate.

In antitobacco programs, public health marketing, and legislation, the particular concerns of women are not often emphasized. Despite women’s core role in modernizing societies and lifting them out of poverty, much antitobacco work is not gender specific. Data collected by governments do not regularly differentiate between men and women, antitobacco public health advertising is often pitched at men, and laws and regulations are not necessarily written with a focus on what motivates women to start smoking.

To address the rising rates of female smoking, particularly in emerging economies, local action will be required, as will culturally specific messages and materials, that make women more aware of how smoking can affect them; that foster policies that make smoking less attractive or feasible; and that empower women to make their own choices—free of advertising or false images.

If rates of uptake by women can be slowed or reversed, the savings in human lives, as well as social and economic costs to society will be sizeable. Our research and interviews suggest, however, that most public health programs in emerging markets lack the resources and expertise to implement women-focused and gender-specific tobacco control programs.

To meet this challenge, the Pfizer Foundation recently launched its pilot program (mentioned above) that aims to prevent smoking among women and identify best practices for effective gender-specific interventions and communications strategies. The Pfizer Foundation has partnered with Rockefeller Philanthropy Advisors to administer and manage this new program.

In partnership with thought leaders in the area of tobacco control, the Pfizer Foundation has identified two themes for grantees to use when piloting new models of health and outreach programs to help women stop smoking:

1. Developing gender-specific prevention programming (for women), including programs to reach subgroups of women (such as indigenous women and rural women)

2.  Supporting antismoking and antitobacco policies geared toward women, in the context of comprehensive tobacco control.

At the forum on Monday, I was encouraged to hear many public health officials recognize the importance of addressing the issue women and tobacco control and encountered many NGOs interested in programs focused on women and noncommunicable diseases.

By the end of this pilot program, we want to demonstrate:

• Several effective operational models for addressing female smoking rates; and
• Additional data to build the knowledge base on smoking trends for women.

We look forward to sharing program outcomes and lessons learned in future blog posts and forums.

We greatly appreciate the support from James O’Sullivan, Donzie Barroso, Joanne Greenstein, Erica Minor, Tej Shah, and Lexie Komisar from the Rockefeller Philanthropy Advisors team, and Atiya Weiss from the Pfizer Foundation, for their helpful comments and insights for this post.

The rankings are in! We have listed below the three most-read posts. Take a look in case you missed one of them when the original tweet or e-alert went out announcing it.

1. “The Colorado Health Symposium’s Debate over Repealing and Replacing the ACA,” by Grace-Marie Turner (August 3).

Heading the list is a post by Grace-Marie Turner, president of the Galen Institute. A well-known proponent of free-market ideas for health reform and a former newspaper journalist, Turner was a panelist at the Colorado Health Symposium’s debate on the Affordable Care Act (ACA). GrantWatch Blog asked her to put on her journalist’s “hat” to report some highlights of the debate. In recent years the Colorado Health Foundation has sponsored the always-popular symposium, which was held this year at Keystone Resort. (The foundation also published Turner’s post on its symposium blog.)

2. “People Post: Who’s Working Where? Staff Changes at Foundations,” by Lee-Lee Prina (August 11).

Next on the list is a short post about comings and goings of foundation staffers. Perhaps this post is something like “class notes” in college alumni magazines: people often like to read about who got a new job—especially in this economy. Among people mentioned here are Anna Gosline, Owen Heleen (who has written for GrantWatch Blog), Tachi Yamada, and Marsha Lillie-Blanton.

3. “Which Grantmakers Are Making Awards in Maternal Health? Report Examines the “Landscape,” by Lee-Lee Prina (July 28).

As you likely know, GrantWatch Blog is affiliated with Health Affairs, the nation’s top health policy journal. In recent years the journal has increased its publication of global health content, so I am glad to see that readers noticed this post. This next most-read post focuses on a report put out by the Maternal Health Task Force. Those working in global health and seeking grants may get some good insights here into where the money has been going.

Would you like to be a guest blogger on the topic of foundations and health policy? Let me know if you have an idea for a GrantWatch Blog post. Ideally, posts should be 600–1,000 words. Guest posts are edited for clarity and editorial style.

This blogger, a former president of a foundation, writes that the value of public health infrastructure is sometimes forgotten.

Investing in our public health infrastructure saves lives.

That’s the bottom-line message of a recent Health Affairs article entitled Evidence Links Increases in Public Health Spending to Declines in Preventable Deaths. Its authors lay out the most compelling case possible for more public health spending. People are alive and healthy today who would not be if money had not been put into public health in the past twenty years.

There is a reason for this. Public health activities–even when they are targeted to special populations–promote the overall health of an area’s entire population. It is not always the investment in specific programs that makes the difference; often it is the investment in the infrastructure itself.

When the Centers for Disease Control and Prevention (CDC) released its list of the top ten public health achievements of 2001–2010, the breadth of these achievements underscored the importance of a robust public health infrastructure. The achievements included:

• Environmental health successes, such as in lead poisoning prevention and tobacco control;
• Improved immunization rates;
• Reductions in cancer and cardiovascular diseases;
• Improvements in occupational and motor vehicle safety; and
• Better preparation for the threats of bioterrorism and natural disasters.

But despite these and other achievements, our public health core activities and infrastructure have been under attack as state policy makers cope with their ongoing budget crises.

A report of the National Association of County and City Health Officials (NACCHO) documented the loss of 29,000 local public health employees between 2008 and 2010, and a spring 2011 news release from the Association of State and Territorial Health Officials (ASTHO) noted that federal and state budget cuts are now jeopardizing many of our most successful public health initiatives.

Policy makers often do not understand that investing in public health infrastructure is both essential and inexpensive. For example, the entire budget of the CDC is less than one-half of one percent of our country’s total health spending.

Fortunately, foundations around the country have been leading the way in helping to finance new public health infrastructure, including public health systems, workforce training, and public health education. Many of these efforts have been documented by Grantmakers in Health in various publications, including its 2008 issue brief Strengthening the Performance and Effectiveness of the Public Health System.

The DeBeaumont Foundation in Maryland is working to build public health capacity and collaboration, and the Caring for Colorado Foundation led in the development of its legislatively mandated state public health improvement plan in 2010. The Kansas Health Foundation has singled out public health education and workforce development as priorities, and the Healthcare Georgia Foundation supports a statewide distance-learning program for health professionals.

The Northwest Health Foundation, which funds in Washington and Oregon, includes public health advocacy and workforce development among its priorities, while the Dorothy Rider Pool Health Care Trust was honored in 2009 by the National Association of Local Boards of Health for its extraordinary ongoing contributions to the development of a regional public health infrastructure in Pennsylvania’s Lehigh Valley.

These are all excellent examples of foundations investing in the traditional government-supported public health infrastructure.

A number of other foundations are working to develop private, nonprofit public health institutes around the country. These institutes partner with other public health professionals in advancing public health initiatives—in areas such as workforce development, access to care, oral health, and health improvement plans—at the state and local levels.

The thirty-six members of the National Network of Public Health Institutes are located in twenty-eight states.

At the national level, the Robert Wood Johnson Foundation (RWJF), which funds extensively, creatively, and effectively in public health (and financially supports the annual county health rankings, which help states and localities compare their progress with that of others), has encouraged the establishment of public health institutes through its support of the national network’s Fostering Emerging Institutes Project.

Among the more established public health institutes, the Louisiana Public Health Institute and the Michigan Public Health Institute have enjoyed funding from many national, state, regional, and local funders. They offer wide-ranging programming and research in public health.

State and local foundations have also played key roles in getting new public health institutes under way. The South Carolina Public Health Institute (soon to be the South Carolina Institute of Medicine and Health), one of six emerging public health institutes that received 2011 funding from the RWJF, obtained much of its core infrastructure funding from the Duke Endowment, which funds in North and South Carolina.

When I was its president, the Quantum Foundation—a county-level funder, which funds in Palm Beach County, Florida—awarded $1 million in core funding in 2007 to staff the Florida Public Health Institute. The Health Policy Institute of Ohio was created by six local and regional funders in 2003, including the Health Foundation of Greater Cincinnati, the Cleveland Foundation, Sisters of Charity Foundations of Canton and Cleveland, and United Way of Greater Cincinnati.

The common theme in all of these efforts is that they have gone beyond program-specific funding to investing in public health infrastructure at a critical time for our nation. Without these investments in infrastructure–if the facts of our history are to be believed–we would soon live shorter, sicker lives.

We would all like to count on finding a healthier future in which we live longer lives. A sound public health system is what will take us there, and funders will find many valuable public health investment opportunities along the way.

Here is a round-up of some “people news” at foundations and public charities around the country from the past few months. I have included staff and board of trustee changes and other news.

Gary Cohen has been named chair of the CDC (Centers for Disease Control and Prevention) Foundation’s board. Cohen is executive vice president of BD (Becton, Dickinson and Company), a global medical technology company founded in 1897. According to a May press release announcing Cohen’s new board responsibility, the CDC Foundation (a public charity), which was established by the US Congress, helps the CDC do more, quicker, by forging effective partnerships between the federal agency and corporations, foundations, organizations, and individuals to fight threats to public health and safety.

Steve Gunderson resigned as president and chief executive officer (CEO) of the Council on Foundations (a membership association of foundations and corporate-giving programs), effective September 1. Gunderson, who is a former Republican member of Congress, announced his resignation in July. (Read about his accomplishments while at the council in its press release.)  He led the council for some six years. Jeff Clarke has been named interim president and CEO of the council until a permanent leader comes on board. Most recently Clarke was a senior fellow at the Rasmuson Foundation, located in Anchorage, Alaska, and previously was Rasmuson’s vice president for nine years, according to an August press release.

Bob Hughes has been selected as the new president and CEO of the Missouri Foundation for Health. He will start there November 1. Hughes is now a visiting research professor at Rutgers University’s Center for State Health Policy, an initiative of Rutgers’ Institute for Health, Health Care Policy and Aging Research. He has also recently done some consulting work for the Rippel Foundation, in New Jersey. Hughes worked for the Robert Wood Johnson Foundation from 1990 to 2010; his most recent position there was vice president and chief learning officer.

Pamela Riley joined the Commonwealth Fund’s staff as a program officer in July. In this job, Riley, a pediatrician, directs its new Vulnerable Populations program, which aims to “ensure that low-income, uninsured, and minority populations receive care from high-performing health systems,” according to Tony Shih, Commonwealth’s executive vice president for programs, in a July e-mail. Riley’s responsibilities include overseeing the Commonwealth Fund/Harvard University Fellowship in Minority Health Policy (program). (By the way, the next application deadline for that program is January 3.) Riley, who was a fellow herself, was previously a program officer at the New York State Health Foundation.

Bob Ross, president and CEO of the California Endowment, has been appointed to the California Health Benefit Exchange’s board, I read in Grantmakers In Health’s July 18 newsletter. This board, consisting of five members, will help California consumers and small businesses shop for and purchase “competitive health insurance” (through an exchange), starting in 2014, the board’s website says. Ross is the California Senate Rules Committee’s appointee, the newsletter reported. Read here about the other members; they include Kim Belshé, who was secretary of the California Health and Human Services Agency during former Republican Gov. Arnold Schwarzenegger’s administration. (She is now with the Public Policy Institute of California, where she is senior policy adviser.)

Ed Schor is now senior vice president, programs and partnerships, at the Lucile Packard Foundation for Children’s Health, a public charity located in Palo Alto, California. He started there this week. Schor was most recently a vice president at the Commonwealth Fund. Read the abstract of a June 2010 article (“How Physician Practices Could Share Personnel and Resources to Support Medical Homes”), which Schor coauthored for Health Affairs.

Readers: Personnel news is normally covered in my GrantWatch column appearing in Health Affairs (print and online). However, because of  peer-reviewed articles under consideration for the next couple of issues, I wanted to mention these changes now, before the news became stale!