Our nation’s health-care challenges are so daunting that it’s tempting to leave it to big national foundations to solve the problems. But it turns out that community foundations, family foundations, and other regional grant makers may be the only ones who have the power to fundamentally transform the U.S. health-care system. The vast costs and complexity of health care have led most local foundations to sidestep the issue. They may pay for a new hospital wing or research on a disease, but they have never had a clear role to play in dealing with the rising costs and varied quality of health care. In this, a tremendous philanthropic opportunity has been largely overlooked.
The key to change comes from research conducted by Atul Gawande, a surgeon at Brigham and Women’s Hospital and a professor at Harvard Medical School. He has demonstrated that our health-care system can be profoundly influenced by community-based efforts with modest levels of support.
To see why local behavior is so important, he studied two close Texas towns. McAllen, Tex., has the second-highest Medicare costs in the country—more than $16,000 per person annually—while nearby El Paso has the same poverty and disease levels, cost of living, and demographic profile but spends less than half as much per person.
Yet as best as can be measured, the six hospitals in El Paso do a better job of keeping patients healthy than the six twice-as-expensive hospitals in McAllen. Surprisingly, such wide variations are the rule, not the exception: Costs vary sharply from place to place, and the best results for patients are usually achieved in the lowest-cost regions.
This paradoxical result occurs because our “health-care system” does not function like a system at all. Each doctor, hospital, or insurer makes choices independently without any awareness or control over how those choices affect the overall cost and quality of how a patient fares. We lack the information and coordination necessary to spread, from one provider or community to the next, innovations that save lives and money—and that is exactly what local foundations can provide.
No major investments or scientific breakthroughs are required. A two-minute presurgical checklist developed by Dr. Gawande, for example, reduced post-surgical infections by 36 percent and deaths by 47 percent. Using the checklist, which costs nothing at all, could save tens of thousands of lives every year. Several countries around the world now require its use—yet it is still not used by a majority of U.S. hospitals because cities and towns have yet to overcome the inertia that inhibits changes in practice.
Community leadership and local coalitions are the essential tools of overhauling the health-care system.
Consider end-of-life care: Doctors know that many patients in terminal stages of disease don’t want the extremely costly extraordinary measures that are usually administered when a patient arrives in crisis at an emergency room. Yet very few people give clear direction ahead of time, so the standard procedures are designed to preserve life at all costs.
A community campaign in La Crosse, Wis., encouraged doctors to talk about advance directives with their patients during routine checkups and added end-of-life questions to the forms required whenever anyone was admitted to a nursing home or hospital. Over several years, the share of local residents with advance directives increased from 15 percent to 85 percent, and the cost of end-of-life care dropped by half.
La Crosse became one of the lowest-cost places for medical care in the country. More people got the care they wanted, and the average life expectancy actually increased, outpacing the national mean by a year. All it took was strong local leadership and a little bit of money.
But has the practice spread to other communities? Not at all.
Often, nobody in a community knows what health-care providers are actually doing. When local doctors in Cedar Rapids, Iowa, wanted to know how many MRIs were being performed in their community, it took three months to find out. The doctors were astonished when they learned that in a population of 300,000 people, 52,000 MRIs were performed annually. Once they saw the data, they began to rethink their practices, and the frequency dropped sharply—again with no deterioration in patient outcomes. It is a safe bet that the doctors in your community don’t know how many MRIs are performed annually, but even a small foundation could easily pay for the research to collect and draw attention to that data.
Every community, large or small, needs a neutral party to bring together the doctors, insurers, hospital administrators, government agencies, and major employers to collect information about local practices and put in place local solutions—a role that regional foundations are ideally suited to play.
Working through a coalition is essential because no single participant can make substantial improvements by acting alone.
Children’s Hospital in Boston, for example, developed a program that reduced the emergency-room visits of children with severe asthma by 80 percent. It required only simple improvements in the home, like making sure the families had vacuum cleaners and knew how to use inhalers.
But asthma admissions were the hospital’s largest single source of revenue; it was going broke by fixing the problem—until the hospital’s major insurers agreed to a new payment plan. It’s a great success story: less cost for insurers and better lives for kids with asthma. But without a community coalition, the program and revised payment scheme hasn’t spread to any other hospitals in Boston, let alone communities across the country.
Only local foundations have the resources, influence, and neutrality to bring together a coalition of CEO-level representatives and key influencers from all major organizations that touch medical care in their communities.
This approach is solving social problems of all kinds, not just health care, and it is growing in popularity. (To learn more, read the article John Kania and I wrote on “collective impact” in Stanford Social Innovation Review’s winter edition of last year.)
Collective impact isn’t just a new name for collaboration. It is a highly structured process for pulling together many nonprofits, businesses, and government agencies that influence an issue, rather than depending on a single group to solve the problem.
Local foundations across the United States have the stature and resources to organize and pay for health-care coalitions that can share what they learn with other communities across the country, building a constantly updated set of resources about the smartest ways to reduce costs and improve care.
It is precisely because of their local focus and power that regional foundations can play this crucial role in ways that national grant makers and government agencies cannot. Individually, regional foundations have the opportunity to make a profound and lasting impact on the health of their communities; together, they have the opportunity to create a national movement to achieve better health care for Americans at lower cost.
