Monthly Commentary from the Executive Director - June 1st, 1996

Smoking Death Benefit

The cigarette industry dodged another major bullet when the 5th U.S. Circuit Court of Appeals threw out last month a major federal class-action suit. While the health problems of smoking are no longer debated, the question of economic impact is. From an article by Laura Mansnerus in the 5/5/95 Sunday New York Times:

"So far, its Taxpayers v. Merchants of Death. Eight states have sued tobacco companies, and more are getting in line with a new legal theory: since states incur Medicaid expenses for smoking-related illness, they should be reimbursed by the industry that causes it."

"There's a snag though. The states are not probably losing the money they are asking for. The inconvenient truth, at least as many smokers see it, is that smokers cover their own medical costs, not only by paying cigarette taxes but also by dying before collecting their full share of health and retirement benefits."

"Tobacco companies aren't sure how to cast this "death benefits argument," but the litigation raises questions for a society obsessed with toting up misery in dollars: How do we calculate what smokers cost everybody else? Should we acknowledge that death sometimes is helpful to the public treasury? And if that's so, where might such an argument end?"

Health Care Upheaval As After Thought

From an editorial by Robert J. Samuelson in The Washington Post, 5/8/96 :

"MSAs are mostly an untested concept. They would allow people to combine a catastrophic health insurance policy with an annual tax-exempt contribution (made either by employers or by individuals) into an MSA. People would use their MSAs for normal health expenses (checkups, colds, minor injuries) and rely on insurance for crises. This, the theory holds, would inspire cost consciousness. Americans would shop for doctors and hospitals with the lowest prices and best care."

"The Congressional Budget Office projected that 2 percent of Medicare recipients would switch; for the under-65 population, the congressional Joint Committee on Taxation put usage at about one percent. If accurate, these estimates mean that MSAs wouldn't do much to cut costs or expand choice. Moreover, the basic theory may be flawed. 70 percent of health spending stems from 10 percent of seriously sick Americans. These people have heart attacks, AIDS or complicated pregnancies. Catastrophic insurance would cover these costs; MSAs wouldn't matter."

"What's the fuss then? If MSAs wouldn't matter much, why not authorize them and be done with it? The main reason for caution is that all the predictions of modest usage could prove wrong -- and if MSAs became hugely popular, they could radically change the health care system. Under today's insurance system, the premiums of younger and healthier workers subsidize the higher health spending of less healthy middle-aged and older workers. MSAs would, in theory, enable millions of younger workers to opt out of this invisible subsidy."

"They could take the cheaper catastrophic coverage and keep the unused portion of their MSAs as tax-free saving to be withdrawn at age 59 1/2. A mass defection of younger workers could have a devastating effect on the premiums of older workers. A study by the Urban Institute estimates that if 20 percent of workers switched to MSAs, premium costs for those sticking with comprehensive insurance would rise almost 60 percent."

"Cross subsidies and managed care (which many MSA advocates dislike) are legitimate subjects of debate. But we should not unleash a health care upheaval simply as an afterthought. If MSAs are as good as claimed, let them prevail as a stand-alone measure after a full debate."

Dishonest Ritual, Dangerous Deception

From "Capital Economics" by Robert Samuelson, Washington Post National Weekly Edition, 5/5/96 (Yea, two references by Samuelson--what can I say, he's on a roll; actually, I like his "two handed economist" analysis as an antidote to the regular political rhetoric):

"The debate over the minimum wage is an exercise in stale symbolism. The proposed increase--from $4.25 to $5.15--would not do much to help the poor. It might even hurt them. As such, the minimum wage is less about social policy than politics. Roughly three-quarters of Americans think raising it is the decent thing to do. So opponents are easily stigmatized as cruel. In an election year, this is a simple way for Democrats (who generally favor it) to embarrass Republicans (who don't)."

"Most economists believe that every 10 percent rise in the minimum could effect between 1 percent and two percent of affected jobs... All exact estimates are suspect. Economists can't predict the precise effects of small changes in government policies. Because wages are rising anyway, a legislated increase may mainly affect the timing of future changes. At most, the poor might benefit slightly; at worst they might suffer slightly. The real deception is that something important is being done when all that is occurring is a game of political one-upsmanship."

"The danger is that people will believe the deception. They will think that government can raise income by fiat, when most people advance through their own efforts and skills. Our leaders are more comfortable with replaying ancient (and irrelevant) debates than facing present problems. These rituals are more than dishonest. They are a sign of political decadence."

Economic Doctrine Vs. Common Sense

For those of us who studied some years ago (and then promptly forgot) basic economics from works written by writers such as John Kenneth Gailbraith, it may come as a surprise that he is still writing. A friend recently recommended to me his new book, The Good Society (Houghton Mifflin, 1996, 150 pages.) While Gailbraith is limited by some as a "liberal," he presents a common sense alternative to today's conventional economic doctrines from both the right and left.

This book doesn't have a section that focuses on health, but those of us in policy or administration of health care need to think of our work in terms of the broader public policies related to national productivity, unemployment, inflation and the national debt. Galbraith writes with such eloquence about this bigger picture that I'm not going to risk summarizing his work; a few quotes will give you an idea of his purpose:

"Policy and action are not subordinate to ideology, to doctrine. Action must be based on the facts of the specific case. There is something deeply satisfying in the expression of an economic and political faith--'I am firmly committed to the free enterprise system'; 'I strongly support the social role of the state'--but this must be seen as an escape from thought into rhetoric."

"In the winter of 1995, the United States Congress came within a vote or two of submitting to the states a constitutional amendment calling for a balanced budget in all but wartime... There could have been no better design for enhancing economic instability."

"The first and most evidently adverse tendency of organizations, large organizations in particular, is that discipline is substituted for thought."

"A call for better-prepared workers as the remedy for recession-induced unemployment is the last resort of the vacant liberal mind."

"So long as there is opportunity, there is also social tranquility; economic stagnation and privation bring with them adverse and widespread social consequences. When people are unemployed, economically deprived and without hope, the most readily available recourse is escape from harsh reality by way of drugs or violence."

Depression: Paralysis and Self-Destruction

Like Gailbraith in the Good Society, Robert McFarlane, Ronald Reagan's National Security Adviser, speaks from his own experience about the dangers of hopelessness when he discusses Admiral Mike Boorda's suicide; from an editorial in Time, May 27th:

"Severe clinical depression is a fairly common occurrence in Washington. As tragic as is the loss of Admiral Boorda--a man of proven courage and high moral precept--it will be compounded if we don't think hard about how to lower the likelihood of such calamities."

"The pathology of depression is deceptively simple. The containment of severe stress--the bottling up of one's problems without communicating to others--contributes to a chemical imbalance that impairs one's ability to function normally and induces a feeling of dispair and hopelessness. It relieved by talk, therapy or medical treatment, the chemical imbalance induces a spiral of decline, which leads ultimately to utter paralysis and self-destruction. Admiral Boorda may have been particularly susceptible. Throughout his adult life his ethic was that of the solitary commander: solve the problem, don't evidence doubt, don't seek help."

Odds 9 To 2 That The Tallest Guy Wins

From Calvin Trillin in Time, May 27th:

According to a recent article by Jay Matthews in the Washington Post... "in the 11 presidential races of what he calls the television era, beginning in 1952, the shorter candidate won only twice." Matthews couldn't be sure who is taller in 1996; "Dole is pretty certainly 6 ft. 2 in., but there seems to be some question whether Clinton is 6 ft 2 in or 6 ft. 2 1/2." The White House is treating the two different measurements "as the result of an honest difference of medical opinion."

Clinton's Praise Helps Thompson, Hurts Dole

From a series on the PoliticsUSA WWW site that discusses the individuals on the Republican short list for Bob Dole's running mate:

By Patrick Ruffini: "Well, it seems to me that if Clinton is rushing to take credit for welfare reform in Wisconsin, then something must be going right with Thompson. The events of the last couple of days with Clinton granting the waiver for Wisconsin's welfare plan (far more radical than anything that GOP 'extremists' on

Capitol Hill have proposed) show that Clinton is fighting to get Wisconsin and positioning himself to the right yet again. Thompson, for his part, is probably better positioning himself in Dole's eyes, having criticized Clinton for vetoing welfare reform which would have done away with the waivers. This and Dole's trip (to Wisconsin) to make a speech on welfare reform shows that Thompson is moving up in the Veepstakes."

Basic Insurance Reform Again In Doubt

With the departure of Senator Dole from the Senate, Washington has been speculating about the impact of this unanticipated event on a variety of issues, including the Kassebaum-Kennedy Health Insurance Reform Bill; from the May 20th Modern Healthcare:

"We will still be in the midst of a presidential campaign, and Republicans are still going to want to pass measures that help them and, by extension, hurt (President Clinton)," said Frederick Graefe, a lawyer with the Washington firm of Baker & Hostetler. "The net result is the chances of passage are still 50-50 at best."

Charles Huntington, Washington office director for the American Academy of Family Physicians, said the loss of Dole's leadership makes it less likely that insurance reform will pass. "Insurance reform seems to be hopelessly bogged down because nobody seems to know what the political calculus is," Huntington said. "Every day that goes by makes it less and less likely. There's always been a bunch of people who don't want it to happen. It's going to take some strong leadership in the Senate."

HMO Execs & Consumers Agree, Disagree

The Response Center, a market research firm specializing in health care, has surveyed two hundred eighty-six top executives from 229 managed care companies, representing 40% of all MCOs within the United States. In addition, the survey measured the attitudes of consumers on a wide variety of similar issues. From a Response Center 5/28 press release:

Coverage of Non-Conventional Treatment

Health care executives agree more strongly than consumers that health insurance should cover AIDS-related treatment (80% vs. 73%) and ailments related to chronic smoking (67% vs. 55%)

Consumers (54%) are five times more likely than health care executives (11%) to agree that experimental treatments should be fully covered.

Containing Costs, Discounts, Preventive Care

Both consumers (82%) and health care executives (63%) feel that health care costs are too high. Consumers are much more fearful of a cost increase than health care executives (67% vs. 25%).

In this survey most executives (67%) are concerned about the ethics involved, and feel that cost savings should be passed on to consumers.

Universal Coverage and Portability

Consumers (70%) and health care executives (70%) agree that coverage should be available to all Americans. While executives agree with the universal coverage concept, only 20% agree that it can be implemented nationwide.

Executives (85%) believe health insurance should have built-in portability -- that employees leaving a job may continue their health insurance.

HMOs' Biggest Challenges for the Future

More than half of the executives consider physician groups one of the biggest threats to HMOs. Many of the executives consider these groups a competitor rather than an ally.

Executives Favor Laissez Faire Government

Most executives (67%) agree that the industry needs a minimal amount of government involvement.

Clinton's Mothers' Day Speech Against HMOs

The growing backlash against the creeping corporatization of medicine has entered this year's Presidential politics through the previously state level arguments around mandating minimum insurance coverage for maternity stays. Until we are ready to discuss how to manage managed care we will continue to jump from one symbolic hot spot to another. Not exactly leadership but good for speech writers. From President Clinton's Mother's Day Weekend Radio Address:

"Good morning... with your help we can honor all mothers by giving mothers-to-be assurance that when they bring a baby into the world, they will not be rushed out of the hospital until they and their health care provider decide it is medically safe for mother and child."

"Today I want to discuss legislation that will guarantee mothers the quality care they need when they've had a baby. In 1970, the average length of stay for an uncomplicated hospital delivery was four days. By 1992, the average had declined to two days. Now a large and growing number of insurance companies are refusing to pay for anything more than a 24-hour stay, except in the most extreme circumstances, and some have recommended releasing women as early as eight hours after delivery."

"This is has gone from being an economical trend to a dangerous one, one that carries with it the potential for serious health consequences... Sixteen states have enacted laws to guarantee that level of coverage and 25 more are considering such a move. Already a Senate bill and separate House bills have been introduced -- most with bipartisan support -- to guarantee 48-hour post-partum hospital stays for mothers and their children. I urge members of Congress to move legislation forward as soon as possible that makes this protection for mothers and their children the law of the land."

"No insurance company should be free to make the final judgment about what is medically best for newborns and their mothers. That decision should be left up to doctors, nurses and mothers themselves."

Additional HMO Restraining Laws

Including the above sited minimum coverage for postpartum stays, states have enacted other laws restrictive of managed care according to The New York Times National Edition, May 19th:

Signs Of HMO Backlash

Postpartum Stay
- "Networks must cover hospital stay for mother and newborn baby for at least 48 hours after a normal delivery."

Any Willing Provider - "Networks must accept any provider who has appropriate credentials and agrees to abide by contract terms and conditions."

Emergency Care - "Networks must pay whenever a prudent lay person would consider a situation an emergency; care may not be delayed to get network authorization."

No Gag Rules - "Forbids networks from restricting what practitioners can tell patients about care choices."

Incentive Disclosure - "Requires that patients, state regulators or both be informed of financial incentives that networks offer to practitioners."

Independent Pharmacies May Get Discounts

From the 5/9/96 AP Wire Service:

"Retail pharmacies could get discounts on prescription medicines just like HMOs under a revised preliminary settlement of a price-fixing lawsuit. One possible outcome is a system in which pharmacies mimic HMOs, banding together to provide discount drug benefits programs... pharmacies will offer benefits programs to insurance companies and major employers that insure themselves and want the convenience of a maximum number of retail outlets."

HMO Community Benefits Guidelines

The Attorney General in Massachusetts has developed Community Benefits Guidelines For Health Maintenance Organizations, published February, 1996:

"These guidelines may be used by HMOs to help focus their role in helping to meet the growing and pressing health care needs of underserved and underinsured populations." A few of the guidelines are:

"The Governing body of each HMO should adopt and make public a Community Benefits Policy Statement setting forth its commitment to a formal Community Benefits Program."

"The HMO should develop and market products which attract all segments of the population."

"The HMO should strive to offer and promote... direct enrollment for non-group coverage and continue to work for insurance market reform..."

"The HMO should strive to help consumers who are about to lose coverage or who are uninsured to maintain or obtain health care coverage, at least for a limited time, at reduced or subsidized rates."

As these guidelines are voluntary it is not clear what if any benefit they will actually have for any community unless the HMOs and major self-insured plans agree to a particular intervention that doesn't place any one of them at a competitive disadvantage. (Fax request for copy to Amy Hudspeth, Consumer Protection and Antitrust Division at 617-727-5765)

One Case Of Turning Predators Into Allies

Lincoln General Hospital in rural Ruston, Louisiana has obtained $10 million in additional capital, without merging, by selling a 40% stake to three regional hospitals. According to Modern Healthcare, April 29th:

"This puts each of the regional hospitals in a position of involvement but doesn't give them a control position...The alliance offered a 'circle of advocacy that would convert predators into allies'... 'it was difficult for the medical community to get behind any one not-for-profit.' Under the proposed structure, each of the equity owners would have one seat on a 10-member board of Lincoln General. The three members would then elect a fourth representative."

NRHA Adopts Anti-Trust Policy

The National Rural Health Association at its annual meeting adopted (with some amendment) a position proposed to it by the Cooperative:

NRHA Policy

a. NRHA believes that the conduct of a health care provider network should be judged on the basis of its reasonableness ("rule of reason" treatment) and not automatically be subject to the "per se" illegal rule.

b. NRHA will aggressively promote the timely development of rural sensitive network guidelines by the Department of Justice and Federal Trade Commission.

c. NRHA will promote the passage and implementation of rural sensitive state action immunity legislation and regulation within each state.

These initiatives should explicitly address what is to be expected by rural providers and communities in terms of both antitrust protection and restrictions.

Statement Of Outcome

Three desired outcomes are:

a. the resolution of a major uncertainty factor re rural network development.

b. a set of federal guidelines that facilitates rural providers working collaboratively with each other and being able to jointly and fairly negotiate with payers.

c. maximizing the use of state action immunity in non-competitive markets.

Rural Health Bill Aiming For July 1st

The National Rural Health Association is working with rural leadership in the House to draft a rural health bill of modest but hopefully doable reforms to be introduced by July 1st. At a minimum it is expected to include 1) a study on the effectiveness of bonus payments in HPSAs, 2) establishment of the Rural Essential Access Hospital program (a downsized hospital with acute care, emergency room and EMS transfer capabilities), 3) amendments to the EACH/PCH program, 4) reestablishing the Medicare Dependent Hospital adjustment and 5) extending the deadline for RRC reclassification.

There is some discussion about including the AAPCC equity language in this bill but I doubt whether this will be attempted outside of a major Medicare reform.

Not Steve Gunderson's Decision To Make

As most of you now know it is final that "moderate" Republican and rural leader Steve Gunderson will not be running for re-election in Wisconsin's 3rd Congressional District. In a letter sent to those who had encouraged him to do so he explained:

"In the end, this was not my decision to make. When people began encouraging me to reconsider my earlier announcement, I established two conditions. First, the agricultural community and the party must be united in making such a request. Second, such an effort could not divide the party. As such, I would not reconsider unless the announced candidates stepped aside.

"While I believe that I could have won a primary, there is little doubt such a contest would have severely divided the party... 'there are many ways to serve people other than the Congress.' And I expect to do so."

Scott Klug Visits With RWHC

Scott Klug, represents Wisconsin's 2nd Congressional District and much of the Cooperative's service area. He is also the first member of Congress to ever have a perfect score on the bipartisan Concord Coalition's "Tough Choices" deficit cutting scorecard. He voted to curb the deficit in all 16 votes chosen as key indicators for 1995 by the Coalition. A perfect record indicated that he went beyond partisan politics to embrace proposals that in the mind of the Coalition were responsible attempts to control the deficit. As the RWHC Board had the pleasure of meeting with Congressman Klug in Sauk City two days after the Coalition's announcement, healthy Concord like grapes replaced the normal allocation of donuts.

WI Workforce Forum Report Completed

The report of the Wisconsin Work Force Forum convened by the Consortium for Primary Care, Meeting Wisconsin's Needs For Primary Health Care Providers, has just been released. The Forum included representatives from the provider education schools, employers, managed care organizations and underserved communities. Aurora Health Care and the Rural Wisconsin Health Cooperative assisted with start-up funding; other major funding was subsequently contributed by Humana, the Medical College of Wisconsin and the University of Wisconsin Medical School. The Report can be obtained by contacting the Consortium at 608-263-5203.

Forum Conclusions:

"The major primary care workforce problem in Wisconsin is the maldistribution of primary health care providers leading to acute access problems in underserved areas."

"Current initiatives aimed at meeting the demand for primary care providers, if continued and strengthened by the educational institutions, are on course to meet the demand in terms of absolute numbers of providers, but may not lead to the appropriate distribution in underserved communities."

"A major factor affecting the practice of primary care is the growth of managed care organizations in the health delivery system."

"State and federal funding mechanisms for provider training play a powerful role in influencing the selection of primary care practice and location."

Recommendations (Summary) Included:

"Support primary care recruitment initiatives."

"Create the capacity to provide technical assistance in three to five communities yearly that have the most severe recruitment and retention problems."

"Encourage collaborative models of primary care and eliminate barriers to practice wherever possible.

"Consider alternative funding mechanisms for physician residency training, including seeking a broader base of funding support for essential academic health professional activities."

"Create new, and sustain current, residency and provider training opportunities in rural and underserved areas since providers often decide to practice in the communities where they are trained."

"Encourage the medical schools, the nursing schools and physician assistant training programs, in concert with managed care organizations to engage in workforce planning and to adjust program curricula and enrollments accordingly."

WI AHEC Looks At Restructuring

At the request of Murray Katcher and Cheryl Morena, Co-Directors of Wisconsin's Area Health Education Center system, two experienced AHEC leaders (from California and Massachusetts) have just concluded a three day site visit. The consultation arises out of an awareness that the current system's organizational structure may have been well suited initially but now needs significant adjustment as it begins to phase off the Federal government being the primary funding source. For some of us, the desired outcome will focus on a greater role in system governance by the four AHEC Centers and a more streamlined program office administration.

Harold Brown Sets A High Standard

Harold Brown, the immediate past President of the National Rural Health Association did all of us proud in his just finished term as President of the National Rural Health Association. His substantial success on both the "business" and policy sides of the Association create a high benchmark for the current President, Keith Mueller and myself as President-elect. To even get close I will be depending on an increased involvement in NRHA by many of you as well as some patience with me as I juggle these responsibilities over the next three years of the NRHA President series. Please do not wait to be asked; while I will be doing that, the unsolicited volunteering of time, money and opinions are all needed and welcome.

An Expanded Coalition For Medicare Equity

The beauty of the now much discussed Medicare HMO reimbursement formula is that it continues Medicare's traditional discrimination against rural communities and also penalizes whole states--Wisconsin is a case in point. As a consequence, Aurora Health Care, BlueCross & Blue Shield United of Wisconsin and the Wisconsin Hospital Association are helping to financially support the Fairness Coalition, a national, independent lobbying effort by state hospital associations and health care systems to bring fairness to the Medicare HMO reimbursement formula. We welcome them in the long standing fight against health care reimbursement and benefit formulas based solely on geography.

Howard Young Joint Ventures With BlueCross

From United Wisconsin Press Releases, 5/28 & 5/29:

United Wisconsin Services approved plans to form a managed care joint venture with Howard Young Health Care, Inc. to serve the rural communities of northern and north central Wisconsin. The Howard Young Medical Center in Woodruff, Wis., is a leading provider of health care services in the state's north central region. Upon finalization of the Agreement, the Joint Venture will be known as Northwoods Health Plan, LLC.

Thomas R. Hefty, Chairman, President and Chief Executive Officer of United Wisconsin Services, said, "Northwoods Health Plan brings together the top quality health care Howard Young is known for with the managed care expertise and resources of United Wisconsin Services. As we develop the broadest possible network of physicians and tailor benefit products to the needs of these rural communities, this partnership will greatly expand access to a wider choice in health care providers and health plans for the people of Wisconsin's Northwoods area."

Hefty noted that the formation of the Northwoods Health Plan Joint Venture is an important part of United Wisconsin Services' strategic plan to pursue partnership opportunities to develop its managed care operations in under-served rural announced plans to form a managed care joint venture with Howard Young Health Care, Inc. to serve the rural communities of northern and north central Wisconsin. The Howard Young Medical Center in Woodruff, Wis. is a leading provider of health care services in the state's north central region. Upon finalization of the Agreement, the Joint Venture will be known as Northwoods Health Plan, LLC.

Douglas O. Rosenberg, President and Chief Executive Officer of Howard Young Health Care, stated, "One of HYHC's key strategic initiatives is to become aligned with insurance carriers to allow for more 'choices' to patients in regard to their health care needs. Instead of relying solely on distant insurance companies making the decisions in the patient's health care, Howard Young will share in this Joint Venture to provide competitive prices with more local influence. All qualified health care providers will be invited to participate in this venture."

Telecommunications Cooperative Save 25%

We have become a member-owner of the Telecommunications Cooperative Network following an audit showing that we could achieve substantial cost savings on our long distance telephone expenses. Our experience has been even better than expected with savings of $500 per month--a 25% saving. For more information call TCN at 703-312-7000 and ask for information about the Cooperative's Technology Benchmarking Program. (This is in no way a paid advertisement, just what we experienced.)

Annual Monato Essay Prize Now $1,000

Competition for this annual cash prize ($1,000 in May of 1997) is open to all students of the University of Wisconsin-Madison, who are associated with the Center for Health Sciences. The Prize was established by the Monato family and RWHC in honor of the memory of Hermes Monato, Jr., a December 1990 UW graduate and RWHC employee. Students are encourage to submit papers focusing on rural health that have been written during the course of their studies. This year, the fourth Monato Memorial Essay Prize was awarded to Dr. Irwin J. Epstein for his submission, "Health Status and Healthcare: A Critical Evaluation of the Determinants of Health in North Dakota."

Myths About Main Street & Rural Health

Ron Shafer, UW Cooperative Extension Community Development Economist lists eight myths about main street revitalization in his May newsletter. His point isn't that they are uniformly false, just that they're not uniformly true. I'll leave it to you to swap a few words to make this a comparable list for rural health:

Rural Development Myths

#1: If We Build It, They Will Come.

#2: If We Demolish It, They Will Come.

#3: Complete A Major Project, They Will Come.

#4: If We Can't Get A Department Store To Come Back, Main Street Will Never Be Healthy Again.

#5: We Can't Get A Department Store, So Main Street Can No Longer Support Any Retail Trade.

#6: Competition Is Bad For Business

#7: For Main Street To Be Successful, Its Retail Businesses Must Keep Uniform Business Hours.

#8 With More Parking, They Would Come.

Talk With New Kellogg CEO

The following is taken from a longer interview with Bill Richardson in Focus, the W.K. Kellogg Foundation National Fellowship Program, Winter 1995-96:

What changes do you plan for the Foundation? "Organizationally we will become flatter, with fewer layers of hierarchy. We will also see increased collaboration across program areas, and a focus on emerging social issues."

Given the political climate, what role do you envision for the nonprofit sector? "We're going to see every aspect of the non-profit sector become more market-oriented. Market forces affect all of society and institutions like schools, universities and health care will no longer be exempt from these pressures. One of my major concerns is helping these institutions become more effective and successful in this emerging context. What we can't overlook, however, are the disadvantaged people who can't afford private alternatives."

Do you have a particular approach that will guide your work at the Kellogg Foundation? "I truly think 'helping people to help themselves' is the key. Our programming helps people begin where they are, build on their strengths, and mobilize their resources.. We believe that people and communities have strengths that haven't been recognized or developed, partly because society focuses too much on old problems."

Competition Can Feel Real Good

For health care providers looking for a good bench mark for customer service, go to the new Circuit City store on the far west side of Madison (again no financial connection). Previous expeditions for boomboxes (an average longevity in our house of 5.7 months) have been dreaded or handed off. This time, a chance encounter with a friend in another store sent me to Circuit City and a new experience; bottom line: in and out in less than ten minutes with the item and price we wanted. That included bargaining over price and a three year maintenance/replacement agreement.

The south central Wisconsin electronic mega-store market seems already over-crowded and the last place for a new comer, but if our experience was typical, Circuit City's entry will be very successful. They certainly made a chore easier for me and consequently I'll be going back, by-passing other more "established," apparently well capitalized competitors.

While I understand the "but they're different arguments," I suspect we in health care will be learning a lot more about the power of a strong commitment to customer service supported by computer information systems to become or stay competitive.

Click here to return to RWHC Home Page.