Challenges and Successes in Reducing Health Disparities: Workshop Summary (2008)

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5 Health Disparities in a Business Environment M any approaches have been taken to addressing health disparities beyond the work that has been done through clinical or com- munity interventions. Myriad organizations have developed suc- cessful strategies and programs to reduce health disparities using a variety of methods. By hearing from representatives of organizations making such efforts, the Roundtable members sought to learn about how specific pro- grams have worked to reach their goals and what challenges or successes they have realized while trying to effect change among their constituen- cies. This chapter summarizes presentations by Ms. Diane Schwartz, the president of the American Conference on Diversity; Dr. Angela Glover B ­ lackwell, the founder and Chief Executive Officer (CEO) of ­PolicyLink; and Ms. Katherine­ Gottlieb, the president and CEO of Southcentral Foundation. AMERICAN CONFERENCE ON DIVERSITY The American Conference on Diversity is a nonprofit human relations organization in the New Jersey area that focuses on recognizing the value of diversity, educating leaders, and promoting respect while working on a broad spectrum of issues, explained Ms. Schwartz. The organization does not conduct clinical studies; rather, it informs the business community about issues regarding health disparities, as well as training and educating people about issues relating to diversity and inclusion. This organization acts as a   This section is an edited transcript of Ms. Diane Schwartz’s remarks at the workshop. 91 

92 CHALLENGES AND SUCCESSES IN REDUCING HEALTH DISPARITIES laboratory in many ways, working to achieve goals that few other organiza- tions are attempting and seeks innovative methods for changing deep-rooted beliefs and institutional procedures that can affect health disparities. A recent project focused on developing a Cultural Competency Train- ing Program and educating trainers to administer the program in hospitals throughout New Jersey. After the program was initiated, the American Conference on Diversity developed an interest in extending awareness of health disparities to businesses that are headquartered in New Jersey. For most businesses, service provision, shareholder value, and operations are the primary focus. While benefits are provided equally to all employees, little attention has been paid to addressing issues related to the health dis- parities among them and the impact that these health disparities have on the company’s performance. The American Conference on Diversity believes, however, that businesses should be aware that when their employees expe- rience problems brought about by the health disparities they experience, these problems—such as increased sick time, absenteeism, and family leave costs—impact the bottom line. Businesses must realize that there are real bottom line costs associated with health disparities, Schwartz commented. According to the Integrated Business Benefits Institute, the full cost of employee absences is more than four times the total medical payment; absence-related costs alone amount to 76 percent of net income when considering lost productivity from absence and wage replacement benefits. According to Schwartz, that is the awareness mes- sage that businesses need to take away from this information. In New Jersey, about a third of employees are members of racial and ethnic minorities, and those employees and their families are affected by health disparities regardless of their income or where they live. By reducing health disparities, businesses have a tremendous opportunity to positively impact their ­employees’ health and quality of life, as well as the companies’ ­bottom line. What steps can the business community take to reduce disparities among their employees? Determining a means for reaching these goals is extremely challenging. Privacy issues severely limit how data can be gath- ered, and even such issues as determining which racial or ethnic group employees belong to are big stumbling blocks. Businesses would have to develop a method for tracking disease, before they could begin to determine the most effective ways to impact the health of their employees and their families. For more than a year, the American Conference on Diversity has been evaluating these issues and developing strategies for tackling some of these problems. Although we do not yet have all the solutions, Schwartz observed, we are closer to finding some answers and to developing pro- cesses for reducing health disparities in business settings. To help address some of the challenges of reducing health dispari- ties through business initiatives, the American Conference on Diversity 

HEALTH DISPARITIES IN A BUSINESS ENVIRONMENT 93 convened a roundtable that included the medical directors of Prudential Financial and Horizon Mercy, a medical economist from Pfizer, a senior vice president from the New Jersey State Chamber of Commerce, and a physician who works in the area of cultural competency. As a result of those discussions, materials were developed to help explain to business leaders how health disparities impact a company’s bottom line. It is imperative that businesses understand that, to be proactive about positively impacting health disparities and their own costs, internal changes in their own busi- ness environments can tremendously impact their employee’s experiences. Last June, as part of its Business Leaders Series, the American Confer- ence on Diversity held a forum called the Health Disparities Score Card for all businesses across New Jersey, with the purpose of creating aware- ness and educating employers about health disparities issues. This forum included very disparate companies and organizations that were interested in these issues, including Johnson & Johnson, the American Association of Retired Persons, Newark Liberty International Airport, major national and regional employers, and local hospitals. The forum provided infor- mation and offered strategies for businesses to follow to benefit their e ­ mployees, reduce costs, and reduce health disparities for themselves and their families. At the forum, several of New Jersey’s larger employers reported that they have engaged third parties to mine their data to collect information about their employees’ health in general, so the employers can begin to develop their own internal programs. Many of these large, global compa- nies have developed affinity groups, which mentor groups of employees who share race or ethnicity and help them advance their professional careers. As these employers begin to understand how health disparities affect their employees’ experiences, they are starting to focus on specific wellness and health-related programs. Moving Forward One Business at a Time To date, the focus has been to spread the message about health dispari- ties to larger companies, yet the American Conference on Diversity would like medium-size companies to know that they also have a stake in this issue. Regional outreach is being planned so working groups can be cre- ated to help the companies that care about these issues to make strategic changes. It is important for all employers to recognize that companies can prosper while providing for their employees’ health-related needs. The American Conference on Diversity would also like to begin pushing for changes in the insurance industry. If large employers start asking their insurance providers to provide incentives in their plan offerings, employees may be more likely to adopt better health practices. Providing free mammo- 

94 CHALLENGES AND SUCCESSES IN REDUCING HEALTH DISPARITIES grams or other routine tests, for example, could result in more employees receiving yearly screenings and other preventive care. Although agreeing with Drs. Horowitz and Lawlor that clinical and community efforts can be combined to address the issue of health dispari- ties, Schwartz observed that the business community can also review its current practices. Businesses focus on the bottom line, but there is a very real case to be made for making internal changes to affect the health of their workforce and, in turn, change their communities. Schwartz believes that insurers will soon start providing new programs and plans that address health disparities issues, and some larger insurers across the country either already have the data or are starting to gather them to address these issues. Change is coming, and the American Conference on Diversity is continuing to encourage the awareness that creates positive change. Reaction and Discussion Dr. Lurie asked if there were any specific approaches or ways of fram- ing the health disparities issues for the business community that have been more successful than others. Ms. Schwartz explained that she has found that the most compelling messages always come down to money and the bottom line for businesses. However, she believes that businesses should not just pay attention to health care costs; they should also direct their human resource staff to seriously delve into these issues to determine the impact of health disparities on their business in general. This is a very big step for some businesses to take. It has been difficult to convince companies to commit to changing their policies and pledging to compile and analyze their employees’ health data and use that information to improve health care and benefits packages for their workforce. Dr. Suggs agreed that businesses are primarily focused on making a profit. No matter what kind of business it is, it must be cognizant of the disproportionate health care costs it has to absorb in comparison to its competitors. Many businesses are looking at these issues in a more serious way for the first time. But when it comes to making changes in the existing arrangements, some people with powerful interests want things to remain as they are because they have been successful with the status quo. Still, there are compelling reasons why the status quo is not acceptable. Businesses can make a judgment based on their economic well-being and decide that they cannot afford to continue to absorb these kinds of health care costs—that it is truly time for a change. Dr. Levi also agreed, adding that people need to be leading healthier   The following discussions were edited and organized around major themes to provide a more readable summary and to eliminate duplication of topics. 

HEALTH DISPARITIES IN A BUSINESS ENVIRONMENT 95 lives. Employers should worry not only about the wellness of their cur- rent employees and their families, but also about the wellness of future e ­ mployees. Future employees do not necessarily need a wellness program to make them healthy, but they need a program now to ensure that they will be healthy when they join the workforce. POLICYLINK PolicyLink is a national organization staffed by a team of dedicated professionals, only a few of whom have experience working in the health community, explained Ms. Glover Blackwell. As a public interest lawyer, most of her work has been in the area of community building and commu- nity and policy development, and all of the people who work at PolicyLink have similar credentials. The organization is devoted to developing a new generation of policies to achieve economic and social equity in order to build a society in which everyone can participate and prosper. When PolicyLink began its work, it focused on understanding the root causes of continuing inequality and inequity in America. Based on data, observation, and insight, Glover Blackwell explained, we concluded that where one lives in America has become an absolute proxy for opportunity. Where a person lives determines whether or not their children get to go to a good school or whether or not they live near good employment opportu- nities or have access to a transit system that enables them to travel to and from their job. Where one lives determines whether or not one’s family will have access to money quickly if there is a crisis. People living in some communities can quickly pull money out of their homes because they are constantly increasing in value, whereas people living in other communities do not have similar opportunities or options. The people at PolicyLink realized that where people live determines how healthy they are, how long they are going to live, and their general sense of well-being. Where people live determines whether or not they have access to fresh fruits and vegetables, whether or not they have access to safe streets where they can get out and walk around, whether or not they have access to parks and other places to get physical activity, whether the air is safe to breath in a neighborhood, or whether people live in a place where asthma is going to be a continuing problem. Based on that insight, PolicyLink studied the work that people were doing in communities and began to tease out the implications for policy— local, state, and national—that could really build on this observation about the importance of place. We began to conduct research, train advocates, and support policy campaigns to try to make a difference, Glover Blackwell   This section is an edited transcript of Ms. Glover Blackwell’s remarks at the workshop. 

96 CHALLENGES AND SUCCESSES IN REDUCING HEALTH DISPARITIES noted. These efforts led us to start the PolicyLink Center for Health and Place, where we could bundle all the work we had been doing but also be more deliberate about identifying the next steps to take. We are involved in this work all over the country, from California to Washington, D.C., from the Mississippi delta to the Gulf region. What has been said here today suggests several things in terms of strategies. She observed that Dr. Lawlor’s discussion of the Local Initiative Support Corporation (LISC) suggests that it is important to join forces with other ini- tiatives to influence them and to help them achieve the goals that are consis- tent with one’s own insights. LISC is one of the biggest intermediaries doing community-development work in this country, and much of it, throughout the years, has focused on housing. During her presentation, Dr. Acevedo-Garcia pointed out the need for housing opportunities in communities that are rich with opportunity, yet LISC has spent $1 billion on housing in low-income communities with concentrated poverty. This is really the opposite of what Dr. Acevedo-Garcia was suggesting, noted Glover Blackwell. The reason for the LISC focus on communities with concentrated poverty is not because LISC does not understand how valuable it would be to live in communities rich with opportunity, but because all of the money it has been leveraging has been coming from low-income housing tax credits, a federal program that provides housing opportunity. One of the requirements for the low-income housing tax credits is that they can be used only in low-income communities. This is an opportunity for people who believe that where a person lives can impact opportunity to join with a vast network of people who have been doing housing and community development and would like to be able to see those investments happen in places that are rich with opportunity. From developing strategies and conducting research, PolicyLink wants to find people who have a common interest in what we are trying to achieve and to join with them, Glover Blackwell noted. We believe that it is very important to get policies in place to put more affordable housing into subur- ban communities that have more opportunity. We have also found out that it is not enough just to have a policy that creates more rental housing and more affordable housing. With the nation’s long legacy of race discrimina- tion, for the most part, just putting that program in place will create more affordable housing opportunities for people who are white and understand how to make systems work for themselves. There is nothing wrong with that; we want more people who understand how to make systems work for themselves. Yet, for the new strategies to actually get to the disparities issue and to affect the people who are being left behind, we have to work with community-development corporations. Many such organizations are in the LISC network, so that they can work with the constituency to make sure they know about housing opportunities. They are getting people ready to move to new areas, and they are working in the new communities to make 

HEALTH DISPARITIES IN A BUSINESS ENVIRONMENT 97 sure that they are welcoming and have the kinds of services and supports that people need in order to be successful. We need to find intermediaries that are working with large numbers of people and running these projects because they deal with real money and real government programs. We need to help them understand how their work improves the possibility of health and well-being for these individuals and families. Additional effective programs need to be implemented. Receiving sup- port from a government agency in the form of foundation grants or innova- tive programs encourages insight and learning. The earlier discussion about race is also very instructive. Many of the programs that are funded and are effective at helping people, whether they benefit Native Americans, Lati- nos, Asians, or very-low-income white people or blacks, generate enormous insight on how to work directly with community members to ensure that the communities’ collective wisdom and preferences are truly reflected in the program structure. Too often, a successful program is started in a community but the money runs out, the leader moves on, the community changes, and the program is lost. It is essential to be very deliberate when initiating new programs to ensure that they are ­appropriate and sustainable. Another insight at PolicyLink is how important it is to make sure that individuals in communities have access to fresh fruits and vegetables. It is terrible to blame people for not eating fruits and vegetables when they do not have access to them in their neighborhoods. Some fabulous programs around the country have been starting farmers’ markets, helping local convenience stores successfully carry fresh fruits and vegetables, and get- ting full-service supermarkets in underserved communities. Insights such as these should be fused into programs that operate on a larger scale. For example, the Fresh Food Financing Initiative in Pennsylvania has put close to $80 million into making sure that underserved communities have access to full-service grocery stores. With the help of organizations that know how to work in different communities, the initiative was able to finance the grocery stores and also learn what makes a program like this a success. Focusing on leadership is another important intervention. There have been many examples in the Racial and Ethnic Approaches to Community Health (REACH) and Steps programs in which individual leaders have been essential in being able to inspire a community. They have been able to work with public officials to make sure that they are paying attention to the community. People have been able to transform communities because they understood how to translate from program and practice into policy. We need to concern ourselves with those segments of the community that are being left behind because of health disparities, and we need to make sure that individuals who are tied to these communities because of their history and their personal commitment, who are often members of racial 

98 CHALLENGES AND SUCCESSES IN REDUCING HEALTH DISPARITIES or ethnic minorities, are identified, promoted, and supported as leaders, Glover Blackwell said. Several of the previous presenters observed that they were not solely responsible for their program’s success, but rather the program succeeded because they worked with dedicated, trusted leaders in the communities who were committed to the well-being of their community. It is not suf- ficient simply to advance a new generation of policies that build on the insight that where one lives impacts health and well-being. It is also impor- tant to advance a new generation of leaders, ones who can work at the community level and develop and advance policy work. Until we are able to move from addressing community needs and community insight to the world of policy, we will be forever working at the edges. SOUTHCENTRAL FOUNDATION Ms. Gottlieb began by describing the state of Alaska as approximately 586,000 square miles that are home to 650,000 people, about 120,000 of whom are Alaskan Native people. In 1987, when she started working at Southcentral Foundation, it had a budget of $3 million and about 24 staff members. The Alaska Native Medical Center is a hospital with 150 beds, and she is the president and CEO of the Primary Services offered through the hospital. She recounted personal details of her life, which have given her moti- vation to change the health care system in Alaska for as long as she can remember. She was born in the Kodiak Islands and is Alaskan Native and Filipino. The village where she grew up had approximately 100 people. She was 16 when she had her first child and is now the mother of 6 children. She finished high school with a GED. She grew up in a family of 12 with an alcoholic and a great deal of domestic violence and abuse in the home. Two of her siblings died at very early ages. While working at Southcentral Foundation, she earned a bachelor’s degree in organizational development and a master’s degree in business. At the same time, changes were taking place in the health care system for Alaskan Natives, she recounted, as we assumed the role of managing our health care from the federal government and as customer-owners created a paradigm shift. Southcentral Foundation has redefined the entire medical system for Alaskan Native and American Indian people living in Anchorage, the Mat-Su Valley, and 60 rural villages in the Anchorage Service Unit. There are now medical teams and primary care physicians in place. When people need care, they can visit the hospital and see their own provider on the   This section is an edited transcript of Ms. Katherine Gottlieb’s remarks at the workshop. 

HEALTH DISPARITIES IN A BUSINESS ENVIRONMENT 99 same day. In addition to their provider, each person has a medical team—a nurse case manager, a case management support person, certified medical assistants, a behavioral consultant, and a pharmacist. Gottlieb was involved in making the decisions about funding redesign and saying what she, as a customer-owner of the health care system, wanted to happen. Rather than creating more complexity, Southcentral developed a system that incorpo- rates effective coaching, coordinating, teaching, modeling, and partnering directly with primary care physicians. It created a system in which patients work collaboratively with their physician to treat body, mind, and spirit—a system in which power is maintained by individuals and family members. Cultural competency is at the central core of everything it does and all ser- vices are added with this in mind, not the other way around. Southcentral Foundation has enjoyed great success. Primary care patient visits to specialty clinics have dropped. Instead of seeing a specialist, patients are being cared for by their own primary care providers. Hospital visits per 1,000 primary care patients have dropped. Since Southcentral assumed management in 1997 and took control from the government, child immunization rates have increased and the number of hospitalizations attributable to asthma has declined. Gottlieb observed that one of the most important messages she heard from the presentation by Drs. Lawlor and Horowitz about the hybrid approach involves having an effective leader. If the true leaders in a com- munity get involved in making decisions and people in power listen to what they say, change can happen. There should also be shared responsibility. In her community, health care provisions are determined by people who are directly involved in the decision-making process. By taking control of their own health care, they have had an overwhelming impact on the community, and health statistics have dramatically improved. By taking responsibility and ownership, she said, we have a say in what happens in our health care system. There is a shift in responsibility; it is now our own fault if something does not happen. We can not blame prob- lems on anyone else. We also know if something is wrong, we can work to try to fix it. Although the resources of Southcentral Foundation are limited, she can influence the tribal entity to advocate for them to be applied to health care. A substantial portion of the funds generated are funneled right back into health care initiatives. An initiative Southcentral has been working on is reducing tobacco use in Alaska. The entire community has become involved in this effort. Laws have been changed so that people can no longer smoke in public places, and the state of Alaska is working on raising taxes for cigarettes. Most public buildings and the entire hospital campus, including all of the off-site facilities, have gone smoke-free. We have worked very hard, she said, to educate people about the dangers of smoking, and we have developed a 

100 CHALLENGES AND SUCCESSES IN REDUCING HEALTH DISPARITIES media campaign to advertise the fact that cancer attributed to smoking is the number one killer among Alaskan Natives and American Indians. Gottlieb noted that several workshop discussions have focused on the value of creating partnerships with local churches and advocating with them as a community. Southcentral has attempted to do this, but with only limited success. One local church formed a nonprofit organization and is in direct competition with Southcentral for health care. Even as we were working with them, they were establishing mini-clinics around the state and drawing resources away from Southcentral. These clinics duplicate existing services and do not offer continuity of care. Other partnerships with local churches have been very successful. We have been working with one local church to help address issues of domestic violence and child abuse and neglect. This church has listened to our approaches for addressing these issues and has allocated resources toward our initiative to reduce domestic violence, child abuse, and child neglect. The day’s presentations, Gottlieb concluded, suggest that I should go back home and work harder to include the entire community of Alaska in our efforts. Our target population has been Alaskan Native and American Indians, but I would like to hear from the municipality, the government, and the other three hospitals in our area, about what they are doing to elim- inate domestic violence and child abuse and neglect. I would like to know what they are doing to effect change around diabetes, obesity, asthma, and all the other health-related disparities in our state. There has been a great deal of mistrust among these different entities. In order for us to form a partnership, it is important that we build trust with the government, the schools, and with other partners in the community. Reaction and Discussion Dr. Wong raised the issue of equity of care. He observed that Cross- ing the Quality Chasm, an Institute of Medicine report (IOM, 2001), mentioned equity as a critical aspect of ensuring quality health care in the United States. Traditionally, equity in health care has been related to performance measures, clinical outcomes, or the kind of the methodologies that are used with quality improvement. As a health care administrator, he asked, how do you view this domain of equity in how you are changing the models of what health care really is in your community? When she thinks of equity in relation to her work at Southcentral, Ms. Gottlieb replied, she focuses on what it has done to target the Alaskan Native and American Indian populations. One-third of the funding South-   The following discussions were edited and organized around major themes to provide a more readable summary and to eliminate duplication of topics. 

HEALTH DISPARITIES IN A BUSINESS ENVIRONMENT 101 central receives is from the Indian Health Service; another third comes from the state, foundations, and other grants; and the final third is earned as a result of existing aggressive building activities that were put in place after Southcentral took over management responsibilities from the federal government. Typically, as a government entity, any money generated by a third-party building would go back into the treasury. Yet as owners and managers, any funds that are generated from a third-party building can be distributed wherever money is needed to address health care disparities in the community. The Nation of Alaskan Natives and American Indians receives only one-third of the funding required for providing health care to the community from reimbursement from the federal government. Dr. Levi raised the issue of sustainability. If community groups are asked to design programs that are sustainable, there is also an obligation on the part of the federal government and other funders to make sure that their funding streams are also sustainable. That is true for the Steps program and other programs as well. There have been discussions during the workshop about how communities need to integrate multiple funding streams into something that creates a true community-wide approach. However, he asked, do you think the current management of public health and health at the federal and state levels needs to change, so that the federal government creates a structure that makes it easier for people to reduce disparities at the local level? Ms. Gottlieb replied that when the federal government began allocat- ing funds to the Nation of Tribes under Public Law 9368, it did so in large lump sums. Money was allocated for emergency medical spending, primary care services, behavioral services, substance abuse, mental health, or other health care services. The allocation of funds determined how much money was put toward each of those health care needs. In 1997, however, the rules changed and the money began to be sent without a set allocation. Now when Southcentral receives a check for $45 million from the federal government, the tribal leadership can determine where those funds are most needed. This change has helped drive its success. Having power over the allocation of funds is the best way to address community needs. Dr. Bracho shared her thoughts on partnerships. There are so many needs and so many jobs that need to be done to address the clinical con- cerns that partnering with other groups in other locations is incredibly challenging. It is extremely difficult to work on diabetes, obesity, or violence when they are associated with other issues, such as inadequate housing, lack of open space, or issues related to immigration reform. All of these issues need to be worked on simultaneously. Some of the examples dis- cussed work more toward establishing partnerships to reach clinical goals rather than being hybrid models. If an organization partners with clinics and the government to improve diabetes management, but they do not 

102 CHALLENGES AND SUCCESSES IN REDUCING HEALTH DISPARITIES tackle other issues related to poverty and inadequate housing, they are not necessarily hybrids, she noted. Dr. Bracho also discussed issues related to community workers. Com- munity workers live in the community and get paid to transform their communities, but they know that financing is needed for their community to improve. Now they are starting to be managed by members of academia and are receiving certification from people who know nothing about the communities that the workers represent. In this way, community ­workers are recognized as community leaders with implied credibility; yet, she asked, what type of community worker are they? How does one train and sustain them? In situations like this, the communities and the hybrid model are being forgotten. Ms. Gottlieb responded that community health aides in Alaska are trained at the community level. The health aides are tribal people who receive training over a 6-month period, and they are often the only trained medical professionals in the entire village. That means that they are the doctor and the behaviorist. They provide all of the medical care in the community, and this system is working. It is simply impossible to provide a physician for $200,000 a year or more to every village. Dr. Bracho countered that she would like to know what else is being done to rectify situations like the one in which Gottlieb’s family used to live. What are you doing in your community to address issues like teen pregnancy or alcoholism? How are your health care strategies connected to the rest of the communities’ efforts to follow a hybrid model, and how much are you doing to initiate change? Ms. Gottlieb responded by discussing how funds are allocated in Alaska. Although there must be accountability, she said, she would still advocate for bulk funding, down to the level of those directly providing services. In receiving funds for providing a health care system, there must be accountability to the constituents who use those services. This means that funding would be allocated for community health workers if providing for these workers has been identified as a priority by the community. Reference IOM (Institute of Medicine). 2001. Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press.