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The Impact of Business on Population Health
The second panel, moderated by Catherine Baase, chief health officer at The Dow Chemical Company, illustrated activities that businesses are undertaking that are having a positive and beneficial impact on population health but which were not designed with population health improvement as the primary goal. Gary Rost, executive director of the Savannah Business Group, opened the session with a discussion of the need for locally relevant data when considering the engagement and impact of business on health. Grace Suh, manager of Education Programs for Corporate Citizenship and of Corporate Affairs at the IBM Corporation, described a grades 9-to-14 “early college high school” education model designed to develop science, technology, engineering, and mathematics (STEM) talent for IBM. Alisa May, executive director of Priority Spokane, described collaborative efforts to enhance community vitality in the areas of economics, education, environment, health, and safety.
THE IMPORTANCE OF LOCALLY RELEVANT DATA
When trying to engage employers, it is important to understand who you are actually engaging, said Rost of the Savannah Business Group.1 Small businesses in a community are owned by people who often have longstanding, deep roots in the community. In contrast, employees of
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1 The Savannah Business Group is a business coalition established in 1982 to negotiate and group-purchase health care services for self-funded employers.
nationally owned companies come and go, and it can be difficult to get their attention and engagement on a local and community level. It is not necessarily the size of the employer, he said, but how willing the employer is to get involved. Employers have expertise in worksite employee wellness, prevention, and disease management efforts, and they have influence and leverage in the community.
Rost shared health risk assessment and bio-screening data from three large employers in Savannah (whose employees collectively represent about 10 percent of the local population). These data suggested that the diabetes rate was as high as 34 percent for employees at one of the companies. However, Rost said, the data from public sources were not local data, and local data from employee health risk assessments done in Chatham County, home of Savannah, showed that the pre-diabetic rate there was actually almost 80 percent and the obesity rate was 50 percent. The local community, from which the workforce was drawn, was very unhealthy.
This is important, Rost said, because when employers are looking for a site on which to build a new plant or to which to move their headquarters, they are now taking into account the health of the community surrounding the site. It is no longer just about infrastructure, education, and workforce availability, but also about how healthy the workforce is.
Rost said that in 2011, Chatham County was awarded a planning grant through the National Business Coalition on Health from the United Health Foundation to assemble key community organizations and define health priorities. This was followed by an implementation grant from the United Health Foundation and the Robert Wood Johnson Foundation. As an example of the importance of local data, participants identified health priorities for Savannah as obesity, low-birthweight babies, diabetes, community data collection, immunization, tobacco cessation, and asthma. Specifically, Rost said, the group wanted to focus on childhood obesity. One data source suggested that one in three children in Chatham County was “overweight,” while another data source said one in three is “obese.” Adding to the confusion, the data were based on five counties in Georgia, which were then overlaid on the Chatham County demographic information. A local data collection collaborative is now in progress to better understand the actual local situation regarding overweight children in Chatham County.
Rost said that in Georgia, the law now requires that BMI and weight be reported for all children in public schools, grades K through 12, and that a fitness assessment be done for all children in physical education class. There is a significant disparity between the best- and worst-performing schools in Georgia. For example, nearly 80 percent of the children in one of the worst-performing elementary schools are overweight, compared to about 25 percent in the best-performing school. Even 25 percent of
our school children being overweight is too much, Rost said. The most recent data show that about 40 percent of Georgia’s children are not in the “healthy fitness zone” for BMI, and 33 percent of seventh-graders failed all five of the fitness tests. One manifestation of this is, Rost said, that the U.S. Department of Defense, which has a very big presence in Savannah, cannot get enough recruits who can pass the military fitness tests.
In conclusion, Rost said that a decade ago the members of the Savannah Business Group were working only with their own employees. However, the coalition now works with many different groups in the community to improve the health status of the community. National organizations serve as information sources (e.g., the U.S. Department of Health and Human Services, the Leapfrog Group for Patient Safety, and Bridges to Excellence), and the coalition serves on a variety of local boards (e.g., the Chatham County Safety Net Council).
Health and education are interrelated, said Grace Suh, manager of Education Programs for Corporate Citizenship and of Corporate Affairs at the IBM Corporation. While direct health education informs people about what it means to be healthy and teaches them healthy behaviors, general education can create opportunities for better health. For example, education can enable people to get good jobs, with good income and health benefits. Income and resources affect where people live (i.e., whether people can afford to live in healthier neighborhoods). Following on Dan Buettner’s comments about living a life with purpose, Suh said that education can also enable young people to think about their purpose in life and, more importantly, to attain the skills to fulfill that purpose.
Across industrialized nations, median life expectancy is increasing. However, Americans who have not completed twelfth grade are actually living shorter and less healthy lives, Suh said. There are many contributing factors, one of which is education. Data on education disparities among millennials (25- to 32-year-olds) show that those with only a high school education are far more likely to be unemployed and far more likely to live in poverty than those with a college education (Pew, 2014). In addition, salaries for college graduates have increased over time, but salaries have decreased for those with only a high school diploma, which has steadily widened the earnings gap.
Suh noted that in the 1980s IBM hired high school graduates and paid them a good salary, affording them an opportunity to make it to the middle class. Today, throughout the national economy, those with only a high school diploma are likely to be among the working poor, making on average $9 an hour. It now takes at least a 2-year college degree to get a
well-paying, meaningful skilled job and make one’s way into the middle class. By 2018, Suh said, there will be 14 million new STEM jobs, but we will not have enough skilled workers to fill them. With this in mind, IBM has been focusing on how to help young people get a degree that matters—a degree that can put them on the path to a good job that will enable them to have better economic, social, and health opportunities and outcomes.
Pathways in Technology Early College High School (P-TECH)
In 2010, IBM began working with the New York City Department of Education, the City University of New York (CUNY), and the New York City College of Technology to reinvent and redesign high school so that students could graduate with both a high school diploma and an associates in applied science (AAS) degree. The goal is to provide students with the academic, technical, and workplace skills necessary either to secure a well-paying, entry-level job in a STEM field or to continue their education at a 4-year institution.
The P-TECH model requires partnerships among K–12 education, higher education, and industry, Suh explained. It is a public school model, open to all students, with no grade or testing requirements and no additional costs to students. As designed, P-TECH serves historically underserved children, enabling them to earn an industry-recognized associates degree for free. P-TECH is also an early college model, integrating high school and college coursework over 6 years, but the focus is on mastery, not seat time, and some students may be able to graduate in 4 or 5 years. A key tenet is career readiness, including skills mapping, coursework, mentoring, worksite visits, speakers, and internships. IBM’s interest in P-TECH is in developing the next generation of leaders and innovators. One commitment that IBM and other companies that partner with the schools make is that students who graduate successfully will be first in line for jobs with the industry partner. There are currently four IBM partner schools: the flagship model, P-TECH, in Brooklyn, New York; the Sarah E. Goode STEM Academy in Chicago, Illinois; Excelsior Academy in Newburgh, New York; and Norwalk Early College Academy in Norwalk, Connecticut.
Suh elaborated on P-TECH in New York City as an example of the model. The school, which opened in September 2011, awards AAS degrees in computer information systems and electromechanical engineering technology. There are currently 335 students, primarily underserved young people (76 percent boys; 60 percent black and Hispanic males; 80 percent of students are recipients of free or reduced-price lunch). Suh emphasized the importance of environment and culture in making the model work.
The principal knows the students by name, and students are expected to progress and achieve, regardless of their academic proficiency upon entry. Early results are promising. Six students are expected to graduate with their AAS degree in 2015, after 4 years at the school. One-quarter of the inaugural class has finished all their high school requirements before their third year of what would be traditional high school. There are 162 students enrolled in at least one college course. Suh shared similar results from the school in Chicago.
IBM’s Commitment to Workplace Learning
In its role as a partner, IBM is involved in all aspects of the school, Suh said, but the company has a special responsibility over the Workplace Learning strand. IBM develops the curriculum that incorporates skills mapping, provides mentors for all students as well as worksite skills-based paid internships, and places graduates first in line for jobs.
Skills mapping involves identifying the skills required for entry-level jobs at IBM and mapping them to the curriculum. This is essential to ensuring that students graduate career-ready, and it brings meaning to IBM’s commitment to making graduates first in line for jobs at IBM, Suh said. All students are paired with industry mentors to inspire them and coach them over the course of the 6 years. Research has shown that mentoring leads to better student outcomes in the areas of educational achievement, health and safety, and social and emotional development (Jekielek et al., 2002). IBM is also committed to providing skills-based, paid internships for students, beginning the summer after their third year in the school. The students are engaged in projects that require them to demonstrate the academic and workplace skills they have learned at P-TECH. This adds value for the students, as they have the opportunity to practice and push the envelope on the skills that they have learned at school within an actual job setting and because it makes them more marketable since employers tend to favor people who have work experience.
The early results of the program have garnered national recognition, including a visit by President Barack Obama to P-TECH in October 2013, Suh said. Major media attention has included a cover story in Time magazine as well as coverage in the Wall Street Journal, the New York Times, and the PBS NewsHour.
The essential next step is replication, Suh said, noting that other companies are participating, with 27 schools that were slated to open in September 2014 and at least 37 to be in operation by fall 2015. In November 2014, IBM, in partnership with CUNY, was scheduled to launch an online playbook that would provide tools and resources for other public–private partnerships that want to launch a P-TECH 9–14 model school. This new approach
to education holds a lot of promise for changing the American education landscape, Suh concluded. These schools are nurturing a new group of innovative leaders while also addressing the U.S. skills gap.
BUSINESS PARTNERSHIPS THAT INFLUENCE HEALTH
Spokane, Washington (population 210,000), is 232 miles east of Seattle and on the opposite side of the Cascade Mountains. The Cascades are a great divide not only physically, but also economically, politically, and culturally, said May of Priority Spokane. Because the city of Spokane serves a large rural geographic area, known as the Inland Northwest, it has developed an infrastructure that many cities its size would not normally have. Spokane has two public universities, two private universities, and a thriving community college system that works closely with workforce development efforts. Two large hospital systems are aligned with health care providers. Fairchild Air Force Base is the largest single-entity employer in Spokane County, which also has an international airport, and a strong industry presence. May shared several examples of business partnerships among these entities that have influenced health.
Priority Spokane
Priority Spokane is a collaboration of community leaders who are focusing on community vitality, especially the social and economic factors that influence health, May said. Members, including the Spokane Regional Health District and Greater Spokane Incorporated (GSI), meet monthly to evaluate data and create strategies for achieving common community priorities.
From 2009 to 2013 the community priority was educational attainment, specifically raising the graduation rate in Spokane public schools and throughout the county. May said that as a result of those efforts, Spokane County was awarded one of six 2014 Robert Wood Johnson Foundation Culture of Health Prizes for engaging in best practices that create a culture of health.2 The county’s proposal was grounded in the fact that education is directly linked to higher incomes and better health.
Greater Spokane Incorporated
GSI is Spokane’s combined Chamber of Commerce and Economic Development Council. May shared several examples of how the organiza-
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2 See http://www.rwjf.org/en/about-rwjf/newsroom/features-and-articles/culture-ofhealth-prize.html (accessed December 12, 2014).
tion is involved in education and workforce issues. GSI hosts a monthly K–12 roundtable attended by all 14 school superintendents as well as by business and community leaders. There is also a Higher Education Leadership Group that meets monthly and includes the leaders of the four universities and the community college system. Committed to Education is a group of business leaders who come together to incentivize businesses to encourage their employees to seek a technical certificate or 2- or 4-year degree. Teaching the Teachers brings teachers into the workplace to learn about the needs of local industries so they can guide their students. Business AfterSchool is an interactive program that connects students, teachers, and parents to the worlds of manufacturing, health care, agriculture, computer science, and engineering.
In addition to the work being done at GSI, Spokane County is benefitting from Excelerate Success, a “collective-impact”3 effort headed by the United Way to increase education attainment, and an active Spokane STEM Network.
Other Business Partnership Examples
Riverfront Park
Spokane was once a thriving economic center and transportation hub for logging, mining, and shipping by rail, but by the early 1970s it was a shadow of its former self, May said. Business leaders sought to revitalize Spokane, and they made a successful bid for the World’s Fair Expo’74. After the Expo, the fairgrounds were transformed into Riverfront Park. There are bike paths and a trail that connects to a 37-mile trail system running from the border of Washington and Idaho to Nine Mile Falls, Washington. Families of all economic statuses bring their children to Riverfront Park to play, May said. Spokane is working on a new master plan to further expand Riverfront Park because it is in many ways the center of health in the community.
Inland Northwest Health Services
Twenty years ago, Spokane’s competing hospital systems had the radical idea of partnering in the operation of their air ambulance system and rehabilitative services, May said. Since then, the resulting partner-
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3 Refers to a concept used by the Foundation Strategy Group (FSG) and others, including the Stanford Social Innovation Review, describing the “commitment of a group of actors from different sectors to a common agenda for solving a complex social problem” (http://www.fsg.org/OurApproach/WhatIsCollectiveImpact.aspx [accessed December 12, 2014]).
ship, Inland Northwest Health Services, has expanded and has become a leader in medical technology and in the sharing and reporting of data. As a business, it has grown from $10 million annually to $200 million annually and from 400 employees to more than 1,000, providing $79 million in salary and benefits to the community.
Academic Health Sciences Center
The business community, headed by GSI, approached the legislature and advocated for a 4-year medical program in Spokane County, which has since become a reality. The medical program is one of several that are part of an Academic Health Sciences Center on the Riverpoint Campus in Spokane, where Washington State University, Eastern Washington University, the University of Washington, and Whitworth University each have a presence. It is expected that by the year 2030, the program will bring an additional $2 billion of revenue to the area, $1.5 billion of which will stay in Spokane County, May said. It will bring in doctors and research staff, and it will help retain medical talent in Spokane. Evidence shows, May said, that practitioners are more likely to stay and practice where they intern.
Understanding the Impact of Collective Efforts
To understand the impact of these various efforts, the Community Indicators Initiative of Spokane is collecting and sharing data under the leadership of Eastern Washington University.4 The Spokane Regional Heath District has also released a report on health inequities in Spokane County that directly links health and education.5 As a result, Spokane’s business leaders are learning about the important relationship of business, education, and health, and they are taking this message to their spheres of influence, May concluded.
During the discussion, participants considered how to sustain business involvement; the role of health systems; engaging other community partners, including state and local departments of health and education; and the potential negative impacts of business on health.
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4 See http://www.communityindicators.ewu.edu (accessed December 12, 2014).
5 See http://www.srhd.org/links/data.asp (accessed December 12, 2014).
Sustaining Business Engagement
Baase asked panelists what would help to sustain business involvement in health. Rost responded that in Savannah the sole purpose of the business coalition is to contain costs. Rost listed four ways of containing and controlling cost: value-based purchasing, value-based benefits design, improving the quality of care, and improving the health of the community. He noted that employers have control over managing their purchasing and benefits plans. They like to move quickly and to deploy solutions and plans rapidly to manage costs. However, the real sustainable change comes from addressing the core issues of quality and community health. Employers cannot accomplish quality improvement and community health improvement alone, and changes occur over the long term.
May added that it is important to have at least one central, coordinating organization that businesses trust, that is committed for the long term, and that is willing to grow beyond its original mission. GSI, for example, has been engaged in workforce issues and education and is now moving into the link between education and health. Businesses trust that GSI will provide benefit to the business community and that it can provide continuity and sustainability for community initiatives.
Suh said that for IBM, the early college high school initiative is not about donating money (although that is needed), but it is instead about bringing the best expertise to the table to work with educators and make a difference. Suh referred participants to the IBM online “playbook” designed to help partnerships and businesses implement the grades 9-to-14 early college high school model.6
Engaging Health Systems as Businesses in the Community
Baxter pointed out that hospitals tend to be the biggest employers in communities, the largest real estate presence, and one of the biggest purchasers, and he noted that there are tensions between hospitals’ roles as businesses and as consumers of resources that could otherwise be going into economic development, education, or other areas.7 Rost noted that working with hospitals usually involves two separate sets of meetings, one with the chief financial officer and the health resources staff, and
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6 See http://citizenibm.com/wp-content/uploads/STEM-Pathways-Playbook_Feb-2012.pdf (accessed December 12, 2014).
7 For more on this topic, see Financing Population Health Improvement (IOM, 2015b) at http://www.iom.edu/Reports/2014/Financing-Population-Health-Improvement (accessed December 12, 2014), which includes presentations and more extensive discussion of the role of hospitals in communities.
another with the chief financial officer and the chief executive officer. Hospitals often do not look at their own data for their employees, so it is necessary to bring the information to them and “tell them the story.” May said that the hospital systems in Spokane have been willing to come to the table, to consider ideas outside of traditional health care, and to be involved in the community. Health care providers are also facing a skills gap, and they need to hire qualified people. Although the 9-to-14 STEM education model started with information technology, Suh said that other employers are becoming involved, including hospitals and advanced manufacturing in health care. In engaging health systems or hospitals as employers, it is important to remain focused on the best interests of the people in the community and to recognize the interdependence of health systems and the business community, Baase said.
Other Partners
George Isham of HealthPartners inquired about the relationship of the efforts in Savannah and Spokane to the local public health departments. The Savannah Business Group works closely with the health department as a resource for expertise, but not for implementation, Rost said. The health department’s priorities in population health include issues such as sexually transmitted diseases, tuberculosis, and lead poisoning. Diabetes, asthma, and obesity are not in its priorities or its budget at this time. However, the department has valuable expertise to share, such as data analysis or guidance on the preparation of grant applications and presentations. May said that the Spokane Regional Health District was the first health district in the nation to achieve national accreditation. The health department has moved away from a model of one-to-one direct provision of care and toward a model of addressing the upstream determinants of health. It is very involved with the educational efforts in the community and readily shares data and expertise.
Suh said that the early college high school initiative is working closely with the state departments of education to change the American education landscape. For example, it is working to develop articulation agreements between the 9-to-14 high schools and 4-year colleges so that young people can carry their college credits forward and continue their education. David Kindig of the University of Wisconsin raised the issue of how to get the business community to understand that education is directly linked to higher income and improved health. May reiterated the value of telling a compelling story and said that the national recognition of Priority Spokane from the Robert Wood Johnson Foundation has provided an excellent platform for telling that story. The story includes what initiatives are happening, why they are happening, and what the positive outcomes
are for Spokane County and Eastern Washington. She also reiterated the importance of having a trusted local entity, such as GSI, that has established relationships with businesses and can convey information to them.
Rost said that as you go more deeply into community, there are more and more potential partner organizations. Some of the best partners in Savannah have been, for example, the YMCAs, the Boys and Girls Club, and the churches. Go into the community and find the organizations already involved in health-related activities, he suggested. Homeowners associations may be creating community gardens and green spaces, for example.
Negative Impact
George Flores of The California Endowment pointed out that while all of the examples discussed were positive, businesses can also have very negative impacts on population health. There is no systematic way of assessing the net negative impact of businesses on health. Instead, businesses are targeted selectively, he said; for example, the soda companies feel they are being treated unfairly and differently relative to other sugar purveyors. He added that some businesses have a competitive advantage because of business practices that either are unhealthy or pose greater risks to their employees, while others provide unhealthy products to the community (e.g., tobacco). He raised the issue of corporate accountability for population health.
Baase referred to the concept, developed by the Harvard School of Public Health and others, of the “corporate handprint.” Although “corporate footprint” generally refers to the adverse impact that an organization might have on the community (e.g., CO2 emissions), the handprint is the net positive impact. It is important to look at both sides of the equation, she said. May said that the Spokane Community Indicators Initiative tracks data in five different areas, including environment and health, and these data can help characterize the impact a business has on the community, whether negative, positive, or neutral.
The Healthy Savannah Coalition wanted to restrict membership and exclude what they deemed to be unhealthy organizations, Rost said, but the Savannah Business Group insisted that everyone be at the table. There is also an organization in town that works closely with several federal agencies and employers who have negative environmental impacts on the community. These businesses are fully within legal limits, he said, but they can do better. The Community Indicators Coalition has the data to be able to inform businesses about how they are impacting the community before asking what they are willing and able to do to improve. Companies do not want to have a negative impact on the community, he said. We need to work together and make sure their impact is minimal.
