7

Reflections on Leadership Investment Priorities

For the last agenda item, Phyllis Meadows of The Kresge Foundation facilitated a small group exercise that allowed participants to reflect on the day’s discussions and apply lessons learned through role-playing as leaders in health care or business investment. To conclude the workshop, Joshua Sharfstein offered his closing comments and called on roundtable members and participants to share their final observations.

LEADERSHIP INVESTMENT: SMALL GROUP ACTIVITY

Workshop participants broke into four groups to consider investment priorities for health and well-being, as well as organizational and leadership challenges, for the fictional city of Ourlandia. The story of Ourlandia was introduced by Meadows, and a set of questions was provided to guide small group conversations. Group participants were invited to consider the scenario and questions from the perspective of a hypothetical hospital board in Ourlandia (i.e., a local health care leader) or the perspective of a pension fund manager (i.e., a business investment leader). A summary of the activity is provided in Box 7-1, with complete exercise materials provided in Appendix F.

Leadership Investment Proposals: Small Group Reports¹

Upon reconvening in plenary session, a rapporteur from each small group shared the outcome of the participants’ discussion and their proposals for hypothetical leadership investments.

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¹ This small group exercise was intended to engage participants in using what they had learned thus far in the workshop. This section of the proceedings summarizes the small group discussions based on the report by each group’s designated rapporteur and should not be construed as reflecting any consensus of the group. All group responses and proposals reported are hypothetical and for only discussion purposes.

Hospital Board Group 1

Malcolm Fox of Culture of Health for Business reported for the first group, which approached the task from the perspective of a hospital board. Per the task, the board is seeking to reposition their nonprofit hospital as a high-value producer of health and well-being for all. Fox noted that there was somewhat of a split among the “board members.” Some wanted to forge ahead with the repositioning initiative, while others believed there was a greater need to address the acute and chronic health issues within the community by focusing on the primary mission of being a provider of health care services. In other words, participants underscored an interest in investments that are attentive to both the short-term immediate health care needs and the longer-term growth initiatives for the hospital’s future in the community.

Given $45 million per year for community health improvement, Fox reported that participants in the hypothetical hospital board decided to dedicate a portion of that funding to address some immediate health-related needs in the community, including infrastructure and housing. To identify the areas of immediate need, “board members” would engage key members of the business community, chamber of commerce, and the local government, Fox said. In addition, participants decided that a much broader community health needs assessment was needed for Ourlandia, and that expert stakeholder committees would be engaged to ensure high levels of community involvement. Another portion of the funding would then be put toward addressing the issues identified, for both immediate needs and long-term strategy investments.

Meg Gilmartin of the National Kidney Foundation added that the hypothetical board was diverse and included hospital staff (nurses, physicians), community members, housing advocates, community advocates, United Way, members of the business community including a local biotechnology firm, and a leading financial institution. She reported that participants identified the need for greater investment by the hospital in training, both for medical staff as well as for new growth (e.g., vocational training). Another suggestion was to invest in making transportation more accessible. Some participants emphasized the need to focus on areas that the hospital, as a health care organization, could uniquely address as a leader, and to also motivate the business community and the broader community to address other fundamental issues that are more outside of the health purview. The sense of hypothetical board members, she said, was that “keeping the status quo was not going to be sufficient.”

In discussing what would be most critical to address, Fox reported that there were strong advocates on the board for housing, transportation, and child care for hospital staff. He noted the need to be transformative and invest for the future while still addressing the immediate needs of the community.

Pension Fund Group 1

Gary Gunderson reported for the first group that addressed the task from the perspective of pension fund managers. He noted that “the fundamental structures of public health and pension funds are radically different,” which made it challenging for this group of public health professionals to role-play as pension fund managers. He said there are fundamental differences between how the $20 billion in assets would be managed from a public health perspective versus the perspective of a pension fund with a fiduciary obligation to retirees. There were also uncertainties in the parameters of the exercise that would impact investment recommendations the group would make. For example, knowing how many of the 200,000 covered members lived in Ourlandia would impact whether significant investments should be made to revitalize the local community where members lived, versus an obligation to members of the fund to maximize the return on investment of the $20 billion in assets. Another challenge noted was the 20-year time horizon of the exercise, which excludes funding some public health interventions known to have high returns on investment for the community over the longer term, such as early childhood education. Gunderson reported that group members also pondered how the pension might be structured in a way that encouraged potential recipients to stay in Ourlandia, or to postpone retirement if they were physically able.

Hospital Board Group 2

Mylynn Tufte, state health officer for North Dakota, summarized the discussions of the second group to consider investing from the perspective of a hospital board. The “board members” discussed the need for a more sustainable business model, she said, and considered the potential for “mergers to increase market share and purchasing power.” Priorities identified by individual participants were “to be more of a team player,” and “multisector accountability, owning the leadership role, and accepting diversity,” she said. The hypothetical board said there had been protests outside during one of their meetings and they recognized that it was “something that we needed to be more accountable for,” Tufte relayed. In considering safety, criminal justice reform, and public health, it was discussed that $1 billion of the endowment would be used to focus on education, workforce, and private-sector recruitment. The group also discussed possibly renaming the city, Tufte added.

Other participants acknowledged it would be challenging for leadership to secure buy-in for spending endowment funds on these priorities and initiatives. Another challenge would be catalyzing a culture shift, including helping to convey “how much short-term pain you are going to

have to endure for this long-term gain,” Tufte said. As one approach to building resilience and hope in the Ourlandia community, the board suggested commissioning a promotional video. Tufte shared as an example a video that was recently disseminated by the Fargo, North Dakota, police department promoting unity.²

Meadows commented that, even though the case scenario for the exercise focused on the negative aspects of Ourlandia and its recent decline, the community still has many admirable assets. She noted that “communities feel the weight of those negative figures and facts,” and rebranding the city, including choosing a new name, can be an effective leadership strategy.

Pension Fund Group 2

Ivana Vaughn of The New York Academy of Medicine reported for the second group that addressed the task from the perspective of pension fund managers. In “doing well by doing good for Ourlandia,” the pension fund managers prioritized developing an approach that would allow for both local investment in the community as well as national and international investments that would generate returns for Ourlandia. The underlying goal the managers sought to achieve was “lifelong economic security for families” through both financially and socially responsible investing. Some participants discussed creating a fund for local investments and seeking guidance from pension managers with environment, social, and governance (ESG) portfolio expertise, and using social impact bonds. Priorities for investment that were discussed included vocational technical education, early childhood education, safety, social and criminal justice, and natural resources protection. The pension fund managers also identified tourism as an important local resource and discussed increasing mass transit as well as hotel and conference space and entertainment venues. The managers would apply a health equity lens to all investments, Vaughn said.

In taking on these investment priorities, the hypothetical pension fund managers would be taking a much more active role in helping to revitalize Ourlandia. They would also be more accountable as community members by, for example, working to decrease waste and increase efficiency through their investment choices in the different sectors. Group participants recognized that transitioning from a traditionally passive role in the community to an active role would require some internal restructuring of the pension fund organization to ensure the short- and

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² The “It’s Time” video shown at the workshop can be viewed at https://www.youtube.com/watch?v=m53bk1Cta6A (accessed June 23, 2021).

long-term sustainability of the investments and to cover the increased administrative expenses. Participants also recognized that there was no guarantee that this new structure and approach to investing would be successful in achieving the desired goals.

Finally, Vaughn said, “fund managers” recognized that institutional leadership might need to address resistance, both internally and from the community and stakeholders, to this restructuring. Some participants noted the need to maintain trust between the leaders and the constituents and emphasized the importance of involving local residents in the conversation.

Discussion

Following the small group reports, Terry Allan expressed his appreciation for the exercise and said it is a plausible scenario that many communities today are facing. The industries in a community will vary, and the path forward will be different, but the need to reimagine their future is common across many communities.

Meadows asked whether the groups considered how their proposed solutions might address the growing inequalities in Ourlandia. Gunderson pointed out that many existing assets were accumulated over decades and under values and rules that are different from those being embraced today (e.g., a focus on equity). As politics and administrations change, it can be challenging to align those existing assets with new values and rules. He suggested that “the challenge is more fundamental than technical” and relates not to deciding where the fund should be invested, but to the fundamental structure, accountability, and rules that constrain the use of those funds. The challenge, he continued, is to influence changes to the rules. In that regard, Meadows observed that some of the groups proposed restructuring to become less passive and more active in the community. She pondered what leadership activities would be needed to make this type of shift in the face of existing governance structures and historical patterns of giving. Some highlights from the small group discussion are provided in Box 7-2.

A participant emphasized the importance of raising awareness of the association between health and the economy. She suggested that developing enduring economic health in a community like Ourlandia is more challenging than addressing social determinants of health such as housing or transportation in that community.

Another participant pointed out that the hypothetical hospital board assembled for the exercise might not represent how board discussions are held in many organizations. For example, a board might not engage the diverse range of community stakeholders in planning and decisions

that the hypothetical boards did. It would be a fundamental shift in governance conversations to change how the agenda is set and how the input from the community is used. It might also shift the decisions made in terms of “how big of a bet do you play versus protecting the long-term assets of the hospital,” she said.

As an example of leadership changing the role of a hospital, Sanne Magnan shared how Lake Region Healthcare chief executive officer Larry Schulz was direct with his board about the need to engage the community and develop a rural health model for the future, underscoring a rural health, not a rural health care, model. She added that Schulz acknowledged that leaders would likely “hear things that we don’t want to hear” from the community, but that a new direction was needed.

Meadows prompted participants to consider the similarities and differences among what the hospital board groups and the pension fund manager groups reported about their discussions. A participant observed that each group initially stayed within their defined roles and were perhaps constrained by those roles. When board members began to think beyond their traditional roles, there was more creativity in addressing the health and economic well-being of the community.

Meadows observed that, even though leaders might understand what is needed conceptually, they might lack the capacity or skills required to effect change. She asked what specific leadership capacities might be needed to reposition these organizations. Gunderson suggested that a leadership capacity that is needed is the willingness to “set our board members free” to contribute beyond the narrow definition of the role of hospital board member. He said many board members hold positions of influence across multiple organizations in different sectors (e.g., health, academia, finance). They should be able to bring all of their experiences and capacities to bear, he said. He observed that allowing bold thinking beyond defined roles is more accepted when there is a crisis to deal with, such as Ourlandia’s plight, than when conditions are positive.

Bobby Milstein added that the exercise demonstrated how there is a strong tendency to operate within the boundaries of one’s role. He observed that the two hospital board groups, faced with the same scenario, each tapped into a different financial resource. One sought to reposition the $45 million community health improvement funding, and the other repurposed $1 billion of the endowment. In many cases a solution depends on how the problem is framed and “the extent to which resources can be used in new ways,” he said. He cautioned against “failure of imagination” and staying confined within established roles.

Meadows closed the discussion of the exercise by posing a question for participants to reflect on in their own work. “What assumptions do we have about the people we want to serve in those communities?” she asked. She suggested that the residents of a community are often not seen as assets because they are “under a dark cloud of economic and health challenges.” She also charged participants to use their leadership roles in their communities to maintain the momentum in addressing these issues.

CLOSING COMMENTS

Sharfstein’s perspective on the undercurrent of the day was “so close, but yet so far.” He called the discussions “eye opening” and said there were many familiar and tangible approaches presented, but there was a clear gap in that these types of investments for health are not yet the norm. The challenge is how to foster more willingness on the part of health care and business investment leaders to invest for health and well-being.

Looking forward to Surgeon General Jerome Adams’s forthcoming Call to Action on Community Health and Economic Prosperity, Sharfstein anticipated that it will summarize the science supporting the association between economic health and numerous public health concerns. The pathway to achieving better economic health, and thereby, improved public health, is not easy, he continued. The discussions identified some

of the “bright spots” in the shift toward new value and investment in health care, but traditional thinking in health care financing persists. For the most part, health care has not moved to value-based payment models. He reflected on the suggestion by Mai Pham to redesign the physician fee schedule, and suggested that it would be very challenging to redistribute payments among the primary care providers and the subspecialists. (See Box 7-3 for a brief overview of tools and platforms for reorienting investment that were shared by several speakers.)

Sharfstein said he particularly appreciated the discussions of the values and priorities of business investors, as he was unfamiliar with that perspective. He noted his interest in the concept of the community development fund, which leverages multiple sources of capital for local

investment. He also expressed an appreciation for both the potential and the obstacles of this approach. For example, he acknowledged the difficulty of placing a value on the fund in a manner that private individuals would be inclined to invest in it. Sharfstein recalled the discussion by Jamie Rantanen of Bank of America regarding how investors are increasingly interested in taking ESG into account when investing. Despite this growing interest, and the many opportunities to invest for impact, he believed that more specific information would be needed to understand which investments would provide the most value and be most meaningful for health and well-being.

With regard to the small group exercise, Sharfstein said it was “daunting” to have to decide where to invest vast sums of money to be successful in promoting population health. He noted the challenges of changing behavior and getting people to think and act fundamentally differently. In closing, he called on the roundtable members to consider what concrete actions the roundtable could take (e.g., publications, engagements) to make sure that the future is not so far away.

Participant Perspectives

Mary Pittman observed that this workshop bridged many of the topics that the roundtable has covered in workshops in recent years, such as education, housing, and rethinking how health care is organized and governed. She said the most significant hurdle to any solution is getting consensus on how to redistribute funding. She suggested that some of the ideas presented should be explored further by the roundtable in a future planning session. She was also interested in hearing from board members of a health system that has reoriented their values and investment priorities to learn how they were able to think and act differently.

Tufte added that it would be helpful to hear from consumers or end users who are the intended beneficiaries of these investments. What was the impact of the fiscal policies implemented and the economic development? She noted that a common phrase on boards in North Dakota is “nothing about us without us,” which she said means there must be full participation of those who will be impacted by the policies.

David Kindig agreed with Sharfstein’s earlier comment that the business investment leader presentation was most interesting to him. It gave him a sense of optimism that, even if health care leadership is slow to change, the new generation of investors from families of wealth seems to be embracing different standards, such as ESG standards investing.

Kaplan reiterated his earlier comment (see Chapter 3) that existing clinical medicine guidelines offer specific actions for providers to take. In many cases, however, these actions can have limited or no effect, he said.

There are no comparable guidelines for clinicians for managing the social determinants of health, and he said there is an opportunity to make specific, evidence-based suggestions for actions that can achieve outcomes.

Marc Gourevitch was encouraged by the concept of ESG investing and the increasing interest in “spending in a socially valuable way.” More discussion is needed on how best to get hospitals and the population health field more engaged in this trend.

Nina Burke from ReThink Health observed that the fields of finance and health care are both necessarily highly risk averse, but innovations continue to emerge from both sectors. She noted the importance of leaders in these sectors taking risks and continuing to innovate. She suggested that the emerging generation of leaders is more willing to take risks, but might not yet have the institutional knowledge to be fully productive. She encouraged those in current leadership roles to continue to innovate, and to also engage the next generation of leaders who are “ready to take this charge forward.”

Marthe Gold lamented that a “commitment to social solidarity” is lacking in the United States at the moment. Still, she said she was encouraged that the impact investing portfolios performed better than the market. This suggests, she said, that people might choose to invest in ESG portfolios, even if only for financial reasons and not for social impact reasons. She also expressed disappointment with how disengaged her own financial advisor was with regard to impact investing, and she suggested that participants have conversations about their interests in this area with their financial advisors. She also said she planned to ask whether her employer was engaged in impact investing.

Catherine Baase reiterated her question about the transparency of decision making by portfolio managers involved in ESG investments. Do companies know when they have been selected for, or excluded from, these portfolios and why? She also observed that investment choices intended to impact health and well-being are being made with little input from those with expertise in what moves population health. She suggested that greater attention needs to be paid to how this selection is made, and that there is an opportunity now for experts in population health to partner with those who manage impact investments to more effectively invest for both health and economic prosperity.

Milstein acknowledged the range of participant comments spanning pessimism to optimism. The origin of the word “wealth” derives from “well-being,” he said, and only in recent centuries has there been a separation between the generation of wealth in the marketplace and the conditions that lead to health and well-being. He said he was optimistic because the workshop discussions showed there are “major market forces that are now linking health and well-being in ways that are different

than they used to be.” There is growing recognition that the disconnect between wealth and well-being “is producing unacceptable risk.” He reiterated the comment by Rantanen (see Chapter 6) that 68 percent of the market value of S&P 500 companies is based on intangible assets. In this new knowledge economy, corporate leaders are recognizing that being on “the wrong side of a social issue” can be very commercially damaging to a company. The question, Milstein said, is the extent to which the health sector will participate in and foster the success of this trend by, for example, informing investment choices or tracking the benefits and consequences of impact investments.