Community Decision Making Process: The Funnel

by  Luisa Buada
CIRHM Executive Director

We can compare the community decision making process utilized by the DRIS Community Health Councils as a funnel process with multiple screens where the mesh on the screens becomes more fine as ideas flow through the funnel. At the top of the funnel, all of the managed care options and opportunities available to the rural community enter the screening process. The options and opportunities pass through a series of screening evaluations which represent the process steps that the Councils have implemented with assistance from the DRIS Consultants:

At the bottom of the funnel, only those options which make it through the screens will go before the community for a “Go, No-Go Decision”. The options voted as a “Go” by the Councils will ultimately be implemented through the community owned Administrative Services Organizations (ASOs) and Community Healthcare Organizations (CHOs) and financed with seed money from the James Irvine Foundation. (See the illustration “DRIS Community Decision Making Funnel” below.)

The first two screens, data assessment and core values, mission and vision, are the safest processes for community members and consultants to work through. The criteria mesh on the screens are quite big, allowing for projects that represent diverse constituents to flow through, building trust and community consensus. In the first year of the DRIS process, it was easy to identify health needs of the community and to reach very broad philosophical agreements on such values as local control, community voices, and access to care. However, as we move into the business development mode, it becomes difficult to translate broad values into realistic business decisions. Hard dollar decisions now determine what gets through the feasibility screen. Sharing governance power and decision making raises the question of who is actually at risk financially. Previously, the power of decision making lay entirely with the Council. Now, decision making is shifting to the business entity and those relationships have not been worked out yet.

Questions that have come up as we work through these last two screens of the funnel include:

• Are premium dollars going to be used to create community benefit services such as health promotion and disease prevention in order to meet the 501(c)(3) charitable purposes of the venture?

• Who sits at the governance table? Public Health? Employers? Consumers?

• What powers will the Community Health Council have in the new business venture?

• Should the Council have some reserve powers?

• Should the Council be autonomous from the business venture?

• Are we going to need a financial partner to make this project feasible?

• Can local ownership be meaningful without local management?

Where we have been in DRIS in the past 18 months is trying to extend the sense of safety and concordance achieved in the first two process levels into the structure of the business ventures which are the third and fourth screens of the funnel— the governance structure/business criteria and financial feasibility screens. What happens at this point is that the community in negotiating its business plan or examining the feasibility of implementing a business process, find that there are disagreements in how to interpret the intent of core values. This creates a log jam that throws the process back to the Council to interpret how these core values can be met. For example, given the core value of “choice” the local provider network may be able to obtain a financially beneficial contract with a tertiary provider by referring all of is services to one entity. However, as individual physician groups in the network come together to collaborate, they may each have competing tertiary networks that they are dealing with already. Does the local provider network then honor both relationships in order to offer choice? At what cost/risk to the community owned venture? Who pays the price difference?

Another example is in how to support the health promotion and disease prevention activities of the community-owned entities. These prevention activities may ultimately have an effect on reducing ER visits, rates of communicable disease, rates of unintentional injury or help with chronic disease management. However, community-wide activities do not necessarily target the beneficiaries of a given purchaser of care such as employees of a self-insured employer or a health plan member. Therefore, it is difficult to measure the financial benefit of community wide interventions on the bottom line health care costs of an individual insurer. Yet the potential to attain financial benefit as a purchaser working with a local provider network that provides medical management is improved by the fact that these new ventures will be 501(c)(3) non-profits. The cost of tax-exemption is in ensuring that the charitable purposes of community benefit are indeed implemented. Health promotion and disease prevention activities, as well as outreach to the uninsured, provide avenues for meeting the charitable requirements of the ASO/CHOs.

In order to reach concordance, compromises between public health values in their broadest interpretation and what’s feasible from a business perspective must be reached. To make the process work we have to bridge the gap between values/mission/public health issues and the business plan within the market imperative. Part of the job is for the business and the public health communities to teach each other their values. The Community Health Councils developed in the DRIS communities provide the forum for this educational process and it is one of the important reasons why defining the continuing role for the Council in the locally-owned ventures is an important criteria for implementation. It may not be necessary that the Council or public health related projects be fully integrated into the new business. There may need to be a different definition of integration, possibly where public health/community health and the business of managed care financing and delivery share a circle on parallel tracks. One informs the other and keeps informing the other as the marker of success.

To reach the end point of the funnel, also the end point of the DRIS Initiative process, a “Go, No-Go” Decision is made by the Council and the Governing Body of the business venture. This also marks the beginning of the community owned ASO/CHO. At this stage in the process, sufficient compromises and business agreements will have been met in order to feasibly begin operations using the James Irvine Foundation seed grant for working capital.

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