As published in Frontiers of Health Services Management (Summer 1995).

By Robert M. Sigmond

Summary: In the current tumultuous health care scene, competitive health plans and capitated delivery systems are the driving forces in the health care marketplace. Although these plans may be successful in containing costs, their competitive nature prevents them from providing leadership in comprehensive, coordinated initiatives to benefit the entire community. By contrast, executives and trustees at the frontiers of health services management are reaching beyond the current scene toward a vision of community care networks. They are taking incremental steps to coordinate care of patients, enrolled populations, and communities-both within and among individual organizations in the public, private, and nonprofit sectors. As they bring increasing expertise in coordination to bear on complex problems of long standing, a health care system that actually delivers more for less to all of us is a real possibility. My historical perspective, dating back to the studies of the Committee on the Costs of Medical Care (1928-1932), convinces me that community coordination is the missing element in moving from our current fragmented health system to an ever more effective system. This article suggests that the CCMC was on the right track in recommending that every community have an agency to exercise coordination functions, relying on knowledge and persuasion rather than control. Presented here are details of how to organize and manage such an entity as well as a discussion of the nature of the leadership and the incentives required to overcome obstacles to this essential approach. 

Everyone knowledgeable about health care systems knows that the United States spends a higher proportion of its gross domestic product on its health care system than any other country, and that its health care outcomes do not measure up to those of many other countries. The general public is beginning to realize that this is the case. Nevertheless, every single reform proposal that has surfaced in Congress projects ever greater expenditures.

Despite a strong commitment to the notion of universal entitlement, the public appears to be skeptical of any reform that diverts more and more scarce resources into the health care system. The public suspects-and rightly so-that once the government makes a commitment to universal entitlement that can only be delivered by the fragmented health care system, health care expenditures will rise at an even faster rate than anyone yet has anticipated. As a result, health care reform at the national level is stalemated, and humane access to the nations ample health care resources continues to be beyond the reach of millions of people without adequate insurance or knowledge of how to "work" the system.

What the general public does not yet know is that almost all professional executives in the health care field will admit that, with strong community partnerships and coordination to reduce the fragmentation that characterizes the health care field, this nation can theoretically have better health care for all, and without any increase in expenditures at all. Many health care executives even agree privately that health status could be improved as health care expenditures are reduced substantially. How much longer can the professional managers hide behind the naivete of the health policy professionals and keep this secret from the public?

The fact that it is possible to reduce expenditures through stepped-up coordination and achieve better results must now be shared with the public. But the general public is not likely to get behind the idea until they are convinced that those responsible for governing and managing the elements of a more coordinated health system actually know what to do. In the absence of that level of understanding, it is not surprising that those concerned with containing health care costs concentrate on marketplace forces or government regulation to do the job, with little or no emphasis on the potential of community and professional initiatives.

Isn't it time for professional health managers to provide leadership by speaking up on what they know to be true: that with community control, support, and patience, they can overcome the fragmentation of the health care system and guarantee access to decent health care for everyone at much less cost, without calling time out and without serious disruption? Even though at this time professional health managers do not have much public visibility or credibility, is there another group who could make this point and be taken seriously? After all, the professional managers are the ones who do the work, and what better way for the health management profession to gain the kind of public credibility that any profession should treasure?

Without historical perspective, the notion of communities getting better health care with fewer resources seems too absurd to be taken seriously. Those of us who remember World War II see the situation differently. Half the physicians and half the nurses left our communities along with the healthiest segment of the population, prices and wages were frozen, and capital investment in the health field was limited to temporary wooden construction in war-affected areas.

With severely reduced resources and a less healthy population, what happened to the health system and to community health indices? In every community throughout the land, community leadership met the challenge-hospital trustees, caregivers, executives, business and union leaders, government officials, volunteer organizations, "just plain folks" -- and the health of the communities was maintained, and in most situations it actually improved. Of course, these were simpler times and the health care system was less complex than today; then the threat of madmen trying to take over the world made it easier to stimulate innovative community action. Times are different now, and community coordination and partnerships must also be different. However, the basic benefits of coordination are the same.

Historical perspective demonstrates that health care managers cannot, by themselves, be expected to initiate and carry out the reforms that will lead to a more coordinated and more effective health care system in their communities.

Strong leadership and commitment will be required from many other forces in the community, and beyond. But this type of community leadership is not likely to emerge in the current health scene unless there is evidence that at least some of the managers are ready to respond and to do the right thing. In that sense, the leadership role of professional health care managers is crucial.

If community health care managers are not ready to be out front on this issue, they are well advised to prepare for the inevitable drastic reduction in health care resources that will be imposed one way or another, sooner rather than later, from outside the community. Without preparation, there will be much pain; with preparation, much to gain. I do not think there is too much time left to consider the options. Managed competition will not be able to do the job by itself. Without community control, there will be much suffering as managers are forced to concentrate more and more on staying afloat instead of on solving health problems.

We have learned that reform is quite different from revolution, particularly in developed countries with complex political processes as in the United States. Where as revolutions usually represent a sharp break from the past, successful reform almost always reflects acceleration of trends and developments that have been quietly underway for many years. This is why historical perspective can be extremely valuable in formulating realistic reform proposals and in assessing the value of the myriad proposals that are always circulating during reform eras. Without historical perspective on the nature of the change processes at work in the health care field, almost all efforts to accelerate the pace of change are likely to be demonstrably inefficient, if not total disasters.

In the current period, many who are formulating reform initiatives at the national level know little of the successes and failures of past reform efforts, but bring powerful analytical tools to bear from disciplines largely untapped in earlier reform efforts in this field. These include economic analysis of complex markets, as well as economic, sociological, and political analysis of organizational development ranging from the individual firm to complex international enterprises and entire nations. We are fortunate to be in a position to benefit from the marriage of today's powerful analytical tools to the lessons of yesterday's reform proposals. The recommendations detailed in the following section provide a frame of reference for the reform proposals of today.

Comprehensive approaches to health care reform in the United States can be dated from the publication in 1932 of Medical Care for the American People, the final report of the Committee on Costs of Medical Care (CCMC) (see Weeks and Berman 1985). This amazing document provides both the factual and the conceptual basis for almost every health care reform initiative throughout the nation for the four decades following its publication. Interest in the CCMC reform proposals tended to fade at that time, as interest began to focus on marketplace incentives and other efforts to exploit mercenary energy and discipline in the public interest. Although the notion of major initiatives from investor-owned profit-driven hospitals, hospital systems, health maintenance organizations (HMOs), and health plans was anathema to all of the CCMC members, it can be incorporated into their framework, as will be shown in what follows.

While major health care reform appears to be stalled at the national legislative level, there is much to learn from the 1932 CCMC volume with respect to how to analyze the health care system, how to develop an appropriate framework for formulating reform proposals, and how to involve diverse elements in a process that was able to produce alternative reform recommendations of great power. The 63-year-old recommendations seem at least as relevant as many of the proposals currently under discussion. The five brief CCMC recommendations are shown in Figure 1.

In summary, looking ahead 25 to 30 years, the CCMC recommended that health services should be provided by organized groups of professionals, preferably hospital-related, with the conversion of hospitals to comprehensive community medical centers, networked within regions; that public health services be greatly expanded and clearly defined to include community-focused activity of nongovernmental entities; that costs should be met by group payment managed by the health service networks themselves; that professional education should be greatly strengthened; and that services should be coordinated at the community and state levels.

Each of the CCMC recommendations can be analyzed and updated, reflecting developments since publication. That work is in progress and provides a great deal of insight into how to make reform work. As an introduction to this effort, the remainder of this article will be devoted to only one aspect of one of the CCMC recommendations that has never been fully implemented and is receiving little attention at this time - community coordination for better health and more effective health services.

Broadly speaking, three of the five CCMC recommendations addressed the three basic subcultures or mind-sets of the health care field at that time: (1) a powerful one focusing on caring for patients dependent on providers; (2) a less powerful one focusing oncaring for communities; and (3) an upstart, vigorous one focusing on educating the health care workforce, or at least the emerging professional segment. A fourth recommendation addressed the next key subculture that was being born at the time: the one focusing on group payment.

An effective approach to community coordination in the current period starts with the premise that every element of a communitys health care system is part of one of these four well-defined health care subcultures, each of which makes a significant contribution, but usually with a somewhat self-serving and too limited perspective on health care system development. Coordination within and among these different subcultures is the essential element of an effective health care system that is missing in this nation's health system; it is this deficiency that must be addressed in any effective health care reform initiative. Miscegenation among the cultures is the obvious answer, as one of my advisors has suggested, but reform cannot wait that long! A systematic approach to coordination in every community, as suggested by the CCMC, will also take a long time, but incremental progress is possible. With strong support and community control of increasingly scarce resources and money coordination may accelerate more rapidly than past history.

The CCMC recommendation that agencies be formed in every state and local community to exercise study, evaluation, and coordination functions, with special attention to coordination of rural with urban services, was hardly developed in any detail in the CCMC's massive studies. In fact, the research and evaluation functions are not discussed at all, in contrast to the treatment of coordination. Even with respect to coordination, the CCMC focuses primarily on identifying gaps and duplications in needed facilities and services, with little or no attention to reform and reconfiguration of uncoordinated and duplicative elements within, as well as among, independent entities of the community's fragmented health care system. With a broader perspective on the coordination function at the community level, this recommendation appears to be one of the most important keys to effective health care reform.

The CCMC emphasized that local coordinating agencies, as contrasted with statewide agencies, must rely primarily on education and persuasion rather than authority. In every instance, however, the local coordinating bodies that were subsequently created were given authority to play a key role in the control of scarce capital resources, resources that the coordinating bodies did not generate. Experience demonstrates conclusively that the control function always undermines the coordination function, except within highly structured management organizations. With a broader definition of the coordinating function, it becomes clear that at the community level, this function is best organized completely separate from, but carried out in close conjunction with, those who have the control function.

Within most independent corporations, the coordination function can be linked much more closely with the "command and control" function, but here again a broader concept of the coordinating function is required than simply avoiding duplication and identifying gaps. The key function of the coordinating role is helping to find and develop more productive relationships among separate elements of the system, both internal and external to individual organizations, in achieving unifying goals and missions.

Without active coordination among the various elements of the health system addressed in the other CCMC recommendations, it is unlikely that any reform proposal will work effectively. As the CCMC recommended, this will require an effective agency to exercise the coordination function in every community. Unfortunately, there currently are no outstanding models and little consensus as to how to proceed.

In the 63 years since the CCMC recommendations, the nation has witnessed a series of initiatives designed to establish a coordination function at the community and state levels, starting with the Hill-Burton legislation right after World War II through the legislation establishing health system agencies, over 30 years later. In between, there were the voluntary hospital planning agencies supported by federal funds, comprehensive health planning agencies, the regional medical programs, and a series of similar initiatives that addressed various aspects of coordination on a less comprehensive basis. Today, almost all of these entities are gone, and forgotten amidst discussions of health care reform. It would appear that the many failures all reflected disregard of the basic position of the CCMC with respect to the coordination functionas educational, involving persuasion rather than authority.

Beyond that, the common approach to community coordination usually identified communities as having "needs" that can be expressed in terms of resources to be assigned to one or another of the various independent organizations serving the community. In the most mechanistic marketplace application of this set of concepts, for a time coordinating agencies were involved in awarding certificates of need (CON) to competitive applicants who could then turn around and sell or trade a CON to one of the other organizations, a scenario most commonly seen in professional sports.

As we now know, the fact that people have personal needs does not mechanically translate into the notion that communities have explicit "needs" for any specific resources. The only thing that a community really needs is a responsive, community controlled, coordinated health system closely linked with a coordinated regional network. Expressing community needs in terms of specific resources rather than in terms of mission driven, coordinated systems responsive to "real peoples" problems inevitably fails. That approach implies a dynamic relationship between the community and health service resources, in which the system is always shaped by the resources rather than by the health status, health problems, and health perceptions of the people. Much experience in the intervening years appears to be conclusive that this approach invariably assumes a configuration of services and relationships that is dominated by various decent but dated (almost inevitably out-of-date or too far ahead!) professional standards that, in themselves, are the major obstacle to effective reform.

A more useful approach is to: (1) visualize a reformed community health system bringing the resources together to attack and solve specific health problems of the people in a coordinated approach rather than designed to meet some theoretical concept of needs; and (2) develop mechanisms that will enable the community health system to move toward the coordinated vision on an incremental basis. Every opportunity to improve the health of the people in a community and to conserve community resources, every problem that the health system faces and every weakness in the health system, reflects the fragmentation and lack of coordination In problem solving of the community's health system as a whole, as well as the lack of coordination within almost all of the various component organizations that make up the system.

The problems and the opportunities are much broader than is reflected in the obvious duplication of resources among independent organizations: different hospitals, the health department, the medical school, the voluntary health organizations, community groups, industrial medical programs, insurance organizations, and more. Each of these to some extent deals with many of the same specific problems as other organizations, but with different and frequently conflicting approaches. Equally significant -- maybe more so in most instances, is the lack of coordination of various elements attacking the same problem from different perspectives within the same organization.

An obvious example is the approach of hospitals and medical groups on the one hand, and the approach of insurance organizations on the other, to conserving resources consumed in unnecessary, frequently counterproductive and expensive inpatientcare. Both organizations employ skilled staffs to second-guess or otherwise influence the behavior of physicians and their patients, two skilled staffs who often are required to spend more time trying to influence each other than in any constructive activity. Think of how many ways some of these professionals could be spending their time more productively in improving health care in this country, or overseas in underdeveloped countries, if these fragmented activities in two different organizations could be consolidated. Or better yet, think of how much costs could be reduced as service is improved by eliminating these activities entirely as a result of more effective coordination among the caregivers themselves.

Literally thousands of other less obvious examples can be cited by experts trying to deal with almost any specific health problem in almost any community. Here are just a few.

In most communities, there are at least three uncoordinated approaches to dealing with the problem of immunizing preschool children with the result that few communities have a success rate much higher than 50 percent. The patient care approach concentrates on building the vaccination procedure into routine pediatric care; the focus is on the management of the individual patient's care and the power of the patient-physician relationship. The community care approach, the public health or community benefit approach, is more visible, with a population focus rather than a patient care focus, relying on a variety of community organizations to manage to influence the behavior of the parent population in the community and often creating convenient immunization sites in the community to supplement the services of physicians' offices and clinics.

The care of an entitled population approach also has a population rather than a simple patient care focus, but manages much more specifically to eliminate the obstacles interfering with the immunization of specific children within the entitled population, ideally employing staff charged to ensure immunization of each entitled child, supported by an up-to-date patient information system.

My own experience as a member of the governing body of an outstanding organization that employs all three approaches simultaneously has demonstrated two things: (1) that none of the three approaches alone is likely to get the job done, and (2) without effective coordination, the combined result of the three approaches is little better than can be achieved by any one operating alone. The waste of valuable resources in uncoordinated approaches to the same problem is quite evident.

But this experience led me to a third and possibly even more important conclusion based on my efforts to encourage a coordinated approach to the immunization efforts within this organization, in the absence of strong support from the executive management team. The three approaches to immunization reflect quite distinct approaches to health care generally, really quite distinct subcultures within the health field, that resist collaborative initiatives. Furthermore, this experience demonstrated to me that such resistance to collaboration tends to be stronger within the same organization, as contrasted with the lesser resistances to collaboration among individuals from the same subculture who are employed by independent organizations.

The benefits of a collaborative approach to immunization were quite obvious to everyone, not only in terms of results (the proportion of the children who would be immunized) but also in terms of costs, which could be greatly reduced with a more coordinated approach. Unfortunately, the executive management team had more pressing problems to deal with and valid reasons to believe that overcoming cultural barriers to effective coordination in this instance would be quite difficult and time consuming and possibly even counterproductive. Without strong commitmentfrom the top or staff trained to deal with cultural differences, there was no alternative but to abandon the collaborative approach within this organization.

The example of immunizing preschool children could be duplicated any number of times and in relation to almost any health problem that is found among populations and communities, heart disease, cancer, or stroke-if one defines health problems in classical medical terms. In a more community health-oriented typography, one could identify such health problems as AIDS, violence, alcohol and drug addictions, family decay, poor nutrition, teenage pregnancy, the infirm aged, limited access to care, you name it! With coordination and community partnerships, almost any health problem can be attacked with much more effective results and much fewer resources.

A less obvious and lesser known dramatic example involves the care of AIDS patients. A few years ago, I was involved with a Blue Cross-Blue Shield Plan that was quite concerned with the increasing proportion of its expenditures absorbed by the care of AIDS patients. At that time, it was estimated that the Plan's enrollees included about one third of all of the HIV population in the communities it served. There was concern that the increasing use of services by these enrollees could bankrupt the plan in the years ahead. After some unproductive exploration of a variety of unilateral approaches to limiting benefits and to discouraging enrollment of HIV individuals, the plan developed a coordinated approach to the problem that has become a model for others. This approach has greatly improved the quality of life of the AIDS patients and reduced the cost of serving them by almost 50 percent.

The solution involved employing a staff of well-qualified AIDS counselors who were experts on: (1) the care of AIDS patients, (2) the dynamics of the AIDS community, (3) the dynamics of the health care system, and (4 ) the nature of the unique relationships of an AIDS patient with the health care system. For all cases in which the patient and the patient's physician would take advantage of the services of this team of counselors, the Blue Cross-Blue Shield guaranteed elimination of all benefit restrictions. Whatever would improve the quality of life of the AIDS patient would be paid for. (Imagine the initial reaction of the plan's CFO to this "far-out, crazy" notion!) The plan paid for services that had never been thought of as even closely related to medical care, and the volume of inpatient care and other ineffective, expensive "covered" services declined precipitously. The plan's AIDS staff also became a major force in the community in various activities designed to limit the spread of this plague. Through a three way coordinated approach to patient care, care of the community and care of anentitled population, the problem is being brought under control with substantially fewer dollars and obviously superior results in terms of patient care and health status.

The AIDS example has broad application beyond the AIDS population: At the age of 75, I aspire to live long enough to become a part of the infirm aged population. I am increasingly sensitive to the similarities between the infirm aged population and the AIDS population. The natural body defenses are running down in both groups, we are both becoming less independent and more subject to the ravages of various diseases, and both of us have about the same life expectancy. And among both groups, the medical care system typically responds to our inevitable debilitation in the same way: with massive application of complex procedures that interfere with the quality of our lives, especially during the last six months of life, procedures that do very little good and greatly increase the cost of health care. Early experience with social HMOs and other coordinated approaches to the infirm aged suggest that a similar approach to that described above for AIDS patients would greatly improve the quality of life of the infirm aged and greatly reduce the costs of serving them.

Physicians and other caregivers tend to do for us what they were taught to do, what they are comfortable with in the sub-culture in which they were raised and trained, frequently with little explicit attention to outcomes. This is generally true for all typesof caregivers, whether Native American healers or board-certified specialists. In this period of health care reform, many of the various health care subcultures of the communities are quite foreign to the various health care subcultures that have shaped the behavior and attitudes of most of the care givers and health care managers. In terms of movement toward health care reform, however, the incompatibility among the various health care subcultures may be an even greater handicap than the cultural incompatibilities between consumers and caregivers. In most such situations, as is clearly the case with AIDS and the infirm aged, those caregivers who are empathetic with the consumers are almost as culturally separate from their fellow caregivers as is their patient population.

As previously indicated, in the 1930s there were three quite distinct subcultures in the health field, each with its own goals and objectives, management methods, education, information systems, reward systems, evaluation methodologies, professional associations, financial requirements, each going its own way. These were the subcultures that emphasized caring for patients, caring for communities, and "caring" for education and research. Today, we have a fourth subculture that focuses on caring for enrolled populations.

These distinct subcultures tend to be concentrated in organizational forms that appear to be more committed to each subculture's survival than to an effective health care system for the community. The hospital is still the current center for the patient care subculture, though possibly not for long. The health department is the center for the community care subculture. Obviously, the academic medical center is the center for the education and research subculture. The HMO is the center for the subculture focusing on caring for enrolled populations.

But there is no clear-cut rigid separation. Although there is no "melting pot," elements of all four subcultures can be found in all four types of organizations, typically with less interaction and real communication among the different subcultures within the same organization as there is between elements of the same subculture found in different organizations. As previously noted, often these different subcultures are attacking the same problem from quite independent perspectives and resources, and with little awareness of other approaches from other cultural perspectives, and sometimes even with adversarial relationships to the others and with unbelievable waste of scarce resources. What is required is a mechanism for integrating these efforts of the different subcultures throughout the community's health system, within and across various organizations.

The approach of attempting to develop specialization of function of various organizations, so that patient care organizations only do patient care and community care organizations only do community care, as suggested by some analysts inevitably will lead to sub-optimal results (see Rundall 1994). When dealing with the health of the people in a community, every organization must necessarily continue to have multiple goals and activities, reflecting not only the contribution of their unique perspective, but incorporating contributions from other perspectives most commonly associated with other organizations. As a result, the broad potential of coordination processes in health care reform involves a number of dimensions, especially:

1. Exploring the potential of more effectively merging similar clinical and other processes associated with different subcultures within the same organization to eliminate duplication of effort. Some successful examples can already be found in the coordination of patient care and medical education. Some outstanding community oriented primary care initiatives (COPCs) even represent successful coordination of patient care, medical education, and community care. When these are capitated, the stage is set for comprehensive coordination.

2. Developing seamless approaches to the application of different methodologies as different organizations attack the same health problem or serve the same family.

3. Exploring the relative efficiency and effectiveness of the different methodologies with respect to any specific health problem, so as to be able to allocate resources among the different methodologies most effectively under varying circumstances. In almost all instances, more productive and less costly results will be achieved by coordinated emphasis in all organizations and subcultures on community care initiatives, on prevention and health education, on primary care, and on empowerment of patients and their families as the key health providers.

The methodologies of the distinct subcultures have quite different starting and ending points. Typically, the patient care methodology starts and ends with patients. By contrast, the entitled population methodology goes beyond that to incorporate an explicit population of individuals or individual families. The community methodology goes beyond individual patients and the entitled population to encompass all of the people in the community and their interactions through various community organizations.

The problem is made even more complicated, and the opportunities for incremental improvements even more pervasive, by the existence of inadequately coordinated subcultures within the major categories of each so-called subculture, most obviously with in the patient care subculture. Within the physician category, the lack of effective coordination between specialists and those in primary care is notorious. But so is the lack of coordination between family practitioners and other primary care specialistssuch as internists, pediatricians, and obstetricians, not to mention the immense potential for better care for less money from more effective coordination between physicians and various categories of nurse practitioners, or that between graduate nurses and ancillary personnel. This list goes on and on, down to more effective coordination between professionals and the basic caregivers who can provide the most tender loving care at no cost whatsoever to the health care system, and with no apparent conflicts of interest, that is, the patient and the patient's family.

In almost all situations, the greatest potential for improving coordination among independent organizations is to be found among those professionals from one of the subcultures who are employed by organizations identified primarily with some other subculture. They are the key links. Every organization that I have encounteredemploys them. Very few organizations recognize and exploit their unique potential. As organizations become more involved in developing seamless approaches not only to patients but also to care of enrolled populations and communities, these individuals tend to achieve recognition and leadership roles. Almost always, they are involved in informal collaborative activities with counterparts in other organizations that provide the best pathways to more formal networking arrangements among the organizations involved.

Modern computer technology can contribute to a more effective coordinated community health system in two important ways. First, with modern computer technology and the vast amount of information available, it is theoretically a fairly simple task to design a reformed health care system for any community or region in which theoretically all obstacles to effective coordination among and within the various cultures and subcultures have been overcome. In this imaginary reformed health system, the various cultures and subcultures function harmoniously, solving health care problems while conserving resources that could be used in other aspects of the public welfare. With only a modest degree of imagination, it is not difficult to design a theoretical health care system that will provide dramatic improvements in health status of the people, and with sharply reduced expenditures by the health system, even lower than is found in most other countries with advanced civilizations. Such fantasy models will never be achieved, but they help to focus on concrete steps that can be initiated to address some of the obstacles. Second, as modern computer technology becomes ever more user-friendly and available within the community and incorporates more useful health information, the consumer and the family can become ever more self-reliant as their own health providers, requiring less and less time from the professional caregivers on whom they must rely for supervision and guidance.

But moving to some detailed, artificial utopian health system is not the immediate answer. Rather, what is required is commitment to a much less detailed but inspiring vision of a coordinated system that can take shape through incremental advances in coordination, evolving into a less fragmented system dedicated to the public good.

In most communities, a move in that direction will require the creation of a strongly supported, specific entity with a long-term goal of promoting community coordination by breaking down cultural barriers within the health system, as well as the barriers between the health system and the rest of the community served. This is the key missing element in community health systems in this country.

As recommended by the CCMC, agencies should be formed in every community to organize and manage the coordination function. Coordination is a basic requirement for improved community health status and for narrowing the gaps between the health status of the more and less privileged segments of the community, as well as for conservation of resources absorbed by the community's health system. Although achieving more effective coordination is a never-ending process that must be carried out by dedicated individuals associated with the various organizations within the existing health system themselves, the pace of change for real reform calls for establishment of a unique, strongly backed, highly credible entity designed specifically to facilitate the process.

In short, any community that can achieve massive coordination within its health system and this cannot be achieved overnight, can become among the healthiest in the world and spend much less money on health care service. No lesser vision islikely to ensure real health care reform or a successful venture in coordination.

Unfortunately, there is no example of an agency for coordination, as was recommended by the CCMC, in any community, although many community-based organizations do promote and encourage coordination in limited contexts. Now is the time to explore the potential functions, organization, accountability, and financing of such an entity.

The functions of a successful community coordinating entity will provide the community with the necessary missing elements to accelerate coordinated programs. These functions should include at least the following: articulating a vision of a more effective health system, maintaining credible information systems, developing an authoritative analytical capability, providing shared staffing and technical assistance, publicizing successful initiatives, developing standards, conducting evaluation and research, and serving as a model of community commitment:

A vision of a healthier community, healthier people, and more coordinated and effective health services for less money can become a powerful force for reform as it is embraced by ever broader elements of the community and of the health system itself. Those who help to get the coordinating entity started should be fully committed to such a vision before the agency begins to function. This means not only commitment as potential board members of the new entity, but also in their ongoing capacity in the community's health system. Given the current level of cynicism about community initiatives in health care, however, a great deal of effort will be required before the idea of an ever more coordinated health system becomes an essential element of community life and a driving force for reform within the community's various organizations. In addition to articulating the vision at every opportunity, the coordinating entity should be in a position to assist any element of the community to formulate its own unique role in helping to turn the vision into reality.

Without continuous support and reinforcement from the coordinating entity, the vision of a reformed health care system throughout the community will tend to be too short term and excessively self-centered to be as useful as possible. For many elements of the community's health care system, which are necessarily focused sharply on getting things done right now, adapting current planning and programming to a far-off vision of the future will be very difficult, frequently reflecting more than one false start that may be expected rather than condemned as proof of untrustworthiness. A wide variety of community transactions should be linked with community goals as soon as possible to accelerate acceptance of the reality of the shared vision of the future.

Community coordination will proceed most rapidly when based on publicly available, highly credible information about the characteristics and dynamics of the communitys fragmented health system. An information system should be designed to provide useful information about opportunities for community coordination, including data permitting the establishment of quantifiable goals for coordination initiatives and measurable results of these initiatives over time in a continuous quality improvement process.

The coordination entity should avoid becoming directly responsible for the collection and processing of new sources of data since almost all the data required should be available within the community's existing health care system. Relying primarily on secondary sources and special sampling studies, the entity should become the recognized and easily accessible source for authoritative information that relates to the potential for improved coordination for better health and more effective health services and for tracking results.

Closely linked with the information system, the coordinating entity should develop the most authoritative analytical capability in the community with respect to the facts relating to coordination opportunities and results. The reputation for objectivity should be guarded scrupulously, especially in the early stages, leaning toward excessively cautious interpretations of trends and results.

Health care organizations have a long history of using shared services, group purchasing, shared collection systems, shared information systems, not to mention a variety of shared clinical services. Shared staffing with respect to external community issues facing the boards of directors and boards of trustees of independent organizations making up the community health system would appear to be a practical and useful extension of this practice. This approach should result in more effective staffing at lower costs, and with less likelihood of obstacles to coordination as a result of conflicting staff work on the same topic by different staffs.

Currently, staffing for the governing board's responsibilities in relation to external affairs is provided by some combination of the work of the executive management team in its spare time and of outside consultants. The first approach has all of the difficulties associated with staff work carried out by individuals not explicitly trained for the work and who lack the appearance of objectivity required for assembling the necessary issue papers relating to the external environment. The common alternative of supplementing the work of the management staff with the use of outside consultants generally costs much more, especially if the consultants take the necessary time to become thoroughly acquainted with the existing community health system and adapt their analysis and recommendations to the unique community environment.

Many CEOs of large organizations have employees reporting to them who are dedicated to staffing the board and its committees, but these employees are involved almost exclusively in arranging meetings, generating and distributing minutes, and performing other housekeeping tasks, as contrasted with staff work on substantive issues to be considered by the board.

Contracting with a community coordinating agency provides a number of advantages to the CEO over the use of outside consultants: (1 ) availability of a permanent, objective staff who have explicit expertise in coordination processes, know the unique characteristics of the community and the community leadership, established credibility, and are trained to avoid involvement in the decision-making processes of the board and executive management team and the caregivers; (2 ) access to continually up-to-date information about the communitys health system and ongoing coordination activities and; (3 ) lower costs than outside consultants. This approach to staffing the board's involvement in external affairs has the added advantage of giving the appearance of a deep commitment to community coordination as contrasted with narrow self-interest. Of course, outside consultants can also be used to advantage whenever that approach is indicated.

The shared staffing approach requires the most sensitive interaction between the shared staff and the staff of the community organization being served. The shared staff must demonstrate an ability to handle confidential information, to respect the governing Board / executive management team relationships, to avoid involvement in internal affairs and current operations unrelated to the explicit assignment, and to resist the tendency of some governing boards to expect the staff to make their decisions for them.

Beyond staffing help with respect to governance issues, technical assistance staffing can be provided to any community organization in any aspect of its efforts to promote greater coordination within the organization, as well as outside of it. In almost any community of any size at any point in time, any number of consultants are engaged in the kinds of assignments that the executive staff does not have the time or background to carry out by itself, which indicates there is a demand for the service.

Not infrequently, a common decision will be made to explore community-wide, broadly sponsored opportunities for greater coordination with respect to some particular health problem or opportunity. This might include community approaches to trauma, long-term care, managing capitation, or almost anything else. Here again, the coordination entity is in a position to provide objective, well-informed, credible staffing for such initiatives.

In a period of health care reform based on a vision of a comprehensive coordinated system, reliance on control of specialized resources and of independent organizations becomes an ever less reliable method of maintaining influence and power. This approach to power will lose its effectiveness, as contrasted with (1) the power of commitment to a vision of a more effective, coordinated community health system, (2) the reputation of basing organizational decisions on objective analysis and on community-wide goals and objectives, and (3) demonstrated respect for the prerogatives of others. The transition from "command andcontrol" to "coordinated decision-making" will be very difficult for the governing board and management leadership of many strong individual organizations in the communitys health care system. In that respect, the, coordination entity should work very hard to serveas a model in its own activities, demonstrating through its increasing strength that power is shifting away from the "control freaks" to those relying on a broader perspective. Avoidance by the coordination entity of even the appearance of a command-and-control approach is essential. The coordination entity must avoid all efforts of others to pass on any decisions within the community's health system, especially with respect to capital investment, allocation of scarce resources, and downsizing. As the coordinating entity becomes increasingly effective, the pressures to make decisions for others will be very strong, but it must be resisted.

Early successes in coordination efforts are the best stimulus for expanding the commitment throughout the community to the development of a more effective coordinated health care system. The coordinating entity should devote significant resources to searching out and publicizing successful efforts, whether or notthe coordinating entity has been directly involved.

One of the strongest motives of the leadership of any health care organization is to be recognized as conforming with the highest standards. Most will do almost anything to avoid being identified as second-rate organizations. This is demonstrated, for example, in the resources and energy devoted by most hospitals and other organizations to meet the standards of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), despite growing dissatisfaction with that organization. Most hospital executives who tend to view community collaboration as virtually impossible all conform with the single community collaboration element of the JCAHO. The fact is that a JCAHO-accredited hospital can turn its back on its community and function exclusively as a competitive body repair shop and meet all of the highest standards, with one exception: The hospital must have a community disaster plan that goes beyond body repair work on the victims brought to the hospital. This point was brought home to me some years ago when I was working on promoting greater collaboration between the only two hospitals in Sioux City, Iowa, and was told that collaboration among these two hospitals was an impossibility. Just then, an airliner crashed at the airport and the communitys disaster plan went into effect and functioned superbly, in conformance with the joint planning outlined in the hospitals response to the JCAHO requirement. Collaboration worked with hardly any competition whatsoever (except for some competition for national TV exposure). This superb collaborative exercise touched almost every aspect of both hospitals and lasted for over a week before "normal" competitive marketplace relationships took over again.

Because of the power of voluntary standards, there are standards for almost every aspect of health services systems and many incentives tend to be built around these standards. Nevertheless, it appears to be clear that the drive to conform with voluntary standards is an important force in itself. With or without accompanying incentives, the notion of standards of community partnership would appear to have great potential in structuring and accelerating community coordination reform initiatives within and among the community's health system organizations. Unless or until national standards are effectively administered by some national accrediting body, the coordination entity can take the lead in assisting community organizations to develop and test such standards. In any event, the entity should provide extensive community recognition to those organizations committed to partnership standards.

The coordination entity provides a logical focus in the community for receiving and distributing funds for research and evaluation that may be expected to be increasingly available in the period just ahead as national interest in the nature of effective community coordination processes can be expected to grow.

A whole series of questions come to mind with respect to a community entity committed to promoting a more coordinated community health system-location, funding, governance and staffing and more.

Where should a community coordination entity be located? Should it be totally independent? Or should it be a subsidiary or element of some existing organization? If so, which one? Or should it exist only in the minds and hearts of all of us? There is probably no one right answer for every community at this time. Each alternative hasits advantages and disadvantages.

(1) Independent organization. The advantages and disadvantages of creating a new

organization are well known. The major disadvantage is tied to the necessity for greater initial financial support and the time and risks involved in the birth of a completely new organization. The major advantages relate to credibility and visibility and degree of independence. In most complex communities, an independent organization would appear to be the only acceptable alternative.

(2) Existing organization. Very few organizations within the communitys health system would be able to overcome concerns about self-service and bias. Conceivably, some communities might consider the public health department, although the perceptions of the limitations of a government agency by key elements of the health system would be difficult to overcome at this time. Less controversy would be involved in selecting the United Fund or the Community Foundation or the Council of Social Agencies or a community college. The business health coalition, the Economy League, the hospital or health council, the Academy of Medicine all would have to overcome perceptions of narrow self-interest. Depending on the history and leadership, however, in some communities any one of these might be feasible.

Another alternative is to establish the entity within an obviously neutral community organization, such as the public library. It is well to keep in mind that the most powerful entities these days in the congressional debates on health care reform are such entities as the Congressional Budget Office, which has no authority at all. Power rests on its commitment to objectivity and reliance on credible analytical capability. (3) Community cure network. In communities served by only one community care network that is clearly committed to designated communities and governed accordingly, the coordination entity could most logically exist within the network framework. That would appear to be the most logical approach, and would help to ensure that the network was truly committed to the community.

(4) Virtual reality. Since the key actors and actions with respect to community coordination are within the various existing organizations that make up the communitys health care system, there are real advantages to having the entity exist only within the minds of those associated with these organizations. In the earliest and latest stages of the evolution of a reformed, thoroughly coordinated community health system, the newest technology associated with "virtual reality" may be the best approach. Those who have been exposed to virtual reality technology, in improving their golf game for example, tell me that there is no more powerful approach to influencing and changing behavior. "

As the entity develops increasing credibility, most of its activities can be funded from fees for services and project grants from a variety of sources. Initially, however, significant funds will be required for start-up costs and for an endowment fund to ensure stability and continuity. Provision of such funds by community-based foundations, corporate foundations and other sources of philanthropy can also be supplemented by contributions from various elements of the community health system itself. Start up without adequate funding for the first five years would in almost all cases be premature. As annual health care expenditures per capita in this country approach $4,000, health expenditures associated with a population of 25,000 amounts to $100 million. For a population of 250,000, expenditures are approaching $1 billion. An investment by the community of just one-quarter of 1 percent of this amount in a community coordination entity should provide a budget with potential for real pay-off.

Ideally, the chair of the governing body of the coordinating entity and the CEO should not be associated with any specific element of the community health system. Beyond those two, there may be as many advantages as disadvantages to drawing on individuals associated with the health system. Particularly with respect to start-up staffing beyond the CEO, there are major advantages to drawing carefully on the existing organizations for full-time staff, temporary or part-time project staff contracted with individual organizations, and volunteers contributed by these organizations.

The word "leader" has two general connotations: being ahead of or in front of others and having strong influence on others. The first obviously does not apply here. Being ahead of everyone else in coordination is a contradiction in terms. Leadership in community coordination refers to the second notion, exercising influence on others. That means that all of us, except those who have no potential influence on anyone at all, have some potential for leadership in community coordination. We can exercise this influence within our immediate spheres of influence (family, work unit, neighborhood, church, union local, professional association, etc.) and also, with lesser impact and greater importance to community coordination, in related spheres of influence where we may not be so dominant (the organization in which we are employed, the school district, the local government, the health plan, etc.). In immediate spheres of influence, our leadership may depend as much or more on the power or authority associated with our

Designated role as on the power of the position that we are urging on others by example or by persuasion. In related spheres of influence, the power of persuasion will be more important.

Any of us who have a vision of a reformed health care system based on greater coordination of fragmented elements have myriad individual leadership opportunities to help others to share this vision and to explore specific collaborative initiatives within their spheres of influence that will move the health care system in more harmonious patterns and confirm the validity of collaborative approaches. Equally important and often forgotten is our followership potential. Frequently, providing leadership in one's own sphere must be closely linked to committed followership with respect to the broader spheres that we may touch. With respect to organizational leadership there is much tobe said, but nothing that is not said superbly in the leadership positions of the American Hospital Association (1990, 1994) that were developed initially in 1982 and subsequently updated. The leadership responsibilities of health care organizations are spelled out in detail, as well as the explicit leadership responsibilities of the governing boards, executive management teams, and caregivers. These responsibilities are outlined and emphasize interrelated responsibilities to promote coordination both within the organization and in its external relationships. Internally, the leadership initiative rests primarily on the executive management team. Externally, the leadership rests primarily on the governing body.

There are many obstacles to be overcome by any community moving toward a less fragmented and more coordinated health system. Of major importance are the obstacles presented by forces outside the community. Of these, the most important are: the threat of antitrust litigation and the fragmented approach of the national accreditation, licensing, and standard-setting authorities, as well as the payment practices of the governmental and non-governmental financing organizations.

Approaches to overcoming these obstacles can and should be incorporated into reform legislation that can not only remove these obstacles but also provide additional incentives for accelerated community coordination. Pending the enactment of such legislation, there are many ways that communities can increase coordination without risking antitrust litigation and by pooling of fragmented health care revenue through capitation and other techniques. With respect to avoiding antitrust litigation, the most obvious approach involves assigning a major coordinative role to the local governmental authorities. Beyond that, comprehensive community involvement is the key. The record should be clear that the only non-participants are those who "exclude themselves."

The other obstacles to moving ahead with coordination initiatives primarily reflect various mind-sets within the community that interfere with moving ahead: ignorance of the risks of inaction and of the potential rewards of a coordinated community effort, skepticism about results, false expectations about what can be achieved quickly, and finally, the insecurity or greed of entrenched interests. All of these obstacles must and can be overcome through fairly well-known processes of community organization and mobilization that involve all elements of the community. It is not easy, but it is not impossible either. With respect to greed, for example, any community or community organization can accept this very human trait and even exploit it in the community interest through tough business contracts, but it should resist policy formulations based on greed as the dominant force.

The health care system is an extremely complex set of elements, none of which can function effectively in isolation, even in pursuing relatively simple self-serving goals. All elements are dependent on a series of explicit or implicit contracts or transactions with other elements, some of which are expressed in terms of money transactions while other are expressed in other measures; some of these can be translated into money terms by economists only with great difficulty and some loss of reality. These contracts and transactions are the essential elements that hold the health, care system together.

In terms of incentives, the key to improved coordination in the community interest is to build community benefit into more and more of these contracts and transactions, increasingly entered into by organizations and individuals who accept the community as a whole, as one of their equal partners. Community considerations can be incorporated in terms of money or other kinds of trade-offs, and they can be built in through positive or negative incentives.

As is well known, money talks and is the key measurable factor in positive and negative incentives in contracts and transactions. Opportunities to receive more money or spend less represent the most common positive money incentives. Conversely, the threat of receiving less money or having to spend more of it represent negative incentives. Although such money incentives are very powerful, they are even stronger when linked to other important human, institutional or organizational imperatives, such as freedomof action and self-determination, pride in one's work, public recognition, but especially community benefit-all of which can be built into contracts and transactions in either positive or negative terms.

Opportunities to build community coordination incentives into health care transactions and contracts are almost limitless at this time. One of the best known and most effective examples is the commitment to community rating for health insurance premiums by the industrial and health care leadership in Rochester, New York. Eastman Kodak and other major corporations have contracted for health care services for their employees and dependents on the basis of the average community rate, which is significantly higher than what they could readily negotiate with insurance companies by making full use of their power in the marketplace. In return, the hospitals have agreed to work together with industry leadership on a community-wide approach to providing cost-effective care. As a result, although the corporations continue to pay at higher rates than they could easily bargain for, their rates in Rochester are significantly lower than they have to pay in other communities where they have major plants but where there is not the same community commitment by either the corporations or the hospitals. By making the community interest a major partner in the contracts, all parties have benefited. The same approach can be built into any transaction into which various elements in the health care system enter, including contracts and other transactions with investor-owned corporations. In every case, the parties can raise the question as to how this transaction and contract can include a factor to benefit the community as well as the parties involved.

To my knowledge, no investor-owned corporation has ever indicated a willingness to put community benefit goals above its basic obligation to the stockholders, but all are interested in any arrangement that has promise of benefiting both. In fact, the healthcare field has a long history of financial transactions with investor-owned corporations serving both stockholders and community benefit organizations, corporations with no interest in taking responsibility for overall community health care policy and accountability. Examples that come to mind are: food service, housekeeping, and laundry corporations; hospital management firms; insurance companies and HMOs; hospital supply firms; emergency services; radiology services; and many, many more. Privatizing specific functions is in the best traditions of the American health system whenever it can do a better job; privatizing or doing away with community governance and accountability is not.

This article developed from an observation about the lack of historical perspective in the debates about health care reform during the past few years. For many of the active participants in the current debates, the fact that almost all of the current ideas, and then some have been discusses in detail for at least 60 years may come as a surprise. Looking back at just one specific reform proposal -- community coordination --that has been neglected for many years, I have attempted to provide a fresh perspective on how this particular reform initiative can be adapted to the current environment, with significant potential benefit. Irrespective of the merits of this particular effort, I hope that it might stimulate others to reexamine the recommendations of the Committee on the Costs of Medical Care and of other significant reform proposals that have been reformulated by a variety of national commissions and other groups in the health care field during this century. Beyond that, I hope the article might lead to a national conference or symposium devoted to analyses of historic recommendations for health care reform.

I wish to thank each of the following individuals for their helpful comments and criticisms of early drafts of this article: William Aaronson, Deborah Bohr, Tom Bite, Bob Blendon,

Doug Conrad, William H. Duncan, Wayne Lerner, Rebecca McDermott, Bruce McPherson, Steve Shortell, Steve Sieverts, Marc Voyvodich, David P. Willis, and Howard Zuckerman. Needless to say, I am fully responsible for the inadequacies of the final version.

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In exploring the concepts involved in a systematic approach to community coordination and partnerships as key elements of health care reform, precise meanings are under development for some of the terms that are commonly used. The definitions of these terms are still being worked on, but the following notes may be helpful:

A Community Partner is any organization with multiple goals, in which the commitment to the health care of designated communities is at least equal to any other organizational commitments, such as to patients, to education and research, to physicians and other providers. Thus, the hospital trustee who always interrupts any decision-making process to ask, How is this good for the community? represents the very essence of appropriate governance of a community partner.

Coordination represents systematic linkage of elements within an organization or linkage of elements between and among different organizations to achieve shared goals of the elements.

Community Coordination represents systematic linkages of elements to achieve explicit shared community goals.

Networks and Networking refer to coordination between and among entire organizations, as contrasted with such interaction only between elements of organizations.

Community Care Networks refer to networks in which the network commitment to designated communities is at least as great as the network commitment to other goals.

Collaboration represents cooperative relationships among elements of independent organizations of a more informal nature, often not directly related to the overall mission, goals, or strategic plans of one or both of the organizations involved. Thus, physicians with medical staff appointments at two or more hospitals represent important collaborative linkages, whereas agreements among different hospitals with the same physicians as to their respective roles and interactions represent an important example of coordination. Collaborative activities such as referral relationships among physicians and other professionals, frequently unknown to the leadership of health care organizations, are pervasive in most communities and are the most important linkages that hold a community's health care system together.

Community, as used in this article, is especially important since it has so many different meanings in various contexts. The precise definition used here is that developed by the Hospital Community Benefit Program at New York University: "All persons and organizations within a reasonably circumscribed geographic area, in which there is a sense of interdependence and belonging." This definition emphasizes that there is no community without some forms of organization. A group of people is not a community for these purposes, no matter how much they have in common, unless there are some forms of organization. For our purposes, communities are necessarily defined geographically and may be large or small; however, the sense of inter-dependence and belonging tends to grow weaker to the point of diminishing returns as larger and larger geographic areas are considered as communities.

A community is to be sharply distinguished from a service area or a market from which patients are drawn, since these geographic areas should generally be much larger than any community that any health care organization can benefit to any measurable degree. As used here, the term "community" emphasizes the diversity of the elements that have a sense of dependence and belonging, especially reflected in the concern for the more disadvantaged individuals and organizations. Thus, the notion of the "physician" community or the "Hispanic" community is quite a different use of the term. The important concepts reflected in those uses of the term "community" are expressed otherwise in this article, since they reflect an important sense of special interdependence and belonging that is usually stronger and more self-serving than with respect to the entire geographic community. For our purposes, these are best identified as interest groups rather than communities.

Community Service of a health care organization is any activity that relates to the organizations community goals as contrasted with other goals. Most health care organizations are involved in much more community service through collaborative activities than the CEO (and especially the CEO) know about!

Community Benefit is community service with an outcome orientation and is a new growing development, though still relatively rare. Community benefit is often identified as community service that supports tax exemption. This seems backward; in this article, tax exemption is viewed as an important support for community benefit.

Community Health Care System is a concept encompassing all the elements that relate to the community's health and their inter-relationships. Some observers believe that most communities have a "nonsystem," but as Les Breslow (1994) has pointed out, "Just try to change something and you will know that there is a very strong system in your community!" Thus, our use of the term "community health system" is very much like geologists use of the term "mountain system." In both cases, there is no necessary implication with respect to purpose; only God knows the purpose of a mountain system. In both cases, extremely useful insights result from systematic analysis that is not judgmental with respect to the purpose of the system or of its elements.

Culture as used in this article is almost synonymous with the term "mind-set," or more specifically as culture is defined by many sociologists: "The sum total of ways of living built up by a group of human beings and transmitted from one generation to another."

ROBERT M. SIGMOND is Scholar-in-Residence, Temple University,

Philadelphia, Pennsylvania.