How strong relationships and a focused strategy can influence policy

A decade ago, Cleveland had one of the nation’s highest rates of childhood lead poisoning, despite spending years trying to solve the problem.

And as Cleveland residents watched the Flint, Mich., water crisis explode, hospital executives and other stakeholders in Cleveland were spurred to work together to get local laws passed before their own crisis worsened.

MetroHealth, University Hospitals Rainbow Babies and Children’s Hospital and the City of Cleveland Department of Public Health joined forces with Environmental Health Watch, a not-for-profit that for decades had worked on lead abatement in Cleveland.

By urging the city council to create a rental registry and enforcing fines if property owners violated codes or practices to abate lead hazards, the group was able to put to use its work gathering and standardizing public health data that had been sitting in metal filing cabinets.

“That project was really the catalyst for sweeping change to the way lead is handled at the level of the city government,” said Adam Perzynski, director of the Case Western Reserve University Center for Health Care Research and Policy within MetroHealth. He supported MetroHealth’s contributions to the collaborative.

Across the country, health system officials are dealing with the undeniable fact that the well-being of their patients is mostly influenced by factors far beyond what they had previously been responsible for. As a result, they’re looking to influence policy decisions made by local, county and state governments that can help them effect change beyond the walls of the hospital.

“The question is, do you want to set the table or be on the menu?’ ” said Tracy Carter, system director of government relations for Akron, Ohio-based Summa Health.

Experts said that a sound government relations approach requires dedicated staff at the local, state and federal levels, and additional support from consultants with specialized expertise and close ties to key decisionmakers. But often, hospital executives find themselves at a disadvantage. Lack of investment in relationships and in the right talent within their organizations can leave them vulnerable to others more adept at playing the game.

“Healthcare is trying to fill in the hole. But policymakers are digging it out. That’s why we’re getting nowhere,” said Brian Castrucci, CEO of the not-for-profit de Beaumont Foundation, which works to build community health. “All these bad decisions upstream filter down.”

Industry associations like the American Hospital Association and America’s Health Insurance Plans have an impact on large, national issues because of their size and established relationships. But there are many occasions when a hospital or health system needs to advocate for its interests directly.

For example, Summa Health, a not-for-profit, integrated delivery system with a provider-sponsored plan, often views issues like provider taxes differently from large, for-profit healthcare systems. “You always want to be proactive versus reactive,” Carter said. “When you do that, you have a better chance of preserving your revenue and your ability to provide care to patients.”

Local hospital and system executives from the C-suite to government relations officials should have constant contact with legislators, regulators and other policymakers to protect their organizations against changes in law, regulations, enforcement and spending priorities—or at the very least keep them informed of those changes. And that requires savvy.

“It is so much more than the handshaking and fundraising that you see on TV. It really is people who have deep, substantive expertise and relationships, deploying that over a period of decades,” said Piper Nieters Su, division chair of external relations at Mayo Clinic.

Chris Howard, CEO of San Diego-based Sharp HealthCare, said industry executives must be willing to invest the necessary time and resources, including their own, to ensure they get the most out of their government relations strategy and team.

The long-term effects of partnering with government agencies bore fruit for the systems involved in the Cleveland Healthy Homes Data Collaborative. Their lead poisoning abatement efforts spawned a broader policy coalition that made more than 30 policy recommendations to the Cleveland City Council, educated the community about critical health-related issues and earned significant media coverage. That can lead to public and financial support.

“The hospitals really have skin in the game when it comes to what the communities are working on,” said Emily Yu, executive director of BUILD Health Challenge, a local not-for-profit that helped finance most of the Cleveland collaborative’s efforts.

When the project started, the city Department of Building and Housing was storing its lead inspection reports in filing cabinets, which meant providers and public health officials couldn’t easily access the information to identify problem areas, Perzynski said. MetroHealth provided matching funds to collect, analyze and act on health risk data. In addition to being used by community members and clinicians across Northeast Ohio to identify healthy housing, the data is also being used by partners at Case Western’s Center on Urban Poverty and the Lead Safe Cleveland Coalition to identify and address a wide range of population health issues.

The financial impact of COVID, as providers across the country had to shut down elective procedures, should serve as a warning shot for the importance of holistically addressing patient needs.

“We’re on the doorstep of having 100% of our patients being covered by some sort of value-based care arrangement,” Perzynski said. “Knowing that we’re going to be accountable for their outcomes, we need to be focusing on upstream determinants of their health outcomes because we can’t solve all that stuff that happens in the community.”

Healthcare experts acknowledge that the social determinants of health meaningfully affect patient outcomes, but there are no clinical mechanisms to address them, Castrucci said. For instance, while providers can help address the social needs of an individual through targeted interventions like providing a food insecure person with meals or making groceries available in hospitals, addressing food deserts can be a better solution.

“That’s government’s role,” he said. “The great con was when we convinced the healthcare industry that everything in the social spectrum was their problem,” Castrucci said.

The de Beaumont Foundation and Kaiser Permanente in 2017 teamed up to form CityHealth, which helps cities enact policies that improve well-being such as raising the age to buy tobacco from 18 to 21, designing streets that encourage walking and healthy food procurement.

Elected officials must take more responsibility for the broader social context that largely determines people’s health outcomes, Castrucci said. But they won’t do it without some prodding from the healthcare industry, which is often among the largest employers in their communities. Hospitals and insurers must take a stand, he said.

“They’re not going to be able to sit on the sideline and be uninvolved spectators. That’s not good patient care,” he said. “Healthcare is going to have to roll up its sleeves and get involved in the political scrap.”

Nearly 25% of health systems surveyed reported spending $750,000 to $1.5 million each year on government relations, according to a report by consulting firm Jarrard, Phillips, Cate & Hancock. Another 18% spend between $250,000 and $750,000, while 26% didn’t know how much they spent on lobbying.

But those numbers don’t tell the whole story. The messy nature of government relations can make it hard for organizations to figure out how much they spend on it and even tougher to understand their return on investment. Some hospitals track changes in reimbursement levels, visits with legislators, publicity and other factors. Still it’s hard to pin down how much government relations contributes to the bottom line.

In some cases, the returns are immediate. Atrium Health Chief Medical Officer Dr. James Hunter said the Charlotte, N.C.-based system has worked closely with public officials to bolster the testing, analytics and vaccination efforts during the pandemic. That’s led to closer ties with local, state and federal policymakers, which has given Atrium considerable influence over the pandemic response in its markets and opened the door to other policy discussions.

Government relations professionals can serve as a much-needed resource for legislators and other policymakers starved for information. They often make themselves available to answer legislators’ healthcare questions and ensure that lawmakers view them and their organizations as credible, accessible sources of insight.

Experts recommend that healthcare executives, whether individually or organizationally, take a targeted approach to government relations since their resources are usually limited.

“You really need to build a team that specializes in the skills that are most relevant to areas you’re targeting. And you need to be realistic about how much you can achieve,” Nieters Su said. “There are dozens of issues that can potentially impact your organization. But you really have to focus on the ones that you need to get across the finish line.”


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