By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“Today we have gathered and see that the cycles of life continue. We have been given the duty to live in balance and harmony with each other and all living things. So now, we bring our minds together as one as we give greetings and thanks to each other as a people.
Now our minds are one.”

– Beginning of the Mohawk Address of Thanks and Greeting to the Natural World.

Much of the health care delivery system in Partnership’s 24-county service area is composed of not-for-profit organizations. Only two of 50 hospitals in our service region are for-profit. Our primary care network is now largely made up of not-for-profit Federally Qualified Health Centers, Tribal Health Centers, and hospital-affiliated Rural Health Centers. Many ambulance providers, hospice and home care agencies, and community-based organizations that we work with are also not-for-profit.

While private physicians, especially specialists, are theoretically for-profit entities, stagnant Medicare and Medi-Cal rates for the last 25-40 years have led those physicians who have not retired or joined a larger group, to not have much profit left. So they are functioning like not-for-profits, staying in business to serve their patients and their community.

Notable exceptions to this trend is ownership of skilled nursing facilities (SNFs) and dialysis centers. Many are privately owned, and a notable number are owned by private equity firms. In the case of small dialysis centers, for-profit entities take over these entities to create a positive cash flow by improving efficiency and leveraging economies of scale. In other cases (SNFs and some specialty groups in our region, hospitals other regions), these firms use their financial strength to gain control of organizations, work to extract value from property/buildings, and then leave town when low quality leads to facility closure, with a net loss of SNF beds in our region. In the Partnership region, private equity owned SNFs have the poorest quality scores.

On June 11, the Corporate Crimes Against Health Care Act bill was introduced in the U.S. Senate. This bill would hold corporate executives personally criminally liable for patient deaths resulting from looting of health resources by private equity firms.

It is hard to know if this punitive approach will have its intended impact on health facility ownership, or behavior of private equity firms. A softer approach in California is to require the state attorney general sign off on any proposed private equity purchase of a health care facility. Any effort in reducing the negative impact of private equity firms on health outcomes is certainly worthwhile.

The not-for-profit sector is not uniform in its focus on improving outcomes for the community. “Not-for-profit” is a tax category, not a reflection of mission or corporate culture. As a result, some corporate not-for-profits are deeply connected to their communities in a way that promotes interdependent and synergistic activities to improve health outcomes. Others may have a mission statement related to health status, but their leadership is more focused on financial returns and growth than on community engagement.

What sets community-based and community-focused organizations apart from other not-for-profits? In her book, Braiding Sweatgrass, Indigenous Wisdom, Scientific Knowledge, and the Teachings of Plants, Robin Wall Kimmerer, a botany/ecology Professor and citizen of the Potawatomi Nation, gives a series of essays on the reciprocity that’s inherent in the cultural frameworks of Tribal communities. People support the Earth/nature, and nature and the Earth supports us.

People living in communities support each other, and the community supports each of us. Community-based health plans support the clinicians, hospitals, county health departments, and other health care providers, and those community-based health centers, specialists, hospitals etc. support the health of the health plan.

When we are in tune with our mutual interdependence, then our relationship is not one of trying to extract concessions in a zero-sum-game frame-of-mind, but that of how we can help each other grow and thrive while the patients we serve also grow and thrive.

In many schools in Tribal communities, each day starts with an address expressing gratitude for our fellow human beings, all living beings, the earth around us and the sun and moon that make life possible on Earth. Although not related to the American Thanksgiving holiday, this address is often referred to as the Thanksgiving Address, and includes the repeated phrase, “Now our minds are one.”

I thank all of you for your commitment to your community and to the interdependent health care delivery system we are all nurturing together.