Guidelines To Enhance Cooperation: Among Rural Providers, Systems & Insurers
- Adopted August 1st, 1997 at the Rural Wisconsin Health Cooperative Forum
- ( An Executive Summary is also available on line. )
- Purpose of the RWHC Forum
- The forum was developed in 1997 by the voting members and affiliates of the Rural Wisconsin Health Cooperative to (1) facilitate communication, (2) foster local and regional cooperation, (3) clarify and resolve conflicting interests where appropriate, (4) explore new opportunities, (5) learn from each other and (6) look for wider synergies.
- Purpose of this Statement
- It is the purpose of this Statement to identify and promote behaviors that encourage cooperation in rural communities, from the perspective of rural providers as well as regional systems and insurers.
- It is understood that regular members and non-voting affiliates of the Rural Wisconsin Health Cooperative (RWHC) and their various insurance partners are free as individual corporations to act as they choose. However, RWHC believes that rural communities are better served when various organizations are able to cooperate around particular services or initiatives. Cooperation "rural to rural" and "rural with urban" is seen as complementary to the broader context of regional systems competing with each other.
- Outline of Statement
- Behaviors by either rural or urban based organizations that are believed to promote rural health are described below with specific examples provided from both local and regional perspectives. They are organized under the following eight general "principles:"
- 1. Respect the Need to Effect One's Own Future
- 2. Involve the Community and Providers in the Planning Process
- 3. Assure All Participants Know They Are Needed
- 4. Share Your Big Picture
- 5: Agree on Methods of Accountability Up Front
- 6: Assure that a Fair System of Arbitration Is Available
- 7: Design an Approach Where Participation Must Makes Sense
- 8. Make Yourself a Partner Who Can Be Trusted
- Principle #1: Respect the Need to Effect One's Own Future
- The preference for autonomy needs to be respected through the promotion of collaborative solutions that enhance the local delivery of health care and the health of the community.
- Behaviors That Promote Rural Health
- · Use a decision-making process that seeks agreement among those directly effected.
- · Frame regional issues in terms of what is the benefit for each participant.
- · Respect the need for participants to reach their own conclusion about what makes the best sense in a particular situation.
- · Discuss how the participants will benefit from cooperation and how the value of that benefit will be shared.
- · Avoiding subjective characterizations, as Sergeant Friday often intoned, "just the facts, mam."
- · Don't take a participants ongoing support for granted.
- · Avoid unilaterally defining a problem or solution other than in the context of a discussion that invites other, additional perspectives.
- · Don't pressure a participant to move forward without the opportunity to make an informed decision.
- Examples from a local perspective ("+" is good; "–" not good):
- + "Plan with local providers and community leaders about what specialty services can be provided locally and which are in the community's interest to be centralized."
- + "Regional insurers participating in the Wisconsin Rural Zones of Collaboration Initiative."
- + "Regional tertiary based systems being a RWHC Affiliate with senior system leadership actively participating in the Cooperative Forum."
- Examples from a regional perspective ("+" is good; "–" not good):
- + Regional tertiary base systems may need to make specialty services decisions that serves their system's need to contain costs.
- - Local providers refuse admitting privileges for regional tertiary based physicians.
- Principle #2: Involve the Community and Providers in the Planning Process
- The planning is interactive, with the plan for the joint enterprise being the result of, and feeding into, the plans of local and regional participants.
- Behaviors That Promote Rural Health
- · Individual leaders need to balance their vision with their responsibility to discover and implement the vision of the key stakeholders.
- · Base united efforts on shared opportunities and threats.
- · Work to facilitate regional system programs consistent with local programs;
- · Allow for the variety of participant circumstances.
- · Allow for the variety of corporate "cultures" in play, ranging from very centralized decision making to very consultative.
- · Consult regularly with each other re ongoing "midcourse" corrections.
- · Don't say "yes" when you mean "no".
- · Don't proceed until you have the critical mass of participants "on-board."
- Examples from a local perspective ("+" is good; "–" not good):
- + "A regional tertiary based system consults with local providers and community leaders before buying land to build a new clinic."
- + "Communicate with local providers about changes in referral protocols while there is still time for feedback and adjustment."
- Examples from a regional perspective ("+" is good; "–" not good):
- + A regional tertiary based system, for proprietary reasons, cannot disclose building projects that would then leak to other competing systems.
- - Not all participants will "be on board" with regional tertiary based systems initiatives until trust is built - decisions will need to proceed in the interim.
- Principle #3: Assure All Participants Know They Are Needed
- All participants must know that they are needed for the success of the joint enterprise.
- Behaviors That Promote Rural Health
- · Respect the unique value that both local and regional players bring to the table.
- · Develop mutually agreed to goals and objectives.
- · Make it clear that the success of the joint enterprise is meaningless without the success of the individual participants.
- · Assure that each participant knows they are a key internal "customer" of the joint enterprise.
- · Recognize and promote the use of the significant pool of knowledge and experience already available among the participants.
- · Never assume you know what an individual participant needs or think.
- · Don't ask for input and then do solely what you want.
- · Never use any one's seniority, position or expert status to try to force a decision.
- · Discourage competition between local and regional programs when no local community benefit can be shown; understand that competition among regional programs may continue in any event.
- Examples from a local perspective ("+" is good; "–" not good):
- + "Timely communication back to rural primary care providers when patients are referred for tertiary care services."
- – "Tertiary care based trauma physicians talk down to local providers and indicate that a regional trauma system would become a reality with or without them."
- – "Urban based HMOs (or systems) extend services into rural markets for the sole purpose of financial gain."
- – "Urban based HMOs sell local employers insurance that negatively affects reimbursement to local providers with no opportunity for communication or input from the local providers."
- Examples from a regional perspective ("+" is good; "–" not good):
- + Urban based HMOs work collectively with local employers and providers to better meet the needs of the community.
- Principle #4: Share Your Big Picture
- Participants need to know where the joint enterprise is headed.
- Behaviors That Promote Rural Health
- · Networking is in large measure information and communication - make sure this is an unequivocal strength.
- · Goals and objectives, once determined, need to be continually communicated - "say it early and say it often."
- · Recognize and without judgment account for the various levels of knowledge among participants - develop efficient communication devices to allow for significant variation in the degree of prior knowledge or experience.
- · Work to get all stake-holders, not just the formal representatives of individual organizations, the opportunity to understand the big picture in a timely fashion.
- · Give individual participants enough information to know when and how to ask for more information - a middle ground between keeping individuals in the dark or hiding the trees in the forest of a million pieces of paper.
- · Don't assume that effected individuals are too busy to be interested in a particular issue; this may often be the case (but let them do the screening).
- Examples from a local perspective ("+" is good; "–" not good):
- – "HMO sells local employers an insurance plan without explaining adequately that enrollees have to go out of town for services (which are available locally).
- Examples from a regional perspective ("+" is good; "–" not good):
- - Competition between regional based systems may preclude some information sharing.
- + Regional urban based HMOs enjoy the same pricing (discounts).
- Principle #5: Agree on Methods of Accountability Up Front
- Participants must always know up front what the rules are and what is expected of them.
- Behaviors That Promote Rural Health
- · Clearly define roles: who is responsible for what, who decides, who develops criteria, who gets to see regional system data.
- · Record in writing all agreements and expectations.
- · Develop and utilize appropriate planning and budget documentation.
- · Don't ever speak for other participants without their prior consent.
- · Don't let familiarity and a collaborative agenda create sloppy business habits when it comes to spelling out an agreement about who is responsible for what.
- Examples from a local perspective ("+" is good; "–" not good):
- + "HMO shares case management criteria and guidelines."
- – "HMO does not share utilization and financial data with local providers regarding the performance of the Plan and the provider's impact on that performance.
- Examples from a regional perspective ("+" is good; "–" not good):
- + Clear documentation support for urban based HMOs will build trust.
- + Local providers work with urban based regional systems and HMOs in supporting medical management guidelines.
- Principle # 6: Assure that a Fair System of Arbitration is Available
- A clear non-threatening arbitration mechanism in case of contractual or other disputes should be agreed to before disputes arise.
- Behaviors That Promote Rural Health
- · Make it easy for participants to express a reservation, concern or complaint.
- · In the case of a dispute that is not being resolved to both parties satisfaction, all participants should discuss openly alternative resolution mechanisms.
- · Determine up-front what arbitration mechanism will be used to insure individual rights against arbitrary group actions.
- · Do not attempt to enforce your "rights" unilaterally or quickly against another participant however clear you believe your case to be.
- Examples from a local perspective ("+" is good; "–" not good):
- + "Using the RWHC Cooperative Forum to discuss appropriate/inappropriate EMS use of helicopters."
- – "The use of arbitrary deadlines to force a contract signature."
- – "HMO changes interpretation of a significant contract terms without prior discussion."
- Examples from a regional perspective ("+" is good; "–" not good):
- + Using the RWHC Cooperative Forum for input, suggestions and guideline development for defining methods of arbitration.
- Principle #7: Design an Approach Where Participation Must Makes Sense
- Organizations may start participating to explore a groups potential; they remain only if they perceive that they are receiving a good return on their investment of time and money.
- Behaviors That Promote Rural Health
- · Recognize that commitment to a cooperative enterprise will vary among participants, over time and across issues.
- · Structure a variety of opportunities for participants to discover and develop the particular set of commitments that makes the most sense for their unique situation.
- · Don't depend on past accomplishments to support future commitment; it must continuously be earned.
- · Don't let the enterprise become impersonal as it grows, commitments are best understood face to face and tend to fail in the abstract.
- Examples from a local perspective ("+" is good; "–" not good):
- – "The attempt to establish a regional trauma system is based on arguments that 'we, the experts, say this is best' rather than grappling with the classical rural dichotomy--we want to be able to fend for ourselves, but are always looking for ways to help our neighbor."
- + As envisioned in the Rural Zones of Collaboration proposal, utilize RWHC's regional credentialing service.
- + As envisioned in the Rural Zones of Collaboration proposal, develop a shared approach for data collection, site visits and other administrative audits required by regulatory/accrediting bodies.
- + As envisioned in the Rural Zones of Collaboration Initiative, create consistent clinical practice guideline review and adoption processes.