Please tell us what you think. We hope you find it informative and useful. - association executive Community building is complicated by multiple definitions, competing languages and models, and an environment where individual and social identity is fluid and changing. In the words of the late author, David Foster Wallace, "Often the most obvious, ubiquitous and important realities are the hardest to see and talk about." But talk we will. Join us on the morning of December 5 for What is Community? Voices and Choices for Sustainability, where the topic is how to build thriving, healthy and sustainable communities in the face of jarring impermanence and change. Dr. Gail Christopher, Vice President for Health with the Kellogg Foundation, will be joining us, plus we plan hands-on, breakout sessions such as a "mini-charrette" to engage all of you directly in the conversation. This is an event with high ROA - Return on Attention. Sign up today. Health Insurance for Arizona Adults, the first of several planned reports based on the AHS, is now available on our website. Future reports are planned in such areas as children’s health, social and environmental determinants of health, and others. With a sample of 4,200 households and approximately 300 possible items, it’s possible to dig deep at the community level and investigate all sorts of relationships between demographics, health conditions, health behaviors, mental health and well-being, health insurance, access to care and social determinants of health. If you are interested in using the AHS to inform your own work, please contact Jill Rissi at SLHI. Nursing programs are expensive to operate compared to fielding English and History majors, so if simply cutting expenses is your goal, this has a certain logic to it. But no matter how you try to dress it up, it’s a slash and burn approach, and illustrates why we need to find alternatives to a fragmented (institution-specific) and uncoordinated approach to workforce planning in this state. Some investments pay big dividends in the future, and education is one of them. We talked about some of this in our 2007 policy primer, Better, Quicker, Cheaper: Educating Nurses and Allied Health Workers in Arizona. Now yet another study has documented that it's the insured - the "regular people" - who represent the majority of emergency room users, not the uninsured. ED overcrowding is the result of a confluence of factors: understaffed inpatient hospital wards, ED closures, a growing shortage of inpatient beds, a growing elderly population with chronic illnesses, and a "Circle K," 24/7 mentality among consumers who expect to walk in and get treated when and where they want. We documented all this over four years ago in Fact and Fiction: Emergency Department Use and the Health Safety Net in Maricopa County. Some myths reinforce popular stereotypes and take a long time to die. 
Dionysius:
"Why do I always see you philosophers knocking on the doors of the rich, but I never see the rich knocking on the doors of philosophers?"
Aristippus:
"Because philosophers know what they need, and the rich don't."
What one early reviewer called "one of the most engaging and comprehensive reports on community building I have ever read" is now up on the SLHI website and in the mail. Weave the People: Threading Healthy Communities is based on interviews with 50 Arizonans about their work in fostering healthy, resilient communities. It's the next iteration of our Resilience: Health in a New Key report in 2005 that laid out the basic principles and strategies of strength-based community building.
"How do we stay connected to a place when we are always defining ourselves by these other communities?"
We had a good turnout and high energy at the Arizona
Biltmore on November 12 for the unveiling of the Arizona
Health Survey (AHS), one of the largest and most comprehensive health surveys ever undertaken in the state. Legislators have consistently trashed national surveys and models unless they were "invented here." Well, here's a state survey with local applicability they can actually use to inform policy. Let's get to it.
In light of the anticipated drop in state funding, ASU plans to cut enrollment in its nursing programs at its Polytechnic and West campuses in 2009. Ironically, this is during a time when there is a nursing shortage in Arizona. 
Talk to most people today and they will tell you that the uninsured – and in Arizona, illegal immigrants - are clogging our emergency rooms and making it hard for the insured and "regular people" to get care.
Occasionally a young person will ask, "How do you get a cool job like working for a foundation? What's the best training for that?"
I really have no idea. I studied literature, philosophy and history when I was young, and still do today. I had no thought of getting a cool job in a foundation, or really, of having a career of any sort, except perhaps as a teacher.
So just how do you get a cool job? What really is the most useful education? Read one person’s opinion in November's The Drift.
In a recent commentary in the New England Journal of Medicine, the noted economist Victor Fuchs posits three "inconvenient truths" about health care:
Fuchs has some ideas on how to fix some of this. Unfortunately, they upset the status quo, where someone's rising costs are someone else's rising revenues. The logic of this is impeccable, if perverse.
"Oil is one of the most important ingredients in our food, and people ought to know just how much of it they’re eating."
- Michael Pollan
It's not commonly known that the way we feed ourselves via industrialized agriculture contributes more greenhouse gases to the atmosphere than anything else we do - as much as 37%. In 1940, each calorie of fossil fuel energy produced 2.3 calories of food; today it takes 10 calories of fossil fuel energy to produce just one calorie of food.
This is from an open letter to the next "Farmer in Chief" from the agricultural activist Michael Pollan in a recent edition of the New York Times Magazine. He goes on to point out that while health care spending has gone from 5% to 16% of GDP since 1960, spending on food has fallen by a comparable amount - 18% of household income in 1960 to less than 10% today.
As we gorge ourselves on cheap calories (eating oil and spewing greenhouse gases), we are literally eating ourselves to death with an attendant rise in obesity, type 2 diabetes, cancer and heart disease. The U.S. food industry produces 3,900 calories per capita/per day, roughly twice the population's energy needs. If trends continue, obesity will account for more than $860 billion, or more than 16%, of health care expenditures by 2030. Plainly put, this is sick - literally and figuratively.
What can you do? Start by observing one meatless meal a week. If all Americans did this, it would be equivalent, in carbon saved, to taking 20 million midsize sedans off the road for a year. Better yet, try two or three meatless meals a week. You get the picture.
Paying for quality in health care - paying for results instead of more procedures and visits that may have little to do with quality - is finally making some traction, based on early feedback from the Medicare Physician Group Practice Demonstration.
The program is designed to reward (large) physician groups by coordinating care to improve patient outcomes while reducing overall costs for treating chronic conditions like heart disease and diabetes. Groups that are able to generate savings of more than 2% compared to what it would cost Medicare to pay for the treatment are eligible to receive bonuses based on improved cost efficiency and performance on 32 evidence-based quality measures.
The Marshfield Clinic in North-Central Wisconsin, which employs almost 800 physicians and invests heavily in things like care management and health information technology (IT), is a case in point. The group saved Medicare about $25 million in the first two years of the program and received close to $10 million in bonuses.
The problem is, only one percent of physician practices in the U.S. have more than 150 doctors. In Arizona, the vast majority of physicians practice in groups of five or less, and it's harder for them to invest in the sophisticated care management and health IT that support a more integrated approach to medicine.
But that could be changing. Economics alone are driving physicians away from small, independent practices and toward salaried positions in hospital systems and other integrated care settings. Nationally, the proportion of physicians in solo and two-physician practices declined from 41% in 1997 to 33% in 2005 and is no doubt lower today. It remains higher in Arizona, however.
Economies of scale and purchasing power translate into more capital and leverage. That, along with new ways of paying providers, will be the difference in ushering in a new era of value-based health care.
November 2008
