Interpreneurship: A Community Coalition Approach to Health Care Reform

Excellus Health Plan, Inc.

Interpreneurship: A Community Coalition Approach to Health Care ReformAuthor(s): Irwin MillerSource: Inquiry, Vol. 24, No. 3 (Fall 1987), pp. 266-275Published by: Excellus Health Plan, Inc.Stable URL: http://www.jstor.org/stable/29771891 .

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Irwin Miller Interpreneurship: A Community Coalition Approach to Health Care Reform

Interpreneurship ?

networking by coalitions to build innovative institutions to

address community and societal problems?has been a vital force in America

since colonial times. In this paper, I describe the interpreneurial framework of

today: the five steps that seem necessary to effect fundamental change in a

community and the four factors that must be considered in attempts to effect change. As an example of this framework, I describe the activity that led to the creation of a health maintenance organization in the early 1970s in Cincinnati.

This case study?in which a Blue Cross Plan played a pivotal role?and my discussion of specific avenues for action might be helpful to communities that wish to develop an interpreneurial reform strategy for change.

In 1751 Dr. Thomas Bond conceived the idea of establishing a hospital in Philadelphia. A very beneficent design, which has been ascribed to me, but was originally his. At length he came to me. I not only subscribed to it myself, but engaged heartily in the design of procuring subscriptions from others. I do not remember any of my politi? cal maneuvers, the success of which gave me at the time more pleasure.

Abridged from the Autobiography of Benjamin Franklin1

Community interpreneurship. Benjamin Frank? lin practiced it in helping found Pennsylvania

Hospital in 1756. Most communities used it to cre? ate their hospitals in the 19th century.2 It was the method used to establish Blue Cross Plans and

prepaid group practice plans in the past half

century.3 It can be defined as creating and net?

working by local coalitions to build innovative institutions to address community and societal

problems.

Today, some health care policy experts en?

courage interpreneurship. They see community coalitions, action, and leadership as essential sources of health care innovation and reform in our large, diverse nation.4 Other experts are dis?

couraged about it. They question whether most American communities have the necessary com?

munity, medical, and organizational leadership and other supportive social structures necessary, for example, to create innovative alternative deliv?

ery systems.5 Most experts?pro and con?call for research on community interpreneurship guided by appropriate theoretical frameworks that aim at creating a body of knowledge that will promote appropriate responses to needed change.

This history of, and advocacy for, health care reform by means of nationwide movements of

community institutions ? building sparked by lo? cal interpreneurship

? is best understood from a classical social control perspective. This perspec? tive stresses democratic self-regulation, the ob? verse of coercive control.6 Social control refers to the capacity of a group (which could be a com

Irwin Miller, M.RH., is a professor of health administration, Governors State University, University Park, IL 60466. Address correspondence to the author at this address.

Inquiry 24: 266-275 (Fall 1987). ? 1987 Blue Cross and Blue Shield Association.

266 0046-9580/87/2403-0266$1.25



Interpreneurship

munity or a whole society) to balance basic social forces ?cooperation, competition, and regulation ?in striving toward an ideal7 Democratic self

regulation implies a challenge to productively bal? ance (and integrate) self-interests and public in? terests.8 The social control idea does not urge do?

ing away with government action or the market mechanism but, rather, combining these two with the wellspring of innovation: local cooperative enterprise.

This paper sees community interpreneurship as an essential, difficult, but masterable strategy for health care change, especially if local initiators function within regional and national networks.

Two Examples

Community Programs for Affordable Health Care (jointly sponsored by the Robert Wood Johnson Foundation, the American Hospital As?

sociation, and the Blue Cross and Blue Shield As?

sociation) is attempting to put community inter?

preneurship into action on a limited scale. This initiative has provided funding for 16 communi? ties around the country to form local coalitions to spearhead the creation of innovative, more affordable health care systems. It stresses combin?

ing social forces and balancing self-interests and

public interests.9 A similar but local effort has been started by the Chicago Community Trust aimed specifically at the underserved.10

The mounting success of the health main? tenance organization (HMO) movement is a clear

sign that many communities are capable of or?

ganizing innovation-building health care coali? tions. In the difficult 1970s, after the Federal HMO

Act of 1973 was passed, HMO enrollment grew from roughly 4 million to 9 million members, with the number of HMOs going from 70 to 220. Be? tween 1980 and mid-1986, enrollment spiraled to 24 million members, with the number of HMOs

rising to 595. More than 100 new HMOs have been started in the past year alone.11

The Community as Focus for Change

Will widespread community interpreneurial ef? fort and achievement help make quality health care affordable? Is emphasis on the local level war? ranted? Eli Ginzberg suggests that the root cause of our cost problem lies in the American people's demand for more and more high-technology health care.12 If this is so, the emphasis on the lo? cal level ?with of course a role for national and

regional policy and action?is justified, because

people ?with their desires, needs, wants, and demands ? exist at the local level. It is at the com?

munity level that people?consumers, physicians, managers, businessmen, clergy, and so on?can

collaboratively reappreciate the character and value of health care in a turbulent world. This

paper's methodology, correspondingly, is commu?

nity focused. In this paper I look at community interpreneur?

ship as an approach to the management of

change. I use the phrase community interpreneur? ship to call attention to other fields concerned with change management: community planning and corporate entrepreneurship. Basically, I see a convergence in the way so many fields in our

society are striving for transformation. Each faces

fragmentation and decline. All realize that no one

corporate CEO, mayor, or hospital president has the formal power to order innovation and excel? lence. All are learning the importance of persua? sion and coalitional politics (the inter dimension) in making change happen and succeed.

I present herein a community decision-making framework drawn from the city-planning field,

modified both by organization theory insights concerning entrepreneurship and by practical health care lessons that have been learned. To re? mind the reader that innovating in the real world is never as tidy as a theoretical framework, I include here some caveats from an HMO inter preneur. I then illustrate the framework by a case

study. I close with a discussion of some practical and theoretical implications of the framework and the case study.

I illustrate my model with the story of the creation of the Cincinnati Blue Cross Plan HMO because it has been used by national health as? sociations as an exemplary innovation; it is an

exceptionally successful program that can serve as a role model for other communities and spon? sors. It is one of the HMOs that the Blue Cross

Association showcased in the 1970s. It also has been held up as a prime example of hospital HMO involvement by the American Hospital Associa? tion13 and the Group Health Association of

America.14

Interpreneurial Invisibility

My case study emphasizes the importance of the

interpreneurial leadership role, which is often overlooked. The innovation process can become

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Inquiry/Volume 24, Fall 1987

obscure. Recall that Dr. Bond was not given credit for the Pennsylvania Hospital in the mid-18th cen?

tury. Consider this more recent remark by a 1970s Blue Cross Plan HMO interpreneur: "When we had the opening-day ceremonies, top manage? ment was there, quite enthusiastic. But the curi? ous thing is that they were also a bit nervous and unclear about how the program had been formed.

They acted as if it had just appeared one day. The

process was somehow invisible."15 Innovation's invisibility in the case of the Blue

Cross Plan HMO was probably due to two aspects of what Rosabeth Moss Kanter calls the "rewrit?

ing of corporate history." The first aspect ?

individuals disappear into collectivities ? results from the empowerment dimension of innovating. Typically an interpreneur persuades others to take over ownership of an emerging innovation. The more successful he is at this, the wider the mem?

bership of inventors becomes ? and the more in? visible the interpreneur becomes. The second

aspect ?current heroes emerge to replace the innovators ? comes into play when the innovation becomes developed to the point of marketabil?

ity. At this point the seasoned interpreneur yields center stage as marketing people step forward to meet the product's current needs. They become the heroes of the moment.16

Moreover, companies can be divided into two kinds: change resisting and change embracing. The former have cultures that are risk aversive and

deemphasize innovation. The latter have cultures that are entrepreneurial and assertive and that

strategically emphasize change and the role of

change agents to promote still more innovation.17 Too many Blue Cross Plans have, I believe, for?

gotten their own innovative actors and processes. They need to research their HMO experience and articulate some important lessons for improved interpreneurial performance. As Leonard Schaef fer, president of Blue Cross of California, sug? gests: "Key individual leaders play an important part in the success of new organizations and should be further researched in studies of HMO

development."18

A Community Decision-Making Framework

What are the lessons of experience for com?

munity-focused health care interpreneurs as they seek innovation through coalition building? One relevant body of experience and knowledge is that of the community-planning field from the turbu

lent Great Society years. What Richard Bolan ob? served 17 years ago about the city planner holds true today for the health care interpreneur: He

must manage a political process. As Bolan said then: "Though planning has never operated in a vacuum, the scope of today's . . . problems seems to impose special demands for awareness of the

complex decision web in which the planner must function. The community decision arena could be considered the 'culture' of planning, since its rules, customs and actors determine the fate of community . . . proposals. Understanding the na? ture of this cultural envelope will help planning and intervention."19

Thus, the health care innovator as corporate interpreneur must master his organization's in? ternal culture.20 It is also vital for the community focused interpreneur to master his community's sociopolitical culture and structure.

A Five-Step Process

Bolan's conceptual framework features a five-step process involving four factors.211 use this frame? work to discuss my case study of the creation of the Cincinnati Blue Cross Plan HMO. In doing so, I meld some community and organizational innovation research vocabulary and insights plus add some practical suggestions drawn from the lessons of experience.

The five steps can be summarized as follows:

1 A community force picks up signals from its environment that change is necessary.

2 Specific community power centers become ac?

tively concerned about needed change. They form a coalition that defines innovations as

proposals for action. They constitute an "in? novation demand" coalition.

3 The coalition structures its decision field. That is, it both assesses prevailing organizational ar?

rangements and roles and defines the political rules by which a decision about innovation de? sign and implementation will be mde.

4 The innovation demand coalition picks an or?

ganization to lead a coalition in innovation de? sign and implementation. This is often the com?

munity force from step 1. 5 Overt decision making starts, which is centered

around the designated innovation lead organi? zation. The organization forms an "innovation supply" coalition to design and implement the innovation.

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In terpreneursh ip

One HMO proponent offers some practical ad?

vice, in the form of caveats, for each of these

steps:22

1 Don't get into the management of change un? less you are an influencer, agitating others into new areas.

2 Don't forget that the impetus for change often comes from outside your organization.

3 You have to like selling new ideas and setting up new things.

4 Don't be surprised if somebody negotiates something that you don't expect. Outside pres? sure moves the process. It builds and maintains commitment to the innovation.

5 Don't assume that innovation development is

quick, easy, or direct. A mounting expertise is

required to make the innovation work. Get a

respected provider partner. Remember, it takes

time, patience, and faith.

Four Factors

In Bolan's framework, four factors must be con? sidered when major change is contemplated. The first factor is the characteristics of the decision field in which change must occur. Do local power centers see the community environment as placid or turbulent? Turbulent environments are ripe for innovation. Such environments feature rapid, spasmodic change that poses substantial threats as well as opportunities to a community's people and institutions. Organizations lose old functions and identities and strive to gain new ones. In the case of health care, for example, business shifts from passive to active health politics player.

Is the community's decision-making structure

(i.e., power elite) formal or informal, centralized or decentralized? Is the structure presently work?

ing effectively in general? Is it working on health care issues? Does the community have one or more (formal or informal) interorganizational problem-identifying coalitions (or networks) to

identify social health issues, and can it judge an innovation's prospects locally on technical and po? litical grounds? Does the community have a

specific organization that has traditionally been, or could be, its designated innovator for action in the health issue arena? (In some communities Blue Cross Plans play this role.) Such organiza? tions are staffed with people who have the techni?

cal, administrative, and political skills necessary for interpreneurial success. They are especially

adept at mobilizing a second kind of coalition, one that builds institutions that solve problems identified by the first kind of coalition.23 The

speed with which communitywide innovation is

adopted may vary with community size. What is the degree of civility of the commu?

nity culture? To what degree do health care

managers, physicians, consumers, and other par? ticipants see themselves as symbiotic parts of the overall community, which needs them to act as

responsible citizens toward it? The second factor is the leadership necessary

to mobilize the community structure to operate as innovative and self-renewing. I see three essen? tial leadership roles, plus some auxiliary ones.

First, there must be an "innovation patron." This is someone who heads a major power center and can phrase a problem in such a way as to convert it into an accepted community issue. He converts

vague turbulence into clear threats and opportu? nities. He can also protect an "innovation cham?

pion," who builds the coalition necessary to de?

velop the specific innovation that addresses the identified issue. The champion, in turn, coaches a band of "young Turks" who do the actual work.

There are lots of ways these political roles can

play out. Let me suggest one pattern. A chairman of a national health care concern decides to fo? cus awareness on health care reform. He then hires an assertive whiz-kid vice president to become cost control champion. The champion then promotes and recruits a young, enthusiastic staff to promote HMO development.

An auxiliary role is the "broker," who can link

champion and patrons. Another auxiliary role

might be called the "Paul Revere" role or, perhaps as a variant, the "outside agitator." For commu? nities that have no effective health issue coalition but need to change, someone playing this role

might serve as a catalyst. The third factor is the action strategies?the

selective cooperation strategies ?that organiza? tions must adopt to survive in a turbulent envi? ronment.24 A community can manage turbulence

by tapping middle (between micro and macro) level organizational networks. These mid-level or?

ganization networks have a regulatory, not a

production, role.25 A local health care coalition is an example of a community self-regulating

mechanism.26

Interpreneurs must blend technical problem solving methods with a community's decision

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Inquiry/ Volume 24, Fall 1987

making culture.27 Crucial here is how a coalition will handle issues of consensus and conflict.28 Coalitional activities should be done with a civil

spirit of negotiation and compromise; strategies should be guided by a sense of community.29 Still, because not every force in the community is a

force for the community, no truly innovative proj? ect can succeed on a consensus basis. Instead, the coalition approach requires tough leadership by the committed.30

The fourth factor is the identification and def? inition of the characteristics of the issues ad? dressed and the innovations deployed, including risk, communication obstacles, ideological issues, and action focus.31 Real progress in health care

delivery can come only if coalitions tackle the gut issue of changing the delivery system.321 suggest that in a turbulent environment, leaders can

change both organizational and interorganiza tional cultures only by patronizing exemplary in?

novations, that is, by backing innovations that teach us how to rearrange our world. Exemplary innovations teach us how to survive and succeed in a turbulent, competitive world by means of selective cooperation. HMOs are one kind of ex?

emplary innovation. Leaders must also assess how new an innova?

tion is to a locality. If the innovation is "not quite novel," it will be accepted more speedily. Are there

any local or nearby examples? Is the innovation

programmatic enough to provide a coalition with a specific (versus global) focus?

By combining process steps and factors, we ar? rive at a community decision framework for com?

munity health care coalition and innovation build?

ing (see Figure 1). In the following section, I

present a case study of the creation of an innova? tive health care delivery system in Cincinnati in the early 1970s.

A Case Study of the Creation of Cincinnati's First HMO

A Community Force Emerges in a Turbulent Environment33

Paul Young, who was instrumental in developing the Cincinnati Blue Cross Plan's prepaid group practice program, described the essence of the coalition activity that led to the HMO: "We needed to work together with providers and the

public in order to offer innovative cost-effective alternatives." One reason the Blue Cross Plan got

involved in Health Maintenance Plan (HMP) was

its perception of the need to diversify its role in health care services to help meet emerging con? sumer needs while restraining the rise in health care costs ? in short, to be a community force to effect needed change. Young felt that the Blue Cross Plan needed to be an active part of this redirection of local health care?to be a part more of the solution than of the problem.

In the early 1970s, the Plan set up a corporate planning function to create a constructive strategy for action on key corporate issues. This innova? tive corporate role presented an opportunity for someone with an interpreneurial mentality to lead the way. Young, who had been the Plan's devil's

advocate, was chosen to fill the role as vice presi? dent of planning. He was integrated into local and national networks of change-oriented health care

people and organizations.

A Community Coalition Demands Innovation

The impetus for focused action began to be felt in the early 1970s, shortly after Young agreed to take on the strategic planning task of finding an

innovative corporate direction. The local AFL CIO labor council's leadership notified the Plan that it wanted a prepaid group practice plan started. The council was the innovation patron. This response was in part the result of actions

by the Group Health Association of America

(GHAA), the national trade association of

prepaid group practice plans, which promoted debate about alternative delivery systems in the local environment.

The Decision-Making Field Becomes Structured

The labor council was open to participation in the emerging activity by local organizations such as the Blue Cross Plan and external groups such as GHAA. The council wanted the notion of

creating a prepaid group practice widely dis?

cussed, but it did not extend the decision-making unit to include nonlabor groups such as local bus? inesses and providers. The climate was not entirely favorable for promoting innovative health care. Local advocates were counteracted by local skep? tics such as a former president of the Ohio State

Medical Association. Council pressure gave Young his first assign?

ment: to explore the prepaid group practice con?

cept. To educate himself and the Blue Cross Plan on HMOs, he mobilized a staff study team

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Interpreneurship

Community process steps

1. Community force detects environmental signals for change.

2. Power centers form "innovation demand*' coalitions, which define innovations as

proposals for action.

3. The coalition structures the decision field.

4. A lead organization to muster an innovation-building coalition is selected.

5. The decision is made and implemented: The innovation is created, evaluated, and

revised.

Independent variables that influence decision outcomes

I. Process leadership roles

II. Decision field characteristics

III. Action strategies

IV. Issue and innovation characteristics

Outcomes

E.g., HMO

Figure 1. Diagram of the community decision-making framework for health care coalition and innovation building

from various divisions and levels of the Plan.

Young summarized the fruits of this research in a report for internal and external distribution. This document was the key tool for debating the

prepaid group practice concept into acceptance. Accurate and persuasive, the report described

prepaid group practice as a viable alternative that in some areas evolved from (but did not replace) traditional fee-for-service, solo practice medicine. The pivotal section of the report was a short, even handed description of how the innovation oper? ated, including its key features, advantages, and

disadvantages. The report helped awaken local

hospitals to the prepaid group practice concept and local purchaser interest in the innovation. Six

months after the AFL-CIO's initial signal, Paul

Young, now a credible HMO champion, went back to the labor council ready to negotiate.

A Lead Organization Is Selected

A meeting was held where labor representatives, assisted by GHAA consultants, mapped out what

they saw as desirable: to set up a freestanding prepaid group practice plan that would contract, they hoped, with a hospital for backup services or, if that were not possible, that would build a new facility. The council intimated that the Kai? ser organization would be chosen to establish and

manage the new program. Young saw problems with the proposal. First,

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Inquiry/ Volume 24, Fall 1987

he argued that Kaiser is a natural and respected marketplace rival for Blue Cross Plans. Labor ac?

cepted this Blue Cross self-interest as a legitimate consideration. Second, the Blue Cross Plan had studied the local situation and had concluded that

more hospital beds were not in the community's interest. Because it was unlikely that a hospital

would contract with the fledgling health plan as

proposed, the council's strategy pointed in the direction of hospital construction. Young argued that this would be bad for the community as a

whole, and came back with a counterproposal: The Blue Cross Plan, a proven local health care

innovator, would take the leadership role in de?

veloping a prepaid group practice program. Labor's response was surprising: They accepted the Blue Cross Plan's proposal.

Decisions Are Made and Implementation Begins

Next, Young had to build an "innovation supply" coalition to implement the lead organization's de? cision. He hoped that out of the interaction with

hospital leaders, one hospital would emerge as an

ally and develop the proposed health plan's med? ical group and the facility to house the group.

During the following months, however, the Plan's overtures to hospitals were continually rebuffed.

With no hospital interest, 1970 ended and seem?

ingly so did the project. Then, in 1972, Young was

approached by Sister Grace Marie, head of Good Samaritan Hospital, Cincinnati's largest hospi? tal, which was going through a similar self assessment process. The hospital had decided that a prepaid group practice would be a good ven? ture for it and the community as well.

In June of 1972, the Plan's board of directors asked management to officially investigate the

feasibility of cosponsoring a prepaid group prac? tice program with Good Samaritan Hospital. Young got the Plan's marketing division to take the lead in this investigation. This fully educated the marketing people about the innovation it would be promoting. In April, the Plan's board committed itself to undertaking with Good Samaritan the sizable task of creating the prepaid program. The two organizations would evenly split development and start-up costs on a long term basis. It eventually cost each of them $1

million. In April 1973 the Blue Cross Plan announced

that if all went well, the new program would open its doors by April 1974. The Plan, however, ran

into a major legal hitch: The state's Blue Cross Plan enabling law did not permit issuing sub? scriber certificates that restricted choice of hos?

pital, which would be the case with Good Samar? itan acting as the prepaid group's sole backup facility. After negotiating with the state insurance

commissioner, the Plan's board decided to incor?

porate Health Maintenance Plan as a separate health care corporation.

The hospital and the medical group decided that the medical group should be a separate cor?

poration, with the hospital as its landlord and pro? vider of all backup services. The Blue Cross Plan would provide the HMO's management and mar?

keting functions. The medical group would be at risk to deliver all medical services to HMP sub? scribers. Under this arrangement, HMP opened on April 1, 1974, and had quick success in the

marketplace. A well-led coalition of organizations in Cincinnati had succeeded in building an in? novative health care institution.

Discussion

The HMP story illustrates many elements of my framework. Let me expand here on the case

study's implications, proceeding in terms of the four factors that are integral to coalition activity ?the decision field, leadership roles, action strate?

gies, and the characteristics of the innovation ?

and offering specific hints about what communi? ties can do when one vital element or another is

missing or not working effectively.

The Decision Field

Cincinnati in the 1970s had a well-working com?

munity structure that nurtured successful coali tional politics and institution building. It had a coalition that spotted a problem and demanded an innovative solution; it had a local organiza? tion with a track record of innovative health care.

Still, it took an "outside agitator," in the form of GHAA, to galvanize the local structure into in? novative action. Where communities lack ade? quate process and structure for innovative action, some variant on the agitating GHAA role in Cin? cinnati could provide the initiative for construc? tive change. A useful first step in building a rele? vant interorganizational network would be a

well-organized campaign to educate the public about local health care issues. The "Health Vote"

project of the Public Agenda Foundation has been successful in this regard.34 "Health Vote" is

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Interpreneursh ip

a means of building consensus. Interested parties view a television program that highlights major health care issues. They then vote on how to re?

spond to these issues by filling out and mailing in a ballot that appears in a local newspaper. Thus, the media can be key players in making a com?

munity aware of a problem.

Leadership Roles

One way to revitalize an organization or a com?

munity is to convert critics or observers into in? novators. This happened with Paul Young. Simi?

larly, a community trust, for example, could hire the community's leading physician or consumer critic of the health care status quo as director of a new health innovation demand project. Or, let us reverse things and assume that the same critic has

already on a volunteer basis formed a fledgling network. How does this champion scout out a pa? tron? He or she could seek the advice of a power broker ?his community's Ben Franklin. Or he could visit prospective local institutions and mar shall his arguments before CEOs. Because newly appointed CEOs are often community patrons with unformed agendas, they may turn out to be

patrons in search of champions to fill out a com?

munity agenda and therefore worth a visit early on. A similar opportunity occurs when an orga? nization has undergone a crisis (i.e., it might need some favorable publicity) or is sorting out its ba? sic business strategy (as was the case with the Blue Cross Plan in Cincinnati).

Action Strategies

Young saw the need to select some providers to work with to create innovative alternatives. This is the selective cooperation strategy that turbu? lent environments necessitate. (An HMO is a coalition ?a subset of local groups selectively cooperating to achieve a goal.) If an essential lo? cal group will not cooperate or is not moving fast

enough, the danger of "outside invasion" must be made clear. This happened in Cincinnati, where labor suggested the possibility of bringing in Kaiser to set up an HMO to compete with the Blue Cross Plan.

Because Cincinnati has a "civilized" commu?

nity culture, the process of interorganizational negotiation there was based on practical give and take, not on ideological insults and demands. The

general atmosphere surrounding the discussions between the Blue Cross Plan and the state insur

ance commissioner was, however, ideologically charged. Nonetheless, the negotiations were civil because the participants appeared to be operat? ing in awareness of civility's two operational ques? tions. Heinz Eulau puts them this way: "We have achieved the politics of civility when we are capa? ble of asking not only,4What is in it for me?' but

also, 'What can I do for you?' It is out of these two simple questions that the politics of civility is born."35

Community politics that operate when people are concerned only with the first question defeat institution building as self-interest clashes with self-interest. Concern with only the second is a

charity-based strategy that is likely to create co? alitions that will never deliver on their promise.

Where neither question is genuinely asked and an?

swered, talk-oriented coalitions form that produce only minor results (see Figure 2).

Communities that have become confronta? tional on health care issues can begin to increase

civility by working first on less ideologically charged health care issues. "Health Vote" cam?

paigns, by stressing the need for a shared fact base, can improve civility. Outside consultants might be called in to help identify and then remove blocks to civility and constructive negotiations.

To increase the chance of success, constituen? cies that are likely to make the innovation suc? ceed after the interpreneurs have made it happen should be included at the outset. Ultimately, of course, innovative health care institutions must win acceptance by the people. Paul Young worked with quality providers in part to use their credi?

bility with consumers to help sell the new HMO in the marketplace.

Self-interest

High Low

w ja Community Charitable

g jS reform shortfall

c_

S ? Raucous Reform j stalemate talk

Figure 2. Community reform outcomes as a func? tion of civility strategies

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Inquiry/Volume 24, Fall 1987

Innovation Characteristics

An important factor in assessing an innovation's

prospects for success is whether there has been a successful first innovation locally or nearby. For

example, the way was paved for federally funded HMOs in Minneapolis by Group Health, Inc., in that city; the way was paved for HMP in Cincin? nati by a successful Kaiser plan in Cleveland.36

Conclusion

For the sake of argument, let us assume that a

community's health care system parallels its over? all leadership and civility. I suggest that there are four basic community types, in terms of their ca?

pacity for leadership and civility, which I present in Figure 3.

The four types of communities can be defined as follows:

Re-forming communities have leadership that embraces change and a culture of civility. Their leaders are interpreneurial. These are "cities that

work." Innovations stand a relatively good chance of success here, provided they truly respond to ci?

vility's two questions, that is, they are looking out for their own interests but are cognizant of the needs of other entities and act accordingly.

Norming communities have shared norms

(values) and are cooperative. They, however, are not (yet) reform oriented. They lack, to varying degrees, entrepreneurial leadership. One or two local leaders can quickly begin to change the sit? uation. A newspaper publisher, for example, might galvanize the community into seeking health care reform. Moving from norming to re?

forming sometimes requires some storming. Storming communities are characterized by

conflict-ridden interpreneurship that may produce competitive enclaves of innovation. Productive coalescence of these enclaves requires civic leader

Civility

High Low

? &

e

?a EC

I

Re-forming

Norming

Storming

De-forming

Figure 3. Community typology in terms of ca?

pacity for leadership and civility

ship that attends to the public interest aspect of innovation. The media, churches, and local foun? dations can lead the way here. This usually in? volves an emphasis on creating or awakening a credible community-focused innovation demand coalition.

De-forming communities have relatively little

civility and leadership. Just as re-forming com? munities do not always succeed at health care in?

novation, de-forming communities sometimes do not fail. They can produce renewal if they recog? nize that they will not survive without increased

cooperation and that they need outside leader?

ship. A dramatic symbolic accomplishment can

rapidly shift these communities into a positive direction.

Communities or organizations that perceive a need for health care reform should investigate these avenues of action:

1 Seek funding and interpreneurial leadership skills from foundations, civic groups, and bus? inesses in the community.

2 Create regional and national networks to share lessons learned.

3 Sponsor experiments in community pairing for mutual learning. For example, pair a big city with a provincial city, or sponsor a conference of people from nearby storming and norming communities.

4 Create incentives to prompt local health care institutions to act as genuine civic leaders.

5 Expand and fine-tune the role of the media in

promoting health care reform. 6 Relate existing foundation initiatives in com?

munity leadership development to health re? form initiatives.

7 Relate existing healing ministries of local reli?

gious congregations to health care reform. 8 Encourage the business community to expand

its health care leadership beyond cost control concerns.

9 Undertake systematic research, including case

studies, using a community focus. We can learn vital institution-building lessons from the past by reviewing the community-focused initiatives ?

regional medical programs, comprehensive planning agencies, and health systems agencies, for example ?since World War II and looking for what is common or complementary in each innovation that worked. Also, a systematic study needs to be done of the successful Blue Cross HMO movement.

274



Interpreneurship

The American mosaic of rapidly transforming local health care arrangements displays the rough and ready political logic of a diverse democratic nation in turbulent times. This political logic flows

out, in part, from the community interpreneurial process. We can learn more about, and get better

at, managing this process. Regional and national

networking of community interpreneurial initia? tives is an important way to accelerate both local innovation and national reform. (This is why it is important to better understand how the Blue

Cross Association networked its members' HMO efforts in the 1970s and 1980s.) The model of

change presented in this paper can be adapted by diverse communities that perceive the need for health care change.

The model is based on community interpre? neurship as a key social force that sparks reform and subsumes an important role for regulation, to increase fairness, and for market forces, to in? crease options. It does not see, however, a magic button in either the nation's capital or in corpo? rations' headquarters for solving our health care

problems. It is a model for turbulent times charac? terized by unpredictable and spasmodic social

change and institutional identity crises. Commu?

nity interpreneurship provides the flexible capac? ity necessary for moderating this turbulence. As a cooperative, locally focused approach to reform, community interpreneurship is an element of the re-voluntarization of American health care.

Notes

1 Benjamin Franklin, The Autobiography of Benjamin Franklin, ed. J. A. Lemay and P. M. Zall (Knoxville: University of Tennessee Press, 1981), pp. 121-123.

2 Paul Starr, The Social Transformation of American Medi? cine (New York: Basic Books, 1982), p. 152.

3 Odin Anderson, Blue Cross Since 1929 (Cambridge, MA:

Ballinger Publishing Co., 1975). 4 Eli Ginzberg, "The Delivery of Health Care: What Lies

Ahead?" Inquiry 20 (Fall 1983): 217; Alain C. Enthoven, "Consumer-Centered vs. Job-Centered Health Insurance," in Saving Our Health Care System, ed. Regina E. Het?

linger (Boston: Harvard Business Review, 1983), p. 48. 5 Lawrence Brown, "Competition and Health Cost Contain?

ment: Cautions and Conjectures," Milbank Memorial Fund Quarterly: Health and Society 59, no. 2 (1981): 185.

6 Morris Janowitz, The Social Control of the Welfare State

(Chicago: University of Chicago Press, 1977), p. xi. 7 George Vincent, "The Province of Sociology," American

Journal of Sociology 1 (January 1896): 488, cited in Morris

Janowitz, The Last Half Century: Societal Change and Politics in America (Chicago: University of Chicago Press, 1978), pp. 27-28.

8 Janowitz (note 7), p. 3; Robert Sigmond, "Quest for Ex? cellence in Health Care Delivery: Balancing Cooperation, Competition and Regulation" (paper presented at the

Eighth Annual Health Forum of Northeast Ohio, Cleve?

land, 1980), p. 3. Sigmond's views on voluntarism's role in health care reform are very close to Janowitz's social control perspective on social policy generally. This paper owes much to both authors.

9 Donna L. Gerber, "Community Programs for Affordable Health Care," Inquiry 20 (Summer 1983): 130.

10 "Request for Proposals: Health Care in Cook County" (Chicago: Chicago Community Trust, 1986).

11 1986 June HMO Update (Excelsior, MN: InterStudy, 1986). 12 Eli Ginzberg, "Health Reform," in The Nation's Health,

2nd ed., ed. P. Lee and C. Estes (San Francisco: Jossey Bass, Inc., 1984), p. 360.

13 Hospitals, Aug. 16, 1979, p. 66. 14 James Dougherty, in Prepaid Health Plans (Chicago:

Chicago Hospital Council, 1983), p. 62. 15 Remark to the author, Blue Cross Conference on Alter?

native Delivery Systems, New Orleans, Jan. 21, 1975.

16 Rosabeth Moss Kanter, The Change Masters (New York: Simon & Schuster, 1983), p. 284.

17 Ibid., p. 286. 18 Leonard D. Schaeffer, review of HMO Development, by

Odin Anderson et al., in Health Affairs, Spring 1986, p. 192. 19 Richard S. Bolan, "Community Decision Behavior: The

Culture of Planning," AIP Journal, September 1969, p. 301; italics added.

20 Gifford Pinchott III, Intrapreneuring (New York: Harper & Row, 1984).

21 Bolan (note 19), pp. 303-306. 22 Paul Young, "HMO Cooperative Planning" (paper

presented at the Blue Cross Association Conference on ADS Planning, New Orleans, Jan. 21, 1975). I want to thank Paul Young for his subsequent help in preparing this case study.

23 Michael Aiken and Robert Alford, "Community Action," American Sociological Review 35 (August 1970): 662.

24 Eric Trist, "A Concept of Organizational Ecology" (pa? per presented at the Melbourne Universities, Melbourne, Australia, July 29, 1976), p. 18.

25 Ibid., p. 16. 26 Walter J. McNerney, "Health Care Coalitions" (Michael

M. Davis Lecture, delivered at the Center for Health Ad? ministration Services, University of Chicago, 1982), p. 20.

27 Bolan (note 19), p. 303. 28 Donald Schon, Technology and Change (New York:

Delacorte Press, 1967), p. 129. 29 McNerney (note 26), p. 12. 30 Gerber (note 9), p. 130. 31 Bolan (note 19), p. 303. 32 McNerney (note 26), p. 10. 33 This case study draws heavily on Paul Young's paper (see

note 22) and on conversations I had with him. 34 "HMO Network in Des Moines," Group Health News 24

(March 1983): 15. 35 Heinz Eulau, Technology and Civility (Palo Alto, CA:

Hoover Institute, 1977), p. 25; see also McNerney (note 26), p. 21.

36 Schaeffer (note 18), p. 193.

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Interpreneurship: A Community Coalition Approach to Health Care Reform

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