ROBERT WOOD JOHNSON FOUNDATION GRANT AND SUPPORT OF PRACTICE SITES: STATE PRIMARY CARE DEVELOPMENT STRATEGIES

The grant application was apparently submitted in October of 1992. The stated purpose of the grant was a collaborative effort to begin to solve the problem of mal-distribution of health professionals in Arizona. In the grant application Alethea O. Caldwell, the director of the Arizona Department of Health Services, wrote that the department was willing to commit $30,000.00 in cash and $73,700.00 in kind support to the project in phase I. The way this works is that the Robert Wood Johnson Foundation gives some money but all of the people who get the money also have to contribute some of their own money in in house types of contributions. The project summary had the following pertinent facts:

ADHS has developed an ongoing coalition with the major public and private agencies and organizations with a commitment to improving primary care in Arizona. The proposed members of the interagency working group include ADHS, other State agencies such as Medicaid and Commerce, The Arizona Rural Health Office, The Health Education Center System of AHEC, Arizona's Primary Care Association, associations representing physicians and mid-level providers, major insurers, business community representatives, publicly elected officials and others. It is noted that Arizona has a "solid support system" for primary care including committed advocacy groups. The IPCA initiative "places responsibility on the community to create a supportive practice environment, it creates a pool of experts which act as "peer consultants", and it develops a grass roots constituency for needed State level policy and financing changes. The content of the grant applications includes a section on existing State structure and on proposed State structure. The designed end point is to effect the structure of State government.
In the introduction it notes that Arizonans place a high value on "individualism and self- reliance" and low value on government intervention in the form of regulation and taxes. While these characteristics often lead to the perception that Arizona is an "unsophisticated" State, a closer look reveals a more "innovative and diverse infrastructure...."
It is stated that "the need for mid-level providers (nurse practitioners, certified nurse midwives, physician assistants) in Arizona is largely unknown, other than that the demand exceeds the supply."
It notes that the number of physicians is a less effective measure of adequacy of physician supply than provider accessibility, accommodation of practice characteristics and geographic distribution. The factors include whether a practice is full-time, whether it restricts the number of Medicare/Medicaid or uninsured patients, whether it has extended hours or bilingual staff and whether it is located in an area with serious health status problems. It is noted that there has been a net loss of providers due to declines in the availability of NHSC personnel, the number of NHSC obligated providers having declined from 53 to 18 since 1985.
One objective of professional recruitment programs is to recruit persons who have a high chance of retention and under-served practices. The approach taken is similar to the RWJ minority medical education effort.
On page 8 it states that community driven needs assessments develop a grass roots constituency for appropriate legislative and regulatory changes, a critical prerequisite to long term Statewide policy and financing changes in an anti- regulatory State.
A method of providing backup services might be "a public private employee sharing venture which could develop into an integrated prevention/primary care program of services with possible partners including private practitioners, hospital ambulatory care clinics, community health centers, county health departments and/or Indian health services. Also possible partners could be the Arizona Medical Association or one of the private HMO's or AHCCCS health plans."
The assistance might be provided on identifying or applying to a local foundation for a computer and software to set up an electronic blackboard. Communities might also use their resource pool to fund activities such as travel to preceptor conferences. Thereby, they obtain the type of expert assistance that is considered desirable by the grantor.
One objective is to bring about financing and policy changes including "regulatory changes that do not require legislation."
"RWJ funds will be used primarily to leverage private funding within each community. Communities will be expected to generate a 5:1 match themselves.
There is a description of the interagency working group beginning on page 21 "The proposed interagency working group IWG is composed of the major public and private agencies involved with improving AHCCCS to primary care in under served and rural areas. Membership is drawn from the IPCA steering committee and key participants in the working groups formed to develop the grant application so their commitment to the project has been demonstrated.
There are four State agencies on the IWG including ADHS, AHCCCS, the Board of Medical examiners or BOMEX and the Department of Commerce. Technical expertise will be represented by faculty at Arizona State University and the University of Arizona.
The project is to be located at the office of planning evaluation and public health statistics. This office has well established working relationships with both public and private providers and advocacy groups.
Interestingly in the time line, dates set are features include the start of the legislative session and the end of the legislative session. Looking at the budget, the greatest single expenditure in the budget is to subcontracts including community development specialists, needs/demands analysis community and community revenue pools is slated for a total of $69,525.00 out of a total of $127,072.00. The next largest expenditure is for Tracy Kirkman-Liff, the project director, who is to receive $15,440.00.
In appendix E, all members of the interagency working group are listed that includes the Chamber of Commerce, The Department of Economic Security, The Board of Medical Examiners, University of Arizona College of Medicine, The Arizona State Legislature, The Arizona Medical Association and the Governors office, truly a public/private partnership. There is a note concerning the type of contractual agreements for each proposed contract for which you request RWJF support you should provide an explanatory paragraph describing the services to be provided. The foundation should not be listed as a party to the contract. I wonder why that is necessary. Included in the grant application are a number of provisos concerning the data to be obtained and the grant is that the foundation shall retain a nonexclusive, irrevocable royalty-free license to use and to license others to use any and all data collected in connection with the grant in any and all forms in which said data are fixed. Some grants require the creation of public use data tapes and full documentation, although this one does not. It is clear that data collection is a key feature of the project.
It is also stipulated that no part of the grant shall be used to carry on "propaganda" or otherwise influence legislation (within the meaning of section 4945 (D) (1) of the Internal Revenue Code).
Looking at the report on the accomplishments of the grants it consists primarily in excuses as to why nothing much was accomplished. In particular, there was no mention whatsoever of whether the access to primary care services anywhere in Arizona was improved. One positive outcome, whether or not it was related to the grant, was the 1995 legislative designation of 10 million dollars for primary care development and financing. Then there are more excuses including turnovers of the various agencies and the fact that ADHS was unable to maintain the balance between its partners needs to be recognized for their leadership in successful legislation and the needs of the project to visibly achieve results as a cooperative venture. Since the IPC a project director as an ADHS staff member had little direct access to key legislators or other agency heads. Promoting IPCA State level strategies had to compete with other external and internal priorities clearly seems to indicate that political outcomes were what was desired. As to the concrete outcomes that were produced, there was a report that showed that the demand for mid-level providers far exceeded supply which was something already stated in the grant application. There was one good outcome that was featured in a letter from Claudette Frederickson, Associated Director of Business and Financial Services, which was a letter from ADHS on May 10, 1995 to the Financial Analyst, Spencer Lester, of the Robert Wood Johnson Foundation. It stated "the partnership roles developed during the planning process continue to be applied in other primary care advocacy and community development activities.
Another letter from ADHS to Spencer Lester concerning the community partners. One community delayed implementations to that winter residents could have an opportunity to participate. They finished the planning process (developing a vision, identifying obstacles, choosing strategic directions, and developing an implementation plan) but the community team feels the implementation planning was rushed and would like to redo it. Another community needed to spend a lot of time at the beginning to develop buy in and commitment from the different factions in town so finished everything but the implementation plan. The third community, because of confused communications, coordinator illness and job changes, spent the whole time developing a core group that would have the time and resources to commit to this project. In other words, the main thing that the project did was to develop networks, advocacy groups, to find partners that seemed to be working well toward whatever the stated objective was, which seemed to have a lot more to do with influencing legislation and regulation than with actually bringing improved access to medical services to anyone. They want to establish the public/private partnership, they want to select the establishment in-group, and they want to set things in stone by means of regulation and legislation.
As to the turning point materials, I have seen most of these before. There is an interesting letter from the School of Public Health and Community Medicine at the University of Washington Seattle from Ron Maynard, program manager, stating that one of the important goals of turning point is to bring together and strengthen collaborative partnerships and of course one of the means by which this is accomplished is through meetings and conferences.