Plenary Panel - Research to Practice

Using Partnerships as Catalysts for Change

Dr. Terry Pavia: Thanks everybody. Let me pop my slides on up here. And let’s see pick a slide set, any slide set. Okay, I do have to apologize for not being able to be part of your conference for multiple days. As Bonnie said, I have several other engagements, which means that I’m going to be really rude. I’m going to speak, finish up our little panel, and run! However, in your packet for the conference is my phone number and email. I have to tell you that I’m sort of difficult to reach by telephone, but I am one of those people that’s addicted to e-mail. I actually have it 24-7 at my house. If you need to get in touch with me, I’d suggest the e-mail route, just because that one will work, and I can’t guarantee the other ones. So, I hope to plant the seeds here for some different ways of thinking about things. And I think as we go through my part of it, I’m going to try to be very specific.

I find that with my students I can’t be too directive about what they should do when they go home. So I actually have some ideas for what you should do when you go home. One of the reasons that I think I’m bringing a somewhat different perspective to the audience today, is our LEND program is structured somewhat differently than other long-standing LEND programs. Long-standing LEND programs tend to be sort of self-contained entities, and the faculty that are the investigators on that program essentially work within those clinics. In Utah what we did is, we formed a LEND program where the faculties are actually still housed in their original departments.

So I’m actually a faculty member at the David Eckles School of Business that is funded partially by the Utah LEND program. What this means is that my master is actually a department chair in the School of Business. And I have to tell you, that is a very different beast than reporting to somebody who is running a LEND program, housed all by itself. My department chair, when he looks at this grant that I’m on, says, "I don’t get why you’re doing this. What do you get out of this?" Well, first of all, I can tell you that as a rule, everybody I’ve met in the LEND program is seriously nicer than the people at the business school. Well, you can laugh about that, but this is going to be a really serious issue, because if you’re used to working with people who are like the folks on the LEND program, and one of "them" comes to your meeting, they behave differently.

These business people are different ducks, you know? And they behave differently, they have different metrics. And part of what we’re working with here, is how to integrate these things. So one of the things I get out of being on our LEND program, is that it’s nice being with nice people. But another thing is that I actually think that there’s quite a bit that the business community can--or the business research can bring to provision of services for children with special healthcare needs.

My son has just enough special healthcare needs that I have one foot in that camp, but not so much special healthcare needs that I can’t be out and have a professional life as well. But I do think that I’ve been granted this opportunity to sort of see it from both sides, to see it from the side of somebody who can possibly to work professionally to make some changes, and to see it from the side of a parent who’s like, "Oh my gosh, can’t they do any better than this?" So, I try to bring both perspectives to what I’m going to talk about today.

The problem that I see, coming as a business person and business researcher into the public health arena, is that as a rule, what public health strives to do is simply not the same objective that business has. So in business school we teach people to maximize certain objectives: profit, market share, what have you. And that’s just simply not what you’re doing. And so it’s very difficult to make a direct translation of what business does into your arena, because the bottom line in public health is not profit. It’s often healthier people. But it’s hard to measure. “Oh, I want people to be healthy.” “Great idea, what did you have in mind?” You know? Or, “I want people not to smoke.” “What does that mean?” It’s all very vague. “I want babies to be healthier.” It’s hard to actually get down to a measurable bottom line, and quite a bit of public health work is spent on developing decent measures. Which for a businessperson is kind of a funny thing, because it’s not that hard for us. We just turn to the accountant, you know? What was the profit last quarter? What’s the earnings per share? It’s not that complicated. You get complicated like Enron, and you get your hand slapped. You don’t want to make it complicated. It’s simple in business. It’s complicated for you; okay?

There is a sense that I get, that the bottom line that is what you’re striving for, although you may not be able to articulate it, you know it when you see it. But, it’s hard for a businessperson who comes in, who’s not immersed in this, to know it when they see it. So it’s hard to kind of "get" what’s going on in a clinic. “What’s the point of this clinic? How do we know if we’re doing well?” At the same time, the costs of public health are really difficult to measure, in part because everything is so meshed together. You want healthier babies, it’s not just your early-intervention program, it’s not just your pre-natal care program, it’s the whole social structure. It’s whether people are going out to bars while they’re pregnant. It’s whether they have a partner that’s supportive, or beating them up. I mean, it’s a whole mess of things that comes together. You run one little program, you can maybe track your costs, but there’s all these other factors coming together.

As a contrast, think about producing toothpaste. What’s the cost of the toothpaste? Well, let’s see. There’s the ingredients, there’s the time on the factory line, and you could amortize the cost of the factory, if you wanted to, there’s the labor, there’s the boxes, there’s the advertising, right down the line: cost of producing Crest toothpaste. It’s a different animal. So that when you take something like a cost-benefit analysis, and you try to move it from the business world over into the public health world, you immediately have these challenges that come up, because it’s not directly applicable.

And what I see when I take MBA students through our LEND program, because that’s who I choose for my trainees, when MBA students come, and they go into one of our, say, early-intervention clinics, they come back from the clinic and they go, "What am I doing here? What am I supposed to do? What do they want from me? I don’t even get how I fit in this whole thing. Plus I’m not quite--I have to tell you, I was pretty uncomfortable being in that clinic." Because of this third issue: efficiency is not a critical attribute. Now, I want to talk specifically about--my mother, my mother was a public healthcare nurse until she retired, and I tried to run past this talk with her last night. And when I got to this particular part about efficiency, she got a little prickly.

So I want to be clear on what I’m talking about, when I say inefficiency. It’s not a negative thing; it’s strictly an observation. So, if you have, let’s say, a multi-disciplinary clinic for children with special healthcare needs, we are not talking about your run-of-the-mill kid coming in. We’re talking about a very complicated child. And let’s say the three of us are sub-specialists in some really complicated area of seizure-disorders or something. The child comes in and sees Bonnie, and Bonnie says, "Oh, now there’s something new going on. We have to send the kid off for some tests." So the kid traipses off for some tests, meanwhile I’m scheduled next. So what do I do? I sit around and I work on my PowerPoints, I do some journals, I’m answering pages, you know, and then eventually the kid comes back, sees me. I think of a few more things, and then Fan--okay.

A businessperson comes in and says, "Wait a minute. The kid was scheduled with Bonnie. Because it’s a complex medical consult, instead of giving them 12 minutes, we’ll give them 20 minutes." Okay? After Bonnie, the kid comes to Terry, and there’s another 20 minutes. Then the kid goes to Fan, there’s another 20 minutes. One hour and you’re out of there. When I come into the clinic, and I see this highly paid professional sitting around doing some PowerPoint presentation, I say to myself, "Here is an underused asset." What in the world is this doctor doing, sitting around waiting for a patient? This is a poorly run clinic. And it’s not just the doctors. When we go and we witness these clinics, we go in so we see how they run, there’s a break room. There’s always people wandering in and out of the break room. They have time to talk.

Oh, the social worker will talk with you for a little bit, you know, and “Oh yeah.” And my students look around and they go, "What is going on here? This is not running like a business." It’s not efficient, and it’s partially the nature of the beast. But if you look at what’s happening right now with public health, for the most part, the people that you can treat efficiently and effectively, are not the ones that are landing in the public health system. They’re the ones that are staying with the doctors that can do 12 minutes, 12 minutes, 12 minutes all throughout the day.

You’re getting exactly the ones who can’t do that, and it’s really hard when a businessperson comes in and says, "I don’t get it. Why don’t they just shape up?" You know? And that’s not what you’re doing. And I think that making that sort of parallel really clear early on, is an important part of the culturation of the business people into some of the public health issues that are raised, particularly for children with special healthcare needs. One of the real issues that I see in public health, as you start to apply some more stringent financial measures, is that the hard decisions that you make in public health are often what we in the business world would think of as a public relations disaster.

Now, when we close a plant, and we decide that we’re going to start doing manufacturing down in Mexico, people lose jobs. Yes, it’s true, people lose jobs. But people lost jobs all the time, and this just isn’t news anymore. You know? Nobody really--it doesn’t make, like, national news. Maybe you get a little local piece, or you get something on the front of the page of your local paper one day, and that’s it. But start talking about taking away mental healthcare funding, or transportation for the handicapped, and suddenly you get the potential for a lot of these heart-rending visuals that can be played up in the media.

And the problem is, you simply are not given enough money to solve everybody’s needs, so when you have to cut here, or you have to cut here, you know it’s going to boomerang back in the media as sort of a public relations disaster. And one of the difficult things, and we’re going to talk specifically about this project that my student did with the cost--sending some sort of a price for doing some of the early-intervention clinics--one of the difficult things is, is that this is what MBA students are trained to do.

We train them, we put them in classes, and we say, "You’re going to role-play right now. You’re shutting down a factory and it’s going to put 300 families out of work, and you’re going to role-play it. And you’re going to do the negotiation, and these families’ livelihoods are on your head, and if you decide that’s what has to be done, that’s what has to be done. We’re going to role-play: here’s somebody with a very complicated medical situation, and you’re going to have to lay them off. That’s just the way it is." And we train them to do this. We train them to make the hard, ugly decisions.

So what happens when you take somebody like one of my MBA students who is in the LEND--she was a LEND trainee, and you send them off to do the job that Fan mentioned. The early-intervention program had to set some sort of a fee, because they were under-funded. Just a fact: you need more money to run the program. So to an MBA student this is not rocket science. Hello? You figure out what the bottom line is, figure out how many people are coming in, maybe do a little income thing, sliding scale, pro-rate it: boom. This is the sort of the thing we give them for homework in, like, their first semester; right? So, she goes to this thing, and she’s like, "Well, la-di-dah, this ought to take, like, one meeting.

This isn’t much of a project for me to be on. You know, but if it helps them, I can make up a little spreadsheet. Boom: job done, on to the next thing." Well, needless to say the job was not done because she comes in with her little spreadsheet. Now, again there’s a big cultural mismatch. She doesn’t come in and have chit-chat. And she doesn’t come in and, "How you doing, da, da, da, da, da." And she doesn’t come in with a lot of rehash. She comes in, "We’ve got a problem. I’ve worked on the problem. I’ve got a spreadsheet. We can discuss this, take a vote, and we’re out of here." You know? Maybe 40 minutes max. No, no, it’s just not what happened. And she came back from the first meeting, and she’s like, "I don’t get it!

I was at this meeting, and the only thing that the staff wanted to talk about was the fact that nobody should have to pay for these programs." She’s like, "Okay, maybe they shouldn’t have to pay, but they’re going to. Now let’s just set a price. Okay! End of story." And so, there was this huge mismatch in cultures. The businessperson simply couldn’t understand why no one could stay on task. I mean--and so what happened is, is that she had a trying time, in part, because it took well more than 40 minutes. She actually achieved some of her objective of earning some hours helping people, because it took so long. But she also ended up feeling really kinda mean, because she was the only one pushing for payments. And it was as though it was her job. They, the people in the group had sort of abrogated responsibility for this, and it became her forcing them to do it.

And there’s this sense that, you know, in your organization, if somebody comes in with a strong business orientation, that they may be forcing you to change. Whereas actually the need for the change is not so much coming from them, as from the external environment, and they become the agent that’s making you aware of this. But actually they’re not--business people don’t go to business school to figure out how to make other people’s lives miserable, although I don’t think you believe me on that one. But it’s true, they don’t! We don’t run classes on how to make people’s lives miserable, maybe faculty’s lives miserable, but not people’s lives.

When I was talking with my Mom about this last night, I said, "You know, the reason that I think a lot of this is happening, and that it’s important for us to have these discussions about business people, and the business-type of thinking in public health, is because, you know, the day may come when your organization, or your state health department is not run by an MD, but is run by an MBA." A day may come, and that may change the culture of your organization quite a bit. And it’s important, now, to begin to build up the skills to talk with people from a different discipline, from a different way of looking at life. So, why bother with the business perspective? I heartily believe you simply have no choice.

For the first time in our history we have an MBA in the White House. We are churning them out of business schools. The world is full of them, and they are everywhere. If not in your organization yet, they’re coming. You really have no choice. The insurers demand it to some extent so that you can show whether therapies are proven to work. They look for, you know, whether there’s evidence of whether things work. Legislatures demand it, so that if you look at part of what’s happening right now about say, newborn screening, and that was one of my students that worked on the question of adding cystic fibrosis to the panel that we use in Utah, one of the things that happens a lot, because it’s so hard to make some of these tough decisions, is that rather than making them on sound business principles, they often end up being made on who can show the most pathos, or the most emotive, or the most emotional thing at the legislative meetings. Or which legislator has a family-member with a particular ailment, or any of these number of things which are not strictly rational business.

They’re much more, all sort of, sort of political, promotional, media-type things that end up coming into play. And one of the things that’s happened around newborn screening, as you know, is that a lot of the groups that make decisions about this are now actually looking at some of the tough financial questions. What does it cost to do this? What will it mean to do the follow-up on it? What’s the benefit that accrues from diagnosing a child at birth, as opposed to one year of age or so, when they’ve started to manifest symptoms? These hard questions are being posed, not to give you more papers to fill out, but because there’s a sense that this type of thinking provides a framework for planning, and for making difficult decisions. The center one: "increasing transparency," I just don’t know how much it shows up in the literature that you read, but "transparency" is sort of a buzz-word in the business world for meaning that you can tell what’s going on.

You can tell which clinic is more cost-effective in seeing children than other clinics. Enron had no transparency, and especially since the whole Enron scandal, and then the ensuing ones after that, the notion of transparency is really seen as a really, really good thing. So if you end up having to talk with a business person, and you tell them that you’re making certain efforts in order to increase transparency in your clinic, and then--transparency and accountability go right together. So you can start using that word, and then it will make you seem more sophisticated. So, why is it so hard to include business thinking in public health?

Well, there’s a couple of reasons that I’ve seen. The first is that even using the word "profit" is seen as sort of a dirty word in certain settings. It’s not just the public health setting; non-profits are like this as well. But you know, just to draw a contrast for you, out in Utah, John Huntsman was a petro-chemical magnate, and he was almost single-handedly responsible for all of those Styrofoam clamshells that used to come around your Big Macs, and all, that won’t degrade until, like, five billion years from now.

Well, with all the money that came from that, he is now building the Huntsman Cancer Institute, and the Huntsman Cancer Hospital, and it’s just--it’s just amazing, there’s so much money going into it, it’s just popping up overnight. There’s so much money there. My students in the business school infer something from this. They believe that you do good in this world by doing well. When you earn a lot of money, personally or as a company, it enables you to do good things in this world. You can’t help others if you haven’t gotten a good, solid core yourself to grow from.

My students see nothing wrong with making money, because if you really want to, in the long run, you can use it to help others. But you can do good by doing well, and I have to tell you that is a different notion than you run into in public health, or the non-profit world. But there’s a lot of people out there who believe that. And so this notion of profit doesn’t necessarily mean that you just end up buying a house on the beachfront; it can also mean that you help fund some kid go through school. And there are a lot of people who are thinking that way these days.

So profit is not necessarily seen as a dirty word. Secondly, the culture of business, another impediment, is the culture of business is not what drew people to public health. For as a rule, business people tend to get to the point, and tend to stay on task. They tend to be over committed; they schedule too many things at once, which is why our businessperson, as case "A," didn’t show up at this morning’s meeting. Well, you know: why? Because he was over-scheduled. Why are we here? Because we didn’t over-schedule.

I think we get more points for staying on task, but in any case. And then, the thing that I’d like to talk to you about specifically is, let’s suppose that you leave this session and you decide, "Yeah, I’m going to do it. I’m going to try to get some business-something in my organization." Okay, what’s your plan? What are you going to do on Wednesday morning? Who are you going to talk to? Who are you going to call? You may email me, but that’s, you know, who else, maybe? Okay, well, I have some specific suggestions for you. One is to contact one of the business schools in your area. Now business schools are usually organized into what we call "functional areas." Of the functional areas: finance, management, accounting, marketing is going to be your best bet.

Because embedded inside of marketing, in a business school--and I’m not talking about going over to the public-policy people, which will be over in political science. I’m talking about looking inside the business school, inside the marketing department. Talk to the chair, or talk to the administrative assistant, who really runs the department, and ask: “Who is it that has an interest, in your department, in public policy, or in social marketing?” Social marketing is a catchall term, so that things like, "Don’t drink and drive," that’s a social marketing effort. So, you know, "safe sex," social marketing effort. "Baby your baby," "use seatbelts," whatever. Or at the outside, you could ask if there’s anybody who has health-related consumer behavior research interests.

Now at the beginning do not tell them, "I have a hard thing that I can’t solve in my organization." Simply ask, "Who has a research interest in this area?" Now, I’m going to let you in on the way that academics works. Remember at the beginning I said that I report to a department chair? What my department chair wants in large measure is publications. What it takes to get a publication is not to solve your problem. Quite honestly, my department chair has no interest in me helping you solve your problem. My department chair wants a paper written. So, you have to ask yourself, “What does it take to write a paper?” Now I’m going to draw a little analogy for you. You know how sometimes you can just, like, read a book; it’s a fun book? Yeah, it’s a fun book. You can tell me the story. When you read a book in school, think back to English class, did you just read the book; it was a fun book; tell the story? No, you have to talk about the themes and the character development, and where it fits in the stream of literature, and da, da, da. That’s what we write papers about; okay?

We write the big things, the trends that are going on, and how things are fitting together, and what we see happening, and blah, blah, blah, blah, blah. But, and here’s the beauty of it: every paper usually has at least one case in it, a little example, sometimes two. And what you would like to do is to say, and I’m going to skip ahead a couple slides, then well go back, okay, because I have some specific examples here. Let’s say that one of our organizations out in Utah was interested in figuring out what sort of information on Down’s Syndrome local pediatricians might like to use online. So it’s the question: “Do they go online?” That’s a first question.

And secondly, “If they are going online, what else would they like to have information, gathered together in one place on?” So that is something that a business professor is not interested in doing. But what a business professor would be interested in is the theoretical question that, when you have a group of professionals that have been trained to seek information in one way, and there has been a radical change in the technology, how does that professional turn? What do they use it for? Are they being pushed by their clients, say the parents, to go online? Are they being pushed by their peers? What do they seek? Now see, that’s a more theoretical question. You could get an academic interested in that, and then you could say, "You know, that’s a good theoretical question.

Would you like some place where maybe we could gather some data? I have mailing lists of all the local pediatricians that we could contact. We have the local meeting happening in town in three months. Do you think you might like to do a survey, or a small session there, or something like that?" That’s the sort of thing where an academic is going to say, "Oh boy! Now I can write a paper, because I can do the theory part, but oh, getting out there and finding the people, that’s always such a huge pain!" That’s what you guys have.

You’ve got the people, you’ve got the connections, you’ve got the lists, you’ve got the clinics, you’ve got all this stuff. And that’s what you can barter with. And in the process of getting the information that you need for writing a theoretical paper, then you can get your problem worked on. So that’s what you’re going to do if you come to a professor. And I just gave a couple of examples here, of the sorts of things that you might have as a problem that you could turn into a research question. And that’s--if you want to write to me, and tell me, "This is the sort of problem we have. What sort of theoretical question could you see us framing this as?" I’m happy to do that, if you want to e-mail me. So, that’s if you want to go to a professor. Now there’s a couple of other options here. And now I’m backing up two slides.

There’s The Journal of Public Policy and Marketing, I would just flip through there and see who’s working in the areas that you’re working in. Find their names, call them up, and just start a discussion with them. There’s actually going to be a Public Policy and Marketing Conference that we’re hosting at the University of Utah in May. You may want to go onto the website, I’ve given you the URL here, and see if there’s anything that looks like it could be interesting, or contact the woman who’s organizing the conference, actually both of them are good friends of mine, and say, "Here’s some of the things we’re interested in. Are there any special sessions or panels that might benefit from somebody like us being on them?" A great way to make connections.

Your local LEND program will have a HSA trainee, a Health Services Administration. Suggest a project for the trainee. Here’s another one that isn’t on here: every one of these MBA programs has a career-services part of the program. They are desperately trying to place students into jobs, before the students get into jobs, great for them to have experience. Call your local career services, part of the MBA program, at your local business school, and start talking with them about opportunities that you have for having an MBA student come in and do a project in your clinic.

I think you will actually get a positive response from that one. So, in the long term, because Bonnie gave me my little "five-minute" thing, interaction with the business community may increase the long-term effectiveness of public health, I do think this is true. And there is a reservoir of knowledge in business research that could be tapped and directed. But currently, I do not think that this conference is appropriately titled for the business community, because it’s not a question of going from research into practice.

Right now very little business research is actually on issues that are germane to public health. What we need to do, instead, is start where we are over here in "current practices." These are the problems you have right now. You need to get in touch with people who are doing business research. Give us ideas. Give us the places to go, the people to do some--for some of our examples, and out of this is going to come improved practices. The business research community, for the most part, has not been doing much social marketing. Social marketing really was an area of study up through the 1970s, and when the Reagan administration came in, it all kind of shut down, and started moving in other areas. And there’s now people starting to come back into more public policy and social marketing research, and they don’t have a large reservoir of organizations that they’ve been working with for years. And I think that there’s a lot of opportunity there for you to make some good connections. So with that, I’ll turn it back over to Bonnie.