An Idea Takes Hold
In 1992, in the basement of his house, Alan Snell, M.D., is exercising on his Stairmaster. He has just returned from a Healthcare Forum conference at which Leland Kaiser spoke of the need for hospitals to partner with other institutions in the community.

Kaiser called on health care administrators to broaden the circle within which they operate, to leverage their resources, to see themselves not as providers of medical care but as community members. "If you can't safely walk six blocks in any direction from your hospital's front door," Kaiser said, "you're not doing your job."

Snell keeps walking on his Stairmaster. In his South Bend practice, he sees patients who are ineligible for insurance or government assistance and who show up in the emergency room needing treatment for preventable conditions. They are people who have no continuity of care, no regular primary care, no pattern of preventative treatments.

Snell sees the same thing as he teaches residents at Memorial Hospital. He has spoken about the problem to Philip Newbold, President and CEO of Memorial Hospital and Health System. He has also spoken to administrators at PARTNERS Health Plan, a managed care company jointly owned by Memorial and based in South Bend.

Snell steps down from the exercise machine. He is thinking of the tithing program at Memorial Hospital that was spun off of Leland Kaiser's suggestion that health care systems set aside, or tithe, 10% of their profits every year for programs that benefit their community's health. Plans are forming at Memorial to provide immunization services, health screenings, clinic care, congregational nurses and school-based educational programs.

Memorial is bubbling with ideas about spending that money. Why not, Snell wonders, use some of the money to provide health care to the working poor?

Snell contacts Newbold who, through a chance meeting earlier with Mary Cornils, a volunteer trustee for the Not For Profits Foundation, had learned of a program in Minnesota that echoed Snell's ideas. Newbold puts Snell in touch with Carl Ellison, Mark Chambers and Barbara Wheeler, administrators at Memorial who are committed to changing the way the hospital thinks about its relationship with the community. Their discussions flesh out Snell's idea and give it a name: the "Phoenix Project."

They get in touch with the Minnesota program, the Community Health Plan of Minneapolis. That program, sponsored by Fairview Hospital, features $10,000 of coverage, a two-year limitation for membership, case management and administration by a managed-care company.

Creating Partnerships
"Alan was making a plea for the medical community to do something," said Mark Chambers. "I think he had a clinic model in mind, but he was also thinking about the Kaiser model of using untapped resources, of broadening the circle. So I talked to the people at Fairview Hospital who had run an insurance-type program for people who had lost their jobs and were without insurance. Fairview sent someone down to talk to us. We arranged conversations with physicians and some potential stakeholders. The health care manager that we contacted was PARTNERS and for case management we were talking to an agency that's called Turning Point now but then it was Family and Children's Services, Inc.

"We thought that case management was the one thing that would make this program different from managed care. We felt that the population we would be serving would benefit from the kind of support that case management could provide, health care skills, life skills, that sort of thing. We could have done that ourselves, but we wanted to partner with others in the community. It turned out that there were problems in that partnering model that we didn't anticipate."

Broadening the Circle
Snell, Ellison, Wheeler and Chambers continue to chart what the program will look like. The circle is widened, admitting Janine Chambers, an administrator at PARTNERS. "Hiring Janine Chambers," says Snell, "was key. She knew what was going on with the initiatives at Memorial, she had the social skills, the experience and the urge for something new. So we sold the program to PARTNERS as a learning lab."

The decision is also made to make the program available for two years to residents of 2 census tracts in southeast South Bend.

"We picked 2 years," Snell said, "because we wanted a way to stop the hemorrhaging if the plan didn't work. We didn't want to make promises we couldn't keep."

Alan Snell drives to Indianapolis with Carl Ellison to speak with the Insurance Commission. Snell recalls: "What we were up to wasn't an insurance plan and we didn't want to be regulated as if it were, so Carl and I went down to meet with staffers to convince them that this wasn't an insurance plan. What we argued was that we were offering a charitable gift. At first they looked at us weirdly, but we explained that we were planning on partnering with a managed care company and that seemed to reassure them. That was after the Clinton reform plan had been rejected, and we were offering an alternative to that top-down model. We knew that we weren't going to make things worse, and I applaud the insurance commission for letting us experiment."