Massachusetts local public health planning, in Charlie Donahue’s telling, died an ignominious death. After the Health Planning Council of Greater Boston pushed back too hard on a proposed hospital move, he said, they found their funding slashed by the state.
“The way this was taken out of a state budget surprised everybody, by the time they figured out what had happened,” said Donahue, who led the Greater Boston council during the 1980s. “We irritated the wrong person, who had the political clout to say, ‘see you later,’ who had no idea what we were doing or what our successes were and who supported us.”
On The Codcast, Donahue reflected on the history of health planning councils in conversation with hosts Paul Hattis of the Lown Institute and John McDonough of the Harvard T.H. Chan School of Public Health.
The Health Planning Council of Greater Boston started in the late 1960s, geared toward involving consumers and locals in health planning. It was set up with support from the federal government, which passed laws in the 1970s supporting health planning agencies across the country, with the broad task of offering guidance to hospitals and institutions and responding to proposed changes in the hospital landscape.
A major goal, Donahue said, was ensuring that the majority of health center and hospital boards be composed of consumers. Discussion of health planning was pivoting away from a purely expert-driven model toward involving consumers and the patients served. Even as the project wilted in Massachusetts, Donahue noted, states like New York maintained robust local health planning agencies.
For powerful hospital systems, bristling at outside influence but also in need of guidance as they explored innovative new technologies, Donahue said the health care providers thought it would be “easier to deal with” the local health council groups than an unwieldy state government. But the councils ended up being too independent for the hospitals’ liking, causing political tensions.
“So part of the reason health planning failed,” he said, “was the hospitals.”
Right out of graduate school, Donahue started spending time with the Greater Boston council. At the time, a major merger was in the works between the Peter Bent Brigham Hospital, Robert Breck Brigham Hospital, and Boston Hospital for Women, which would later become the second largest hospital in the state – Brigham and Women’s Hospital.
There was little a small organization could do, Donahue said, but they pushed for consumer representation on the board of the new hospital.
“It created a lot of controversy internally to have representatives that weren’t under the control of the hospital,” Donahue said. “And that’s the most crucial thing when you think about Steward, and you think about all these other hospitals. They appoint a board of directors that are very supportive of the management, no matter how incompetent it is.”
Donahue said planning councils could have been an essential player in detecting warning signs from the spiraling Steward Health Care. While the state-level commissions grapple with the fallout and possible next steps, Donahue said Steward’s entry into the state should have been met with a sharp, independent eye at the community level.
At the beginning of community health planning in Massachusetts, business groups were most concerned with health insurance costs, Donahue said. They were eating up a big pot of money in union negotiations, so a major focus of the planning council was helping reduce insurance costs, mostly for self-insured employers.
Donahue touted the group’s successes in evaluating on the ground work in hospitals, picking through financial peculiarities to detect systemic failures. He highlighted a hospital with an unusual number of hysterectomies, which looked into the high rate of the surgery after the local health council raised concern.
The chief of surgery contacted Donahue to say, “we knew one person was outta control, doing too many hysterectomies, made a little extra money,” he said. “Your data proved it.” The group distributed the data to other hospitals, Donahue said, explaining the issue. “We got a lot of them beginning to question whether they were the cause of some of the high rates,” he said.
Among other directives, the small council was tasked with considering certificates of need – sign-offs required from the government before a new health care facility can be built. The process, which hospitals decry as creating unnecessary barriers for expansion, involves assessing the impact on the community where the new medical center would be cited and the broader health care market.
They were only advisory, Donahue said, but the friction with the hospitals would turn out to be fatal for the council.
“The bottom line was we were right in the first place in the things we recommended,” Donahue said. “Health planning in Boston ended when $800,000 of state support disappeared, when we disagreed on a certificate of need of a hospital that moved out to the suburbs wanting more beds – recommending that they work with the local hospitals and their low cost beds instead of adding new high cost beds.”
The hospital rallied political support against the health councils, Donahue said, leading to the substantial budget cut. “And that’s how health planning ended,” he said. “That was a failure, you might say.”