This is an oral history of Deborah H. Ward, Ph.D., who was elected to the Board of Trustees of Group Health Cooperative in 1994 and has served three terms as chair. The interview was conducted by Karen Lynn Maher on February 5, 2002.
Maher: How did you become involved with Group Health?
Ward: When we moved here, I had heard a few little tidbits about Group Health through the public health literature. I had also just finished my Ph.D. in health policy, which was the degree that made me eligible to apply for this job (Assistant Professor, University of Washington). In the course of earning a Ph.D. in health policy, of course the name Group Health came up, but I didn’t understand what it meant. All I knew was that Group Health was a place where people received health care. So, when I signed up for my employee benefits, I chose Group Health. We were living on Bainbridge Island. Group Health had a clinic on the island. My choice made good sense. I liked the concept of integrated care, which I had not experienced.
My first involvement was serving on a committee about long-term care; I started meeting some people. Then at the Seattle Home Show, a man approached me and asked, “What do you think about being on the Board of Trustees at Group Health? Would you like to run for the Board?” He was a member of the Standing Nominating Committee of the Membership and had heard me speak somewhere. Well, I felt ignorant about Group Health. I didn’t know what it meant to serve on the Board. Plus, I was going up for tenure. So, I said, “No, I’m too busy. It’s not a good time.”
The following year, the offer came up again. I had done a few other things at Group Health besides the long-term care committee I mentioned earlier. I decided to pursue running for a trustee position. I went through the Standing Nominating Committee review, including a group exercise that was observed by the members of the committee. Caroline MacColl dominated the “bejeezus” out of the group process. I saw that it was a very interesting, political, sociological and power structured deal; I found the process very appealing. I thought there would be a lot for me to learn, so I kept going through the process, albeit blindly.
Bainbridge Island is an over-privileged community in many ways and one of the things that happen on the ferry between Bainbridge and Seattle is that a lot of political activity gets done each day. People are on the boat for an hour each day so a lot of business gets accomplished. One day on the boat, Elaine VonRosenstiel (a member of CEO Phil Nudelman’s Strategic Leadership Team) came up to me and essentially said, “Phil Nudelman wants to know who you are.” I realized at that moment that I had a real chance of becoming a trustee. I thought, “Oh, this isn’t PTA or a group of community volunteers who comes in and sits around.” I realized that the Group Health Board of Trustees was integrated into the system much more profoundly than I knew. My conversation with Elaine led to my first conversation with Phil Nudelman.
I have to tell you a story about Phil that makes me laugh. Group Health has taught me so much about the business of health care, particularly finances and risk management. There were so many things I knew nothing about that I’ve learned from being on the Board for which I am truly grateful, especially how to handle being thrust into social situations. Theoretically, given my class background, I should have been better prepared. But, I wasn’t because I grew up in Bakersfield, California, instead of Hartford, Connecticut. As a trustee, social situations arose for which I was unprepared. The first one was the first December I was on the Board. Phil Nudelman gave extravagant holiday gifts to the Board members. One day I went into Phil’s office for what turned out to be the event at which he gave trustees their gift. I was thunderstruck to get some incredible thing like a fossil. Phil handed me the gorgeous present and I said back to him, “Phil, if I had known about this I would’ve spent five dollars on a present for you.” I blurted out that stupid comment. I have only told that story to a few people -- my family and a few trusted advisors. It was a terrible experience to be unaware of corporate gift giving and how to receive a gift from a CEO.
Maher: That is a great story!
Ward: It was pathetic, but useful.
Maher: What has been your most significant health care experience with Group Health?
Ward: I was thinking about this as we’ve been talking because I have a significant story and I will tell it to you. But, I don’t want my passion and authentic feelings for Group Health and for health care in general to be confused with my personal story. I feel very passionately about Group Health. My personal experience plays a role in it, but equally important to me emotionally and intellectually is my feeling about consumer governance and the way that Group Health is trying to chip, chip away at changing the warped way health care gets delivered.
This morning I met with a Group Health committee responsible for granting credentials and privileges to the medical staff. Part of the process is to review consumer complaints and clinical quality, which are tracked and reported in a formal, structured way. (The Vantive reporting system at Group Health is used to support efforts to improve customer service.) Physicians, as a rule, are not used to being talked back to by consumers and others in formalized ways. In the meeting this morning, I heard the worry, resistance, and concern from the physician groups about having their decisions questioned. There is tremendous transformation taking place and it’s difficult for everybody, but Group Health is leading the way.
I would feel misrepresented if the reason, the driving force, for my vision about a transformed health care system had to do predominantly with my personal health experience. My vision has more to do with my love of democracy and my belief that Group Health is struggling admirably against forces that are at work to make health care just another American commodity full of racism, inequalities, and privilege. My intellectual and emotional commitment and my feeling about democracy at work at Group Health are the most important factors that bind me to the Cooperative. I do not want my passion for Group Health interpreted as stemming from my personal health.
Now, to focus on my own health care experience. I had only been in Seattle for a few months. I enrolled and went in to meet my new physician. During the physical exam, my terrible family history of breast cancer was noted. An examination of my breasts revealed nothing, but a mammogram showed a great big mother lump. That was a terrible experience, which was poorly handled. There have been great improvements in breast care at Group Health since the day I was sent home knowing that something terrible was wrong, but not knowing what it was. I did have breast cancer and I had surgery. I received terrific care from great nurses, a great surgeon, and a great, great radiation oncologist Tom Johnson, who recently died. I am now 14 years away from surgery so I’m back to the normal pool. But, my illness with cancer was a terrifying experience. So that’s my big health care experience and a key reason for my bond with Group Health.
Another important personal bond for me are the University of Washington students who have graduated and gone on to work at Group Health. I teach in the nursing school. We have nurse practitioner students and others who go to work for Group Health; I love hearing from students over time about what they’re doing. It seems that all the family nurse practitioner students work for the consulting nurse service at Group Health. I’ve taken a lot of interest in how the students help make the consulting health nurse service work. So, I have my personal health connection and I have the students who bring back news of the Cooperative.
Maher: Let us focus now on consumer involvement. Why does consumer involvement matter?
Ward: Because we live in a democracy. Because the wild disproportion between the silence of patients and the vocal self-interest of professionals is criminal. I don’t believe in that kind of a system. It’s hard for me to talk about it because it seems so painfully obvious that people who receive the services should be informed and active. Sometimes I daydream that one day there will be a generation of clinicians who are not used to silent patients. They will welcome interactive patients and they will consider a long list of complaints and comments as a sign of being engaged with their patients. In my dream, clinicians who are not suited to being engaged with the population they serve should have responsibilities other than direct patient care. Clinicians who lack interest in dealing with the public shouldn’t be in the health care business.
Maher: Why do you think it’s such a difficult thing to get people involved in consumer governance?
Ward: I think there are two issues. First, it is difficult to get people to talk back to high status professionals. Second, people are reluctant to get involved in a structure that interferes with family obligations. Consumer governance is poorly designed to attract individuals with families. Committee meetings occur on weekday evenings. The annual meeting is on a Saturday at a time when soccer games are taking place. The range of opportunities for people to participate is limited.
If every housing development, every neighborhood center, and most homes were equipped with the little videoconferencing camera that costs about $200, we could call up a random sample of consumers and seek their guidance on specific issues. Another option to explore might be email discussions. We need to explore new ways to communicate with our members beyond those currently in place.
When I first started coming to Group Health meetings, I didn’t have a car in town so I came to meetings by bus or by cab. Some ways of consumer participation are focused on people with certain kinds of skills and disposable income that makes it possible for them to cover expenses, e.g., cab fare, airplane ticket, and be reimbursed -- a normal way business is done. Well, what percentage of Group Health consumers who could be excellent, articulate, thoughtful contributors to consumer governance are able to front money for expenses even though they will get reimbursed? Or, what percentage would realize that they could actually travel to a meeting by cab? Consumer governance is designed for a certain economic echelon and there isn’t much recruitment of people outside that echelon. That is one thing that could be considered when designing consumer meetings. People’s interest in volunteer work in America is still extremely high, so why haven’t we tapped it? For example, how many Group Health consumers don’t know that they can become (voting) members? Virtually everybody can be a Cooperative member now; there’s no fee. But, it just doesn’t happen.
I feel that getting people to contribute their opinions, come to meetings, and become a member are solvable problems. But, it is going to take more capital than we possess right now and more focused energy than anybody’s got to devote to the issue. However, the more challenging problem to solve is getting people to participate in a system that has historically depended on the high status of professionals and the silent, quiescent but eager buying power of consumers.
Maher: When you think about your own participation in governance during the past seven years, what has been your most significant experience?
Ward: The night Teri Lafnitzegger, a woman who had terminal brain cancer, spoke at a consumer forum. (The forum was held on April 15, 1999.) The newspapers covered her story, including her search for experimental treatments for which Group Health was not contractually obligated to pay. She pursued public and legal remedies. It was a very interesting case. As a result, much conversation occurred through the Cooperative about experimental and investigational therapies and the role of employers in the design of health care contracts. Teri was a federal employee and a major part of the issue was what the federal contract covered. It wasn’t about a heartless bean counter in the basement of Group Health saying, “I’m going to condemn you to death.” It was about interpretation of the contract -- a really complicated issue.
The Cooperative sponsored a series of consumer forums about the issues related to coverage of experimental and investigational treatment. Teri came to one of them and it was the most wonderful experience to witness her getting up and saying her piece and consumers saying their piece. The people who attended considered the hypothetical scenarios. In the end, people were asked to answer the question, “Would you pay for experimental investigational treatment?” The straw vote result, with Teri present in the room, was “no,” they wouldn’t pay. I left the meeting feeling blown away, akin to what it must feel like to serve on a jury -- an experience I have not had. The public came in, looked at the case, expressed thoughtful contributions, and made a decision. That evening was incredible.
The annual meetings have always been incredible to me, particularly the ones that I’ve had to chair. I don’t like surprises and that’s not a good place for somebody who doesn’t like surprises. We try to orchestrate the deliberations and keep the meeting under control. Even though we ask members to refrain from talking about their personal health issues, one year a guy got up and talked about his toe fungus.
Consumer governance is democracy in action; it is people speaking up, for which I am psychologically not well equipped. I’m actually pretty controlling. As a teacher, I have a lot of tricks to control what goes on in the classroom. Let go of the group and just let it happen? I’m not very good at that. However, Group Health has afforded me some opportunities to practice; my experience has been fantastic. I have so much to learn and this (consumer governance) has been such a good experience for me.
Maher: We talked about the Cooperative transforming health care. How do you see Group Health transforming health care?
Ward: I have so many visions about this; some I articulate, some I lobby for, others I keep under wraps for a little bit longer. I think we could bring a lot of people at Group Health together and have them paint a picture of what health care would look like in 20 years. The picture would include incredible levels of consumer information and open medical records. Let’s take the Teri Lafnitzegger case. I think about this one a lot. Teri received a terminal diagnosis and walked out of the doctor’s office without the kind of support a person needs after receiving terrible news. I wasn’t there so I don’t know exactly what happened.
I have daydreamed about a better scenario. She walks out of the office having at some point been asked about and given the chance to express her desires about end-of-life issues. We know her preferred learning style, so she receives information in the best way suited for her. She stipulates the kind of information she wants and how she wants it conveyed. Then, we have a guaranteed method of following up with her. In my daydream, she walks out of the office and the nurse says, “Are you safe to get home? Do you have a ride? I’d like to call you tonight, may I?” The attention the woman receives moves up in priority given her terminal diagnosis. The library and hospice nurses call to offer information and support. With ease, all of the support services that actually exist now at Group Health become available to the patient.
One of the tricky parts about the decision to call upon the resources is that it falls out of the hands of the individual practitioner and requires involvement by the whole health care team. It goes back to the issue of the relationship between high-status professionals and low-status, silent, consumers.
Maher: Do you mean the communication gap you spoke about earlier?
Ward: That’s right. So, as we work to transform the health care system, which is occurring with glacial slowness, the role of the individual professional is also changing. The word “professional” may even get changed. That is really hard. We have to figure out how to manage that one too.
I just read an article about physician-as-worker. I’m picking on physicians, but there are a lot of players in this system that participate in keeping the professionals at the top and the patients silent at the bottom. The article about physician-as-worker is really interesting because it means an enormous change in the self-concept in the people who will enter clinical medicine. I think it (change) is to everybody’s benefit, but I understand that the changes are going to be really tough. One of the reasons I’m dedicated to Group Health is because it is actually making the transformation. It is not just what happens in the clinician’s office, but also what happens in the payment system and what happens in the nursing school. All the parties involved have to change.
Maher: When you think about your involvement in the past seven years at Group Health, what has been your most significant contribution to the Cooperative?
Ward: I think I have put in some words behind the scenes that have led to changes. Some of them I don’t think I can actually talk about because they occurred kind of under the table -- some points of view about economic decisions, some thoughts about labor. I know I have contributed things to Group Health. I have given my time and I have injected some humor and I’ve brought some different perspectives. I don’t mean to say that those aren’t valuable things, they are. But, it is much clearer to me what has come back the other way -- what has come to me. For example, I appreciate just hanging out with Aubrey Davis. He is a guru to me, politically. He is such a smart guy. He is a great guy with no ax to grind. His ego is totally under control. He exemplifies such goodness plus savvy. He is not dumb or naïve in any way. He is a really, really good man.
I have gained a lot of personal relationships. I treasure my relationship with Cheryl Scott; it has grown into a friendship that really matters to me a lot. Cheryl’s partner, Hannah, and I have embarked on a number of schemes. The people in the Board of Trustees Office -- Pam MacEwan and Theresa Tamura. I feel like the personal relationships have been incredibly valuable to me. Learning about the business has been valuable from the beginning -- sitting in former Chief Financial Officer Grant McLaughlin’s office trying desperately to understand a budget with more zeros on it than I have ever seen before. I understood the health care system from the clinical side and from theoretical side, from getting my Ph.D. So, I didn’t come to Group Health as a peon, although I began my health care career as a home-health aide so I was low, low. But, I was never going to be consigned to “home-health-aide-dom” for the rest of my life. I knew I could move out of it. As a new trustee, I knew nothing about the business, so learning about it was fantastic for me and was such a help.
Maher: Has it helped you in your teaching?
Ward: Oh, incredibly. Quite crassly, I knew that getting involved with Group Health would have great benefits for my professional life and it absolutely has. I have met a lot of people, made contacts, and gained understanding about the business. There isn’t a course in the world, short of leaving this job and taking a job at Group Health, that could have taught me everything I’ve learned as a trustee. I am intensely grateful; it has been a good deal for me.
Maher: What is Group Health’s greatest strength?
Ward: I think this is the place where you’re supposed to say, “Oh, the people.” It’s true. They are.
Group Health is still waving the banner that is earthed in old time left-of-center liberalism or even progressivism. I still like that old flag. I like it when Lyle Mercer [former Trustee] stands up and says, “Brothers and sisters ... .” It is a little glimpse into the past. There are many a marketing person who would shudder at the image, but it (the image) does things for me that it may not do for many other buyers of health care. I guess then, I’d say that Group Health’s greatest strength is that it is looking to make an incredible knowledge and status change. I still maintain that it stems from those old cooperators who said there should be a way for all of us to contribute equally and get out what we need because life is not fair. And, we can do things to watch out for each other. That was part of the impulse for starting Group Health and I think it is a wonderful thing.
Maher: Why should a young family consider joining Group Health?
Ward: Because they should participate in the transformation. They should use their online abilities and get straight access to their practitioner. They should take advantage of an integrated system that takes their little kid with ADHD [Attention Deficit Hyperactivity Disorder] and sends them to the correct evaluator, corresponds well with the school system about the problem, works out his drugs, teaches him to manage his own medication, and links him up with other little kids who have ADHD. The pieces are all there. The primary struggle for an integrated health care system is all the coordination.
Most young families find that the best Group Health can offer is what they really need; the Cooperative is resource rich, information rich, and efficient. Many of the old hierarchies (ways of providing medical care) don’t apply to young people. Group Health is actually working to break down the hierarchies and open up information to better suit the way many young people have been educated and the way many young people are employed. There are a lot of people who are constructing their own work environment. Group Health should be able to meet their needs. It remains to be seen if it actually happens, but that’s the goal.
Maher: How has Group Health changed the community and why are those changes important?
Ward: The sign out front makes it [Group Health Cooperative] a gun-free zone; that’s a good voice to have in the community, although there was push back about that decision. Group Health was instrumental in creating school-based clinics and working with that movement. Locally, Group Health does a lot, including maintaining an incredibly close connection with state government as they try to work out financing. Politically, both sides view Group Health as an honest broker; we have done that a lot. We promote wellness at community events, e.g., Folklife Festival, athletic events. Nationally, Group Health promulgates a good model of health care delivery. We have been talking quality of care, safety, and prevention—founding principles -- for 50 plus years. Our message has been consistent.
Maher: How do you describe Group Health to others?
Ward: It is the country’s largest consumer governed not-for-profit health maintenance organization. Those are the words I use. I guess the people I hang with mostly know what that means. It’s certainly true that I hang around here in town with people who know Group Health, but some reason makes them not get their care there. I don’t know if it is the “group death” tag, habit, or some snobbery. As the marketing people will tell you, these are great barriers and I personally think it has something to do with status that prevents people from saying, “Oh, not only is this a good idea I’ve read about -- in the newspaper or in some health professional’s journal -- I’ll go there too.” It is the “I’ll go there too” decision that is still the big leap.
Maher: When I say “Group Health Cooperative,” what immediately comes to mind?
Ward: The marketing people want it not to be a picture of Lyle Mercer standing up and saying, “Brothers and sisters ... .” But, that is what immediately comes to mind for me. This is mundane, but I think about the Administration and Conference Center -- the building across from the Pink Elephant Car Wash -- and the sculpture in the lobby of a black hand and a white hand clasped. I’m not particularly fond of that sculpture, but it has great meaning.
Maher: What are the emerging trends in health care to which Group Health should be paying attention?
Ward: The need for consumers to have access to more information and the enormous issue of how to pay for health care.
We’re doing a laissez-faire method of providing information. We guide consumers to a website to find out what they want. We need to be more targeted about providing information. We need informational nurses or information guides that really help people. Harborview has a library down in the basement next door to the gift shop where any Tom, Dick, and Harry can come in and say, “Upstairs the doctor just said I have ... . What is that?” Information is available in many languages -- Thai, Laotian, Cambodian. We need to target the information needs of our population.
We talked a lot about equalizing the health care hierarchy. That is an enormous trend and health professionals of all kinds need help to recognize and accept the trend. They need a lot of support and coaching. Then, after a point, if professionals are not on board the train, they are going to have to get off.
The other enormous question is, “When are we going to decide about paying for health care?” Are we going to decide that in fact health care is going to become the major business in America, next to exporting arms? Uwe Reinhart, an economist from Princeton and a health care commentator, asks whether it is a good thing or a bad thing that health care is a big percentage of the gross national product? Well, if it becomes the dominant industry of America, what does that mean? Group Health has to think hard about what its position is out there in not-for-profit consumer-governed land. If the rest of the country is saying, “Yes, let’s get into full-body CAT scanning,” which is offered and available to an executive group, regulation is not going to happen. We’re not going to regulate the creation of profit in this country. So, given that, Group Health is going to have to decide how it will wave the banner for buying a reasonable amount of care and making it available to lots and lots of people. I don’t know; that is a really thorny one.
The professional hierarchy stuff is going to get fixed. The consumer information stuff is going to get fixed. But, the big conflict between the creation of profit and the equal spread of resources is a big struggle in this country, and where we’re going to come down on that as health care becomes a bigger and bigger business in this country, I don’t know. Good luck.
Maher: In your mind, what is the single greatest challenge Group Health faces in the next five years?
Ward: Financial well-being. There are 20 little parts underneath that heading. What’s going to happen as we switch to defined contribution as opposed to defined benefit? What is going to happen with Medicare? What is going to happen as the state withdraws funding? Some elements of our state economy are going to make us lag even further. Our unemployment rate bottomed out quicker than the rest of the country and it’s going to take longer to recover. Cheryl Scott is waving this flag and she’s doing a fantastic job, but we’ve got to increase our appeal to younger families. We’ve got to spread our risk at the same time as we’re doing all this other stuff, like providing more information. Are we going to have the capital to do all these things? I don’t know, but Cheryl is right to be making everybody pay attention. It goes back to what we were talking about before. Will citizens decide what they want to buy and will they buy it? For the most part they’re blind to costs. Will they come to a greater consciousness of what health care actually costs? That was the intent of defined contributions. What decisions will they make based on their increased awareness? These questions will be answered more slowly than our need to be able to predict our financial future.
Maher: How do you think Group Health’s past—its roots—prepared it to meet the future?
Ward: I think the question is, “Do its roots prepare it for the future?” It would be good to ask a labor historian that question because the roots of Group Health are in organized labor. Are there elements of organized labor that have outlived their usefulness, which has led to decreased labor participation? I don’t think that’s quite true and I’m sure there are pockets of labor activists and labor intellectualists who would talk about labor having a new view of globalization, but I don’t understand that. We have a long history of talking to each other and that is good. People talking to each other prepared us for the present and the future.
Maher: What are your greatest hopes for Group Health Cooperative?
Ward: Once upon a time, as a young pup, I would have said that my greatest hope is that the model of Group Health would become a national model and it would spread throughout the country, financed by a single payer. Thanks to Aubrey Davis, I do not hold that same goal anymore because I have a better understanding of what pluralism actually means. So, I think my greatest hope for Group Health is that it continues on the road to transforming the professional hierarchy, enhancing the availability of information, increasing consumer governance, and identifying new kinds of participation for consumers. We have an army of physicians and others who go out and tell the rest of the country how Group Health does its fabulous quality of care. I think we need a little army of citizen spokespersons who go out and tell the world how consumers should participate in health care.
I also hope for some miracle to happen to ensure Group Health’s financial viability for the next 20 years. People will look at me and say, “The miracle isn’t what you’re praying for. You’re praying for some good economic news and lots of hard work on our part to turn things around so that we can feel financially secure and get back to a strong balance sheet.” I don’t see Group Health Cooperative conquering the world. I see it continuing to be a clinical leader and continuing to do its business here in Washington with an assured future through financially stability. I wouldn’t have understood that at all eight years ago; I would have thought it was a matter of will or ideology. Now I understand it, and that is barely the beginning.
Maher: I’ve gone through all my questions, and I want to offer you an opportunity to say whatever else you want to say.
Ward: I think I have. Those were good questions, thank you. It’s fun to talk about it.