Board Responsibilities

The Important Role of Trustee Advocacy

Four Executive Leaders Discuss Their Advocacy Agendas

By Kara Witalis and Linda Summers

Although there is no doubt that the past three years have put enormous strains on health care provider organizations, the reality is that the health care sector undergoes regular waves of change, uncertainty and significant turmoil. Prudent leaders understand the important role that effective trustee advocacy plays in building organizational resiliency and fortitude to navigate whatever challenges come next.

Advocacy is a key part of trustees’ responsibilities going back to the origin of the community hospital and the requirement for community governance. As a community asset, the not-for-profit hospital is required to have a board of volunteer community members to represent and advocate on the behalf of the community. Hospital trustees have a unique and powerful role as key communicators of the benefit provided by their hospital. Because they are volunteers, trustees are seen as unbiased, impartial protectors and stewards of the hospital’s cherished mission, values and vision.

The goal of advocacy is to represent and support the community and the work being done, as well as the work needed to serve the mission. In the broad sense of the word, trustees are more than advocates. They are also ambassadors, educators, connectors, and partners. Through advocacy work, trustees provide insight, leadership, community trust, clarity and perspective.

Executive perspectives

In this report, we interviewed four executive leaders from hospitals and health systems around the country to learn what is on their advocacy agenda, as well as some of the secrets to their success in collaborating with trustees to ensure their organizations can deliver high quality care to their communities.

Based in Springfield, Ill., Hospital Sisters Health System (HSHS) is a 15-hospital Catholic health system that serves patients in 14 communities in Illinois and Wisconsin. The health system has its roots with the Hospital Sisters of St. Francis, who began providing care services in the area in 1875.

What are your organization’s top advocacy priorities for 2023?

Boatwright: We work to influence federal, state and local health care. Our advocacy priorities are in line with our mission, and our advocacy agenda is centered on acknowledging the value of life across the entire life span and the inherent dignity of all. This includes challenges such as reasonable gun control to reduce gun violence. We advocate for policies that support better public health — safe streets, affordable housing, clean water, improved literacy — essentially the social determinants of health.

I believe there needs to be an attempt to enhance the Affordable Care Act to further benefit our communities and those we serve. The ACA is not in and of itself ideal and there is much to improve. We need bipartisan support to make changes to the act that moves us toward affordable and more accessible care. HSHS will advocate for enhancements to the ACA this year when we see the opportunities to do so.

What do you see as the trustee’s role in advocacy in general and for 2023 in particular?

Boatwright: I appreciate when I as a CEO can partner with my trustees to advance any one of the issues we support. My organization’s trustees have a wide variety of expertise, which can be invaluable for strengthening support and advocating in areas that they know. We cannot do this alone. Trustees bring with them a network of people they know along with resources that can impact these issues and create change. It can be in the form of phone calls, donations, writing letters, opening doors to legislators, etc. Typically, board members are well connected in the community. They can also assist in connecting us to the legislative language that will be well received and positively impactful. We only have so much information and need to use the resources available to our organization. It is important to use their connections and their voice to ensure we can successfully address important advocacy issues.

What are a few strategies that have been effective in leveraging trustees in your organization’s advocacy efforts?

Boatwright: Our board members have helped us build allies who have been able to obtain support for our organization and our endeavors in certain situations. This has been valuable when we advance initiatives such as building a new hospital or consolidation/changes in services that might require both community and statewide support. This might come in the form of certificate of need support, for example.

Lobby day participation has been key for our trustees as well. This is an opportunity we leverage to advance our advocacy agenda. Our board members have been asked to testify to legislative bodies for specific issues on behalf of our organization.

Personal outreach to legislative members is also of great importance. Our trustees are unpaid and are volunteers. I do think that gives them more credibility because they are viewed as less partial. Their advocacy comes from a position of commitment to the mission, not one of supporting their livelihoods.

Trustees can also be helpful when we consider potential business ventures that may benefit the organization, such as mergers or acquisitions. They can serve to support those initiatives with their experience, connections and expertise.

The two most important roles for board members are overall governance/strategy and advocacy. I believe a key board role is advocating for all that is best for the organization.

St. Lawrence Health (SLH) is a three-hospital health care system at the Canadian border in upstate New York that recently affiliated with Rochester Regional Health, an integrated system that also serves western New York and the Finger Lakes area of New York. St. Lawrence Health offers a full range of health care services in northern New York, including acute and emergency department care, urgent care, primary care and specialist care. The system includes a critical access hospital, two sole community hospitals (one of which is in the process of converting to critical access hospital status) and primary/specialty clinics located throughout St. Lawrence County.

What are your organization’s top advocacy priorities for 2023?

McGregor: Our board advocacy work takes a number of different forms. Local advocacy is in the domain of community health needs. Board advocacy with state and federal legislators and regulators is focused on policy decisions that impact rural health care in our state and across the country. Specific topics include lobbying for transformation grants for sole community and critical access hospitals, the 340b [drug pricing program] and what it means for rural health care and funding opportunities and optimizing the reimbursement structure to help the expansion of rural health strategies like women’s health care, advancing primary care, transportation, addressing social determinants of health.

What do you see as the trustee’s role in advocacy in general and for 2023 in particular?

McGregor: In terms of the trustee’s role in advocacy, again, it takes many forms. First, the trustees are our direct connection with the communities that we serve. St. Lawrence County is the largest by geographic size but one of the smallest by population in the state. We have three population centers, each with their own population demographics and health care needs. Our trustees work to understand those local needs and advocate on the behalf of their communities with regard to service offerings to address those needs.

Secondly, they are ambassadors of the health care system itself. They work to represent SLH, share our story and the work that we do in support of our community, and they make important connections with other organizations to further the work together.

More broadly, our trustees advocate on behalf of and in furtherance of rural health care with state and federal regulators and policymakers.

What are a few strategies that have been effective in leveraging trustees in your organization’s advocacy efforts?

McGregor: Our trustees’ advocacy strategy starts with education — giving them every opportunity to learn about health care trends and challenges, best practices and current and potential policies that help or hinder our progress toward our mission. Our board members attend the HANYS [Healthcare Association of New York State] conference routinely and are given education on an array of health care trends and fundamentals at board meetings as well.

We also ask board members — those who have interest and
capacity — to be on other boards with community-based organizations. This creates a great partnership and link between SLH and other organizations doing similar but not the same work. We create a much bigger impact when we can join together.

Another simple but very effective advocacy strategy is developing board-sanctioned talking points that trustees can use out in the community to advocate for SLH and help to tell our story.

John Muir Health is a mid-sized independent, not-for-profit health system located in the San Francisco east bay area. In addition to its foundation-based and independent physician groups and multiple clinics across the area, John Muir Health includes two acute care hospitals — John Muir Health, Walnut Creek Medical Center is a 554-licensed bed hospital that is designated as the only trauma center for Contra Costa County, and John Muir Health, Concord Medical Center is a 244-licensed bed hospital that has long been recognized as a preeminent center for cancer care and cardiac care, including open heart surgery and interventional cardiology.

What are your organization’s top advocacy priorities for 2023?

Thomas: Legislators at the state and federal level as well as media outlets are painting hospitals and health systems in a very negative light. For example, the Washington Post recently published an article about the number of people in financial hardship because of medical debt, and hospitals are being blamed. There is no mention that health plans are now predominantly selling low premium high deductible health plans that leave patients with large deductible payments they cannot afford. Health care costs have always been driven by several factors and we, like many health systems, are working hard to lower the cost of care for consumers. But we cannot do it alone. For example, we have achieved savings with health plans, but those savings are not passed on to local consumers in the form of lower premiums. They are absorbed to balance losses in other parts of the state.

Additionally, there is growing momentum in several states to introduce hospital price caps, which would be devastating for hospital finances. There are also many managed care policies that favor insurance companies and are harmful to hospitals. California’s Department of Managed Health Care has recently taken steps to hold health plans more accountable for their payment and denial practices with hospitals/health systems.

What do you see as the trustee’s role in advocacy in general and for 2023 in particular?

Thomas: By far, the biggest challenge facing hospitals and health systems is that government sponsored payers, Medicare and Medi-Cal [California’s Medicaid program], do not come close to covering the cost of care. At John Muir Health, our government sponsored payer mix has increased from 50% in 2009 to 72%, and growing, currently. Over the same period, we have migrated from profitability to operating losses. The growing gap between government payments to hospitals and health systems and our actual cost of care is the reason that one-half to two-thirds of hospitals and health systems are now losing money. We have had a number of discussions with our board about health care finances and they are helping to articulate our challenges to key stakeholders in the communities we serve.

What are a few strategies that have been effective in leveraging trustees in your organization’s advocacy efforts?

Thomas: We do know there is a growing need for hospital/health system advocacy at the state, federal, and local levels, and we are fortunate to have board members with very diverse backgrounds, including in politics and advocacy. They believe deeply in John Muir Health and our mission, and we will be leveraging their connections and respected voices in our future advocacy efforts. The priorities I spoke of are also the reason that expanding our trustee focus on philanthropy is an important priority and a key strategy for growth and sustainability.

Tahoe Forest Health System, a DBA of Tahoe Forest Hospital District, was formed in 1949 by a vote of the general public to develop a new hospital in Truckee, Calif. The district health system now includes two critical access hospitals — Tahoe Forest Hospital and Incline Village Community Hospital in Incline Village, Nev. — as well as an ambulatory surgery center, home health and hospice programs and a variety of community health outreach programs.

What are your organization’s top advocacy priorities for 2023?

Weis: Our health district has been in place for over 70 years with our town growing up around us. Our service area covers five rural counties across two states and spans approximately 3,500 square miles.

For 2023, our most pressing advocacy effort is to achieve voter/town approval of a master facility plan in order for us to accommodate demand and meet the needs of patients in our communities. We need and want to grow our facilities to meet the needs of our communities but need the community to recognize that we cannot achieve this within the existing footprint and within current zoning requirements.

Labor supply and costs are also a major advocacy priority for us. We are a most favored place to work and pay well. That said, California Senate Bill 525 [which seeks to establish an hourly minimum wage of $25 per hour for health care staff], should it pass, would significantly raise the cost of providing health care and cut into our ability to provide services to the community.

What do you see as the trustee’s role in advocacy in general and for 2023 in particular?

Weis: As a health care district, we have an elected board of five members. Their role in advocacy is to put in the time to engage with our local community and with other town officials. We ask our board members to help our communities and citizens understand that for the health care district to provide the level of service excellence that we all expect requires state-of-the-art, modern facilities, adequate and well-trained staff and fair reimbursement for services.

What are a few strategies that have been effective in leveraging trustees in your organization’s advocacy efforts?

Weis: We provide education and information to our board members that they can use when advocating on our behalf. For example, we provide them with data on how different policies — local, state and federal policies — will impact our health care district as well as rural health care generally.

There are roughly 1,358 critical access hospitals across the country that provide necessary health care services to rural America. Without critical access hospitals, people are forced to drive long distances for basic health care services or even go without care. Yet, many are at risk of closure. Critical access hospitals need strong support and advocacy specifically on topics like CMS [Centers for Medicare & Medicaid Services] cost reporting, labor supply and cost, access to capital and reimbursement for telemedicine. For example, unless we receive the same reimbursement from CMS and insurance for a telemedicine visit as we do for an in-person visit, it will be nearly impossible to keep physicians and advanced practice providers like medical assistants and physician assistants practicing in rural towns.

We need to deal with these issues or there will be an acceleration of the disappearance of critical access hospitals and health care deserts in rural America.

Greater Need for Advocacy

As providing care and managing the business of health care becomes increasingly complex, the need to rely on the voice of governance to support and advance the priorities of health care has become ever more significant. Enacting targeted strategies and partnering with trustees can provide health care organizations with the needed advantage to continue to meet the health care needs of the communities they serve while building organizational resiliency and fortitude to navigate whatever challenges come next.

Kara Witalis (kwitalis@viahcc.com) is principal and Linda Summers (lsummers@viahcc.com) is senior principal at Via Healthcare Consulting, based in Carlsbad, Calif.

Please note that the views of authors and interviewees do not always reflect the views of the AHA.