This is an oral history of Dorothy H. Mann, Ph.D., who was elected to the Board of Trustees of Group Health Cooperative in 1987 and served until 1996, including four terms as chair. The interview was conducted by Karen Lynn Maher on January 29, 2002.
Maher: How did you become involved with Group Health Cooperative (GHC)?
Mann: I first became involved with Group Health not as a patient, at all, but out of a background as a community health activist. Before I ever knew I would move to Seattle, I had been a program officer with the federal Office of Economic Opportunity’s (OEO) Community Health Center Program. We had funded a project with Kaiser Permanente in Portland, Oregon, with the requirement that it organize a consumer advisory committee. We were seriously into consumer involvement or “maximum feasible consumer participation,” as it was referred to in the enabling legislation. The intent was to empower poor and underserved communities to have a voice in the decisions that affected the quality of their lives. Having a consumer advisory board was a breakthrough for Kaiser Permanente because generally individuals became members of the plan because of their employment -- the employer offered the Kaiser Permanente plan along with other health coverage options. Members participated in that way (by choosing the health plan); there was not an organized consumer advisory body from which Kaiser-Portland leadership was required to seek advice.
When I came to Seattle in 1979 I selected Group Health as my health plan. I had been favorably influenced about integrated health care delivery systems by a professor at the University of Michigan School of Public Health where I earned my Master’s Degree in Public Health.
When I arrived in Seattle as Regional Health Administrator of Region X of the U.S. Public Health Service, I was already known by some of the Cooperative’s consumer leaders because the OEO had given a grant to Group Health to cover the cost of care of low-income families -- I believe 2500 -- in the Puget Sound area. So, I was aware of Group Health in that context, but I did not get involved as a consumer myself until Gail Warden was hired as chief executive officer (CEO). [Gail Warden became CEO in 1981.] I had known Gail from my work with Chicago area community health centers; he was a strong supporter of consumer involvement. When I called to congratulate him and welcome him to Seattle, he said, “Thank you, and why don’t you come on over and get involved here. You know how this consumer involvement stuff works.”
Initially, I was invited to become a member of the Group Health Cooperative Foundation Board. That experience gave me a way to learn about the organization and to determine if, in fact, it was a good match for me. Did my philosophy of consumer participation match that of the organization’s governing board? The answer was, “yes.” After serving on the Foundation’s Board, I was interviewed by representatives of the Cooperative’s governing board and was invited to run for election to the Board of Trustees. I was elected in 1987 and completed a nine-year tenure, including four years as Chair of the Cooperative -- an absolutely incredible experience. I like to think that we did some things under my tenure that advanced the role of meaningful consumer participation in the organization.
Maher: What were your most significant contributions as a Cooperative leader?
Mann: During the time I was in a leadership role at Group Health, I believe the Board came to understand more clearly the rhetoric of the three-legged stool -- the three-way partnership among the consumer Board of Trustees, management, and the medical staff. The organization had “spoken” that [partnership] for a long time and I think there were some consumer members who really saw the legs of the stool as equally weighted or that consumers actually owned the Cooperative. However, some of what we learned was that the legs are uneven and always will be that way. At times, the Board must be out in front because there are some overall policy questions to ask and decisions to be made. But, by and large the CEO, acting as the Board in residence, and the medical staff, who provide the health care, have a broader and stronger role on a day-to-day basis. They carry out Board mandates, but they also provide critical information that the Board needs to perform its role. This was a difficult thing for some of the more traditional members to learn.
I remember some of the crises of equity in health care coverage. Coverage of mental health services is one example. A recognized consumer “caucus,” aided by the medical staff, successfully lobbied for improved coverage. There were times when consumers actually felt, to use a dramatic word, “betrayed” by the organization. As industry cost pressures continued to grow, we had to address the issue of increases in premiums and adjustments in covered benefits. The Board had to make some decisions that were more business-oriented, and it rose to the occasion. We learned the meaning of “no margin, no mission.” We realized how important it was to be a well-run, high-performing business. As a nonprofit organization we did not use the term “profit,” but we knew we had to manage well to be able to provide the level and kind of health care for which we wanted to be known.
Maher: Is it fair to say that the Cooperative experienced a turning point under your and Gail Warden’s leadership?
Mann: Yes, I think it is because it was the first time that an “outsider” was at the leadership helm. Gail, of course, was known and respected in the health-care industry nationally and his record speaks for itself, but he was unknown in this part of the country. I was first known as a federal employee, albeit a benevolent one in some people’s minds. But, again, we were different from the original cooperators -- the people who came to Group Health in the beginning with a specific vision and consumer perspective. Yes, it was a turning point for the concept of managed care as we confronted the same cost pressures as other models of care -- aging population, costs of prescription drugs, and new technologies. During that period, the Cooperative was increasingly recognized as a leader in delivering quality health care and enhancing the role of consumers in the organization. We presented some ideas that challenged the way people saw the organization. We learned about our place in the health care industry and how we could contribute to the public debate on health care as a right.
Maher: What was your position in the U.S. Public Health Service at that point in time?
Mann: I had come to Seattle in late summer of 1979 to accept the position of Regional Health Administrator for Region X of the U.S. Public Health Service. I was the representative of the Assistant Secretary of Health and the Surgeon General in the four-state region. It was a wonderful platform for me to advance the public health perspective and to coordinate my work with local and state health leaders. My job gave me an opportunity to see health policy issues broadly, which I hope had some value for my work on the Group Health Board.
Maher: What do you believe has been the Cooperative’s most significant contribution to you?
Mann: For me, Group Health was a laboratory to work through ideas and insights I had gained over the period of time, beginning with my work with the OEO’s Community Health Center Program and continuing through graduate school. My work with Group Health allowed me to represent the consumer viewpoint across the country and in Latin America and Europe. I had the opportunity to see first hand that there is a significant and qualitative difference when patients, consumers, members -- whatever you want to call them -- have a voice and can influence important decisions, such as selection of management and medical leadership, and overall quality of service.
Maher: So, you got to see the theory of consumer involvement play out in practice.
Mann: Yes, on several levels. I remember a conversation with my primary care physician about showing respect for patients by asking permission to call them by their first names. Later on at a point in that relationship I said, “You know, I want to be able to call you by your first name when you call me by my first name, except when I’m very sick. Then, you’re 'Doctor' and I am 'Dorothy' and that is quite all right with me.” The important thing is that individuals get to share responsibility for the quality of their doctor/patient relationship. So, yes, being involved with Group Health has been an incredible experience for me, one that I value tremendously.
I recall a Board action to have test results sent to patients whether or not they were positive -- taking the burden off the patient to remember to place a follow-up call. Many improvements were made through ongoing dialogue among managers, medical staff, and consumers through consumer councils.
Maher: What was your most significant experience in Group Health governance?
Mann: Probably, having a key role in selecting and hiring a CEO. It is the most important decision any board makes. Second, as I mentioned earlier, the privilege of representing the Cooperative in meetings and conferences. I value the confidence that the Cooperative’s consumers and leaders had in me, especially my colleagues on the Board and Phil Nudelman, who was CEO during my tenure. I have fond memories of my Group Health experience. I gained a lot and hopefully I gave as well; it was a quid pro quo. Even though I am no longer affiliated with the organization, except as a member, I run into people all the time who remind me of the period of time during which I represented Group Health in the community.
Maher: You worked with several CEOs: Gail Warden, Aubrey Davis, Phil Nudelman, and Cheryl Scott. How do you feel Group Health has changed the Seattle community over time and why has that change been important?
Mann: I’m not sure I can speak to a change. I can safely speak to a continuing influence. At every level in the public policy debate -- city, county, state, nation -- Group Health’s voice has always been one that is looked to for an understanding of the essential issues facing health care -- cost, access, and quality. Group Health has also been looked to for fair and equitable ways to address those issues. In the early years before I lived in Seattle, according to legend, Group Health was expected to be as accessible as public health clinics -- its social mission was that strong. As I understand it, community health activists held Group Health to a different standard than other providers. I’m sure that is because of its history as a cooperative. I think that Group Health will continue to be expected to be at the forefront when and if there are breakthroughs in the ultimate goal of universal access.
So, one could argue that Group Health has, over time, changed the dialogue. People like Aubrey Davis, Cheryl Scott, Phil Nudelman, are sought out for their insight. I’m not sure that we have yet changed the political well of voters and interest groups in terms of advancing the goal of universal coverage, but we certainly earned a place at the top of the list of organizations that have a track record of delivering quality care in a way that has value for consumers. We have earned a place at the table.
Maher: What do you believe is Group Health’s greatest strength?
Mann: (Pause) I don’t know this to be true in the last few years because I haven’t been that close to the organization, but I have always thought that its strength is in its employees and their commitment to the Cooperative’s objectives. Beyond that, I think it is probably in its ability to attract providers who value a strong physician/patient relationship and who value patients/members as partners in the health care experience.
There was a time when Group Health attracted a certain kind of physician, one with a strong social mission. They wanted to come to Group Health because they saw its social mission as matching their own.
Women physicians have, at least at one point when I was closer to the organization, found a friendly work environment at Group Health. Early on, it allowed shared practices and made daycare available. I think on balance, Group Health is seen as a health care system that cares about its employees and creates an environment where employees want to do the best they can for members when they use the system. I do think that Group Health, as I said before, is held to a higher standard than other systems or non-systems in the community.
Maher: What has been your most significant health care experience with the Co-op?
Mann: I’ve been really lucky -- knock on wood -- in terms of my own personal health care status. I’m happy to report that I do not have a major experience to share. I can say, though, that I feel very supported in my own disease prevention and health promotion strategies. I appreciate being reminded when it’s time for a mammogram, about diet and nutrition, and generally being listened to carefully when I ask questions or describe a concern.
Maher: Group Health Cooperative has a new purpose statement that focuses on transforming health care. How is Group Health fulfilling its purpose?
Mann: I recently heard Cheryl Scott, the CEO, describe this strategy and the issues underlying it. I am not clear on the implementation plan. What is encouraging is that the Board and management realize the need to do things differently -- not doing the old things in different ways, but the need for a true transformation. The challenge is moving a large, complex organization in new directions. Even more important is answering the question, “What will that transformation look like in the market place?” Purchasers are looking for value, evidence of quality, and assurance of patient safety. The Cooperative has to walk its talk.
Maher: Why should a young family consider joining Group Health?
Mann: Well, I don’t know that it (a young family) should. I’ve come to be a strong enough proponent of integrated health care systems that I feel comfortable saying that in its classic form, Group Health may not be attractive to every consumer. America is a culture of choice. Group Health has to market quality as well as the whole care experience. Each person and each family has to look at its needs in order to make a good decision. In an ideal world, a young family would include young children who need pediatric care, a mom who needs the full range of women’s reproductive health care, and a father who needs ongoing preventive and curative services related to his health status. (My comments assume that women and children tend to use more health care services than men). Optimally, a family would find an organization like Group Health very attractive because it represents the classic one-stop shopping health care system. But, the decision is very personal.
If a young family asked me what kind of place would be most satisfying, I would advocate for Group Health Cooperative. But, I believe it is a very personal decision. What I tend to say to people is, “Make a list of questions that are relevant to your particular situation, ask the questions, consider the answers, and make the best decision possible.” I hope that the family would choose Group Health.
Maher: You were involved for a long time and saw Group Health Cooperative evolve. Why, today, would you say consumer involvement matters at Group Health?
Mann: I hope it matters. My fear is that the public debate about managed care as a generic concept over the last period of time has led to cynical consumers whose first thought may not be about the Group Health model of consumer involvement, but about access limitations. The failed Clinton plan and some of the issues here with Washington state’s lack of money to support a viable basic health plan may be contributing factors. Many have questioned whether it is worth their time and energy to be at the table in the continuing debates about health care. I think Group Health’s governing board, where the consumer still has a significant role, albeit a changing one because of all these other factors, can be a model for the value of consumer involvement.
However, I think we have to honestly look at the percentage of Group Health enrollees who participate actively as consumers compared to the total number of people who could participate. It is clear that there is more to do in educating enrollees to the value of their active participation.
Maher: What would that message be?
Mann: Well, I’m not so sure. At the least it could be, “Your voice counts.” There is, in this particular organization, an opportunity through the Board of Trustees and its various committees and regional consumer forums to have your voice heard. Being involved and informed about health care issues helps members in their ordinary lives and in their community organizations. They can participate in discussions about what influences health care costs, the difference between generic and brand drugs, and the role of a primary care physician as an advocate rather than “gatekeeper.” The education that comes from consumer involvement is a value that we could give more focus. Being an informed consumer and learning how to make the best decisions for one’s self and one’s family is something that may still have resonance.
Maher: What do you see as innovative ways to provide the education?
Mann: It’s hard to say because I have no empirical evidence. Technology comes to mind ... websites and emails. But certainly in some form the Cooperative should seek its members’ views on the best ways to provide health care education. Perhaps, some sort of focus group process or other way to gather accurate data about what the members say they want and how they feel. We certainly can’t presume that the way we’ve done consumer governance for the past 50 plus years is the way we should continue to do it in 2002 and beyond. So, a first step may be to find a way to know what consumers want from the Cooperative, beyond the assurance that health care will be there when they need it and that it will remain affordable. It may look totally different than the way we do it now. Or, it may be the same, but we need to know that with some confidence. So I say, ask the members.
Maher: I have one more question. It is an opportunity for you to give guidance/advice to those presently involved in Group Health and to those who follow. Is there anything else you want to share about your involvement with Group Health Cooperative?
Mann: Being involved with Group Health Cooperative has been an affirming experience for me. I’d like to think, too, that I contributed in a meaningful way in telling Group Health’s story. I like being a stakeholder. I like being a citizen activist. I like knowing that my voice counts. I learned a lot from Gail Warden, Aubrey Davis, Caroline MacColl (a former trustee), and certainly Phil Nudelman. Also, I learned a lot from the leadership of the medical staff. I couldn’t be more pleased to see Cheryl Scott become CEO of Group Health. She is providing brilliant leadership at a critical time in the history of the organization. Clearly, my involvement with Group Health is one of the more important and positive contributions to my professional and personal life.
Maher: If you were to choose one word to describe your experience with Group Health, what would it be?
Maher: Is there anything else you want to say?
Mann: For the Cooperative to take the time to do this (oral history project) speaks volumes for Group Health in terms of its social mission. I am impressed that Group Health and its leadership, through Cheryl Scott and her staff, are willing to allocate limited resources for this project. I’m very proud to have an association with an organization that takes the time to preserve its history while working to transform itself as a delivery system. I think it is something that the larger community can learn from. I congratulate the Cooperative.
The following questions and answers were provided after the interview via email:
Maher: How do you describe Group Health to others?
Mann: It would depend, of course, on the audience and what it knows about managed care or integrated health care delivery systems, and if they have strong feelings one way or the other. In general, I might mention Group Health's history of a strong and proactive partnership with members through its consumer-led governing board, it's social mission, and the quality of care.
Maher: When I say Group Health, what immediately comes to mind?
Mann: For me what initially comes to mind is “partnership” with my primary care physician. Next would be access and the overall care experience. Beyond that, what comes to mind is the concept of "one stop shopping." I know that in Group Health's integrated system I can receive the care I need at whatever level is appropriate -- primary, secondary or tertiary -- and that at each level the health/medical professional in charge can easily be in communication with other members of the health care team.
Maher: What is the single greatest challenge Group Health faces in the next five years?
Mann: Distinguishing itself in the marketplace. As time goes by, fewer and fewer customers will know or care about Group Health's wonderful cooperative history and mythology. Purchasers (employers/employees/individuals) will be looking for the best value in terms of access, quality, and choice.
Group Health will need to price its services to attract a mix of enrollees -- age, sex, health status -- to avoid adverse selection issues, while being seen as reaching out to the larger community both as a delivery system and as a caring corporate citizen. It will need to be seen as the place we look to for the best care given by the best providers at affordable costs. Above all, it will have to convince a skeptical buyer that it offers the best quality.
Maher: How do you think Group Health's past -- its roots -- prepare it to meet the future?
Mann: Group Health’s roots prepare it to be at the table as a recognized and reliable voice in the health care policy debate. Because of the respect in which Group Health is held locally, regionally, and nationally by elected and appointed officials, Group Health will be able to positively influence public policy decisions going forward.
Maher: What's your greatest hope for Group Health Cooperative?
Mann: That it grows and thrives and continues to attract the best and the brightest in management, medical staff, and consumer governance. I can't imagine a time when I would not be a member of Group Health and expect to receive the best health care possible based on science provided by highly trained, caring health care professionals.