UNDERSTANDING COMMUNITY RESPONSES TO CHANGES IN THE HEALTH CARE SYSTEM: A COMMUNITY FIELD PERSPECTIVE
In his book The Rural Community in America (1991), where he describes and defends the usefulness of the community field approach, Wilkinson (1970) defines the community field as "a process of interrelated actions through which residents express their common interest in the local society." For Wilkinson, the interactional community has three essential properties: local ecology, social organization, and community action. Local ecology refers to an "organization of social life" critical for meeting individual needs as well as the ensuring the responsiveness of the local society in adapting to change. Social organization implies that the community is a "comprehensive interactional structure" that represents the needs and interests of community members. Community action arises out of the "bond of local solidarity," i.e. community members come together to pursue opportunities and solutions to local problems. This phenomenon occurs even as the individuals involved simultaneously participate in multiple special interest fields through horizontal linkages within the community and vertical linkages outside the community. For example, community residents may participate in local government activities, shop at local establishments, and work on local service organization projects while traveling outside the community for education and employment opportunities.
Rural communities, defined and impacted by their local ecology, social organization, and community action, can provide the setting for research that looks at how communities adapt to change. As a case in point, many changes in the health care system are being driven by cost, efficiency, and quality concerns. The decisions behind these changes are often made by interest groups, insurance companies and health care providers outside the community. Community field theory suggests that responses to these changes will reflect the community's essential interactional properties of local ecology, social organization, and community action. Communities interested in defining and shaping their health care system can test the ability of their local ecology to adapt to change. They can draw on their interactional structure to respond to needs and interests of community members and organizations. They can craft an action strategy to design and implement consensual solutions to their problems. Researchers can use the community field approach to examine how communities responded to the changing health care environment by looking at how the various components of the interactional community contribute to efforts that enhance the community health system.
Consider what is happening in the health care sector. In the not too distant past, rural community residents accessed the health care system by going to a solo or small group practice and a community hospital either in their community or in a nearby community. Residents covered by employer-sponsored third party insurance could choose the providers and health care facilities they wanted to obtain health care from. Recent changes in the relationships between insurers, providers, and purchasers of health care (Medicaid, Medicare, employers, and individual consumers) have resulted in the creation of new health care delivery systems that require individuals to obtain their health care from a specific network of providers which is part of a contracted, competitive health care system. The new delivery systems combine the financing and delivery of health care and provide health care through various forms of "managed care plans." These plans offer health care through networks of providers who are part of competitive health care systems. Managed care works under the premise that primary care provided by a "gatekeeper" is an efficient and cost effective way to manage the health care of individuals. Primary care is emphasized along with prevention, screening, and community health education. Specialty care is accessed through referrals usually within the network. Visits to other health care providers (both primary care and specialty care) without appropriate referral and authorization from the "gatekeeper" result in additional costs to the individual.
Under the new systems, some community members are finding that the managed care plan offered through their employer requires them to obtain primary care from unfamiliar doctors because their traditional family doctor is not part of the network. Likewise, referrals to specialists and hospitals may also involve new and unfamiliar providers.
When community members had "choice" in selecting their health care providers, they tended to let the traditional health care providers make deicisions regarding the local health care system. Under managed care arrangements, choices are limited by urban-based networks that are seeking to expand their market share in an increasingly competitive health care market. Thus, the health care infrastructure in the local community is not as accessible as before and the local society is limited in its ability to meet the needs and interests of community members. This situation can result in more local health care dollars leaving the community thus reducing the community's ability to meet health care needs through the support and use of local health care resources.
As a response to these changes, community members are initiating collective responses to take charge of their local health care system. These community responses are emerging from a variety of local interests, or interaction fields, as awareness increases regarding the changing economics and institutional arrangements of the health care sector and the consequences for community health systems. This situation provides evidence of Wilkinson's contention that in adapting to change, "the community field cuts across organized groups and across other interaction fields in a local population" (1991:36).
FIELD THEORY IN ACTION
The community field impacts the ability of community members and organizations to respond to change. The ability of diverse interest groups in the community to come together to respond to the changes in the community health care system will to a large extent depend on the development of the community field. The success of communities that decide to take charge of their local health care system will depend on the ability of the diverse components of the community field to influence the community health system.
The community health system represents part of the organized social life for meeting individual needs and responding to change. Individuals and organizations interested in health care are joining with providers in rural communities to take a pro-active role in responding to market changes and efforts as urban-based networks move into rural areas and communities. The reason for this pro-activeness is two-fold. First, they want to be able to choose the urban-based providers with whom they want to affiliate with. Second, they want to form their own networks as a response to urban penetration. Generally, rural providers are at a disadvantage when negotiating with larger urban providers and plans. One conclusion in a study by Alexander and Ricketts (1997) is that rural practices will have to network with other providers and organizations within their communities to offer appropriate and financially viable services and meet the health care needs of the community.
Public sector programs are driving network development efforts due to the important economic benefits derived through cost savings for Medicaid and public sector employee benefit programs financed with tax dollars. Publically financed benefit programs that pay a set monthly rate per enrollee provide key revenue sources for financing managed health care systems. Businesses and consumers are engaging in discussions with managed care plans, and they are participating in decisions related to network development in rural communities. Businesses are interested because of the rising costs of health care and the benefits derived from prevention programs, wellness and healthy behavior, and the emphasis on primary care and community health education. These factors relate to business expenses and to employee absenteeism. Similarly, consumers and employees are interested as purchasers of health care who want to have access to local providers to meet their individual and family health care needs. The interactional structure that emerges through the relationships of these community-based organizations can provide insights into the importance of this aspect of the community field in adapting to change.
A Rural Policy Research Institute (1996) study identified a number of new community-based network development activities underway in rural areas across the country. There are many examples as each state has its own set of policies, laws, regulations and institutional relationships, as well as different social, demographic and economic resource bases. Most of these efforts allow rural providers some flexibility and choice in affiliating with urban networks. Often, the communities faced threats leading to the fragmentation of services and the decline of the local health care system. Community involvement strengthened local health care services by relying on residents' decision-making processes.
Several community development approaches have emerged in recent years that stress broad-based participation of community members and constituencies in assessing local health care needs and identifying problems, analyzing information, choosing which problems and needs to address, and locating the resources to get the job done. These efforts are dynamic processes that create and alter community structures through the purposive collective action of local residents. Community-based approaches build on the tendency of community members to interact with one another on locality relevant matters. Consider the following two examples. Iowa's Hometown Health program is a process where the community, its leaders, and its health care providers study the community to identify problems and issues, and create their own solutions. The three objectives of the program are (1) to inform and educate residents of the health care status of the community; (2) assist the community in understanding utilization, access and availability of health care in the community; and (3) work with the community to develop and implement an action plan to address access and availability of health care by combining the resources of the community, the university, and government. Community Solutions for Rural Health is another initiative that involves community health needs assessment with the broad-based participation of community residents, businesses, organizations, and health care providers. Funded by a variety of private and public sector partners, this program uses information from the community health needs assessment to develop and implement an action plan to meet the community health care needs identified through the process.
IMPLICATIONS FOR COMMUNITY FIELD
The traditional view of the community as a local society capable of meeting most of the needs of its members has changed because of the growth of extra-local linkages and ties. In many rural communities, residents are involved as consumers, employees and participants in regional, state and national systems, and special interest groups many of which are located outside the community. Though extra-local relationships increasingly impact rural communities, there remains a strong interest in living in rural communities as evidenced by employee commuting patterns and the inmigration of retirees to rural communities. The community field is important for community efforts to enhance the health care system since the availability of health care and access to health care services is important to every individual and family in the community as well as employers who provide employee health care benefits.
As changes in the relationships between health care providers and purchasers of health care unfold through the development of competitive managed care organizations, there are important consequences for community members who desire to obtain their health care from community-based health care providers and facilities. Community health education, public health and primary care services are important services that can be provided locally in many rural communities. They represent important components of the social and economic infrastructure that contribute to meeting the needs and interests of community members. Health care providers and facilities are being courted and cajoled into developing institutional and financial linkages with outside urban-based networks. When this occurs, economic resources leave the community and this factor impacts on the quality of life in the community. Increasingly, the link between components of the local health care system and the local economy provides the rationale for developing and sustaining local support for these resources as a community and economic development activity. When community-based rural health networks are developed to meet the health care needs of the local community, it usually reflects support from all the interested parties including health care providers and facilities, employers and other business interests, and community consumers of health care. Examples are emerging where varied interest groups in rural communities have developed the "bonds of local solidarity" and initiated community action to support and sustain the community health system. They provide opportunities to explore the dynamic processes that result in new or altered community structures arising out of purposive collective action designed to meet the needs and expressed interests of community members.
In thinking about Wilkinson's three essential properties of the interactional community, namely local ecology, social organization, and community action, it is clear that community responses to the changes occurring in the health care industry can be used as a framework to investigate the extant community field. A community's success in developing and sustaining a local health system which meets the health care needs of community members and strengthens the local economy may be dependent on how well various interest fields in the community come together and initiate "locality-oriented collective actions." Community members and organizations can create the collective demand for utilizing existing community health resources. This provides a powerful economic argument when it is supported by providers, purchasers and consumers of health care resources; when support is missing from any of these diverse interest fields, it is quite likely that the outside influences will have a greater impact on the economic and institutional arrangements that control the choice and utilization of health care providers, and the flow of health care dollars both within and outside the community.
The health care issue above provides an example of a way in which the community field approach can contribute to the resolution of an important community issue. This underscores an important part of Wilkinson's work. He was interested in developing useful and pragmatic ways to study community and the ways collective community action can have a positive impact on community members. The changes in the health care sector and the potential impacts on community members provide an opportunity to put his ideas to work. Various interest fields coming together for purposive collective action to develop and support the community health system represents one example of the community field in action.
Ken Martin is currently doing research work in the areas of rural development policy, community health education, and impacts of cost containment measures on rural critical access primary care providers. His extension work includes a plan of work entitled "Enhancing Community Health," and the development of an educational curriculum on sustainable community food systems. Dr. Martin also teaches an undergraduate leadership course entitled "Leadership for Social Change."
Dr. Kenneth E. Martin
Director, Pennsylvania Office of Rural Health
7C Armsby Building
Penn State University
University Park, PA 16802
Phone: (814) 863-8656