The Consensus Prescription: A focus on customers, not programs
Dr. Robert K. Ross
Director of Health and Human Services, San Diego County, California
Late in the summer of 1995, a group of children’s advocates in San Diego came to Robert Ross with an idea. The advocates wanted to overhaul the way children’s mental health services are delivered, and as the county’s health director, Ross was the man who could help them do it. The plan was to piece together all the fragmented services and funding sources involved—from therapy to special education to delinquent services—and integrate them. It was the sort of idea that sounds great, but requires the improbable cooperation of many disconnected players.
The group made its pitch, and Ross listened. Sharon Kalemkiarian, the group’s head, says that was as far as she realistically expected it to go. But before long, Ross called her for another meeting. “Just two weeks later,” Kalemkiarian recalls, “I find myself in a room with Dr. Ross, the county’s chief administrative officer, the head of social services, the superintendent of schools and the head of probation.” Ross had assembled all the key people. “I had no idea THIS was the next step.”
Four years later, Project Heartbeat, as it is known, is nearly ready to go. By next July, 1,200 children will be receiving integrated mental health services, and ultimately that number will grow to 13,000. By keeping all of the disparate interests at the table, Ross has ensured that this largest effort ever of its kind will become reality.
In six years with San Diego County, Ross has emerged as a master consensus-builder in a notoriously fractured field. He not only has managed to keep the doctors, clinics, insurers, advocates, community groups, bureaucrats and the recipients themselves from fighting with each other, but has brought them together while completely restructuring the way the county delivers services. “His optimism is never-ending,” says Greg Knoll, director of the Legal Aid Society of San Diego. “He walks into a meeting and says, ‘Nobody is leaving here until we’re done.’ ”
Ross’ most ambitious ongoing effort is to train the massive social services bureaucracy away from its fixation on individually funded programs, and to focus instead on the customer. Historically, families were sent from office to office, chasing down caseworkers for different services. Ross merged two departments—health and social services—that serve many of the same people. He then sliced the new super-agency into six geographic regions. Each location will offer the full range of services. “Categorical funding resulted in a fragmented system—actually a non-system,” Ross says. “We couldn’t unilaterally fix the funding problem. But we could at least fix what families see, and deal with funding issues in the back room.”
A pediatrician by training, Ross is guided by a doctor’s philosophy of early intervention. When the agency merger yielded some administrative savings, Ross plowed the money back into preventive programs such as child immunization. Meanwhile, people like Knoll—who are usually in the business of suing the county on behalf of low-income patients—credit Ross for championing patients’ rights. As California moved toward Medicaid managed care, for example, San Diego not only gave its enrollees unique flexibility to choose their own health plans but created a consumer advisory board to watch over the process.
In a county that has left public health underfunded for some time, Ross scored a key victory this year by securing all of the county’s $945 million share of the national tobacco settlement for health care. Yet he remains wary of the sentiment that money alone buys miracles. “We could always use more money in certain areas,” Ross says. “But the crisis now in this field is more a lack of creative ideas than a lack of money.”
— Christopher Swope
Photo by James Aronovsky