This transcription was edited from a panel discussion that took place on July 16, 2004, in Chicago, Illinois, at the American Academy of Pediatrics Community Access to Child Health and Medical Home National Conference. The panel consisted of local, national, private, and public funders and was moderated by Edward L. Schor, MD, Assistant Vice President of the Commonwealth Fund. The original title of the session at the meeting was “′Show Me the Money' (Part 2): Private and Public Foundations.”
INTRODUCTORY REMARKS BY THE CONVENER
Jeff Kaczorowski, MD (Department of Pediatrics, University of Rochester, Rochester, New York)
As impetus for the discussion, I'd like to tell you a brief story. A resident and I had just seen a 15-year-old boy who had been in a fight on the street and had had the corner of his mouth cut open with a knife. I said we could take care of this boy's wound but that I was much more worried about what would happen to him on the streets again afterward. I told the resident something I had learned from Bob Haggerty, one of my mentors in Rochester, that in a city in the United States an adolescent male who comes to the hospital clinic or emergency department having been the victim of a violent assault has a shorter life expectancy than if he has just been diagnosed with AIDS. The resident told me: “It should be someone's job to do something about that.” I said: “It is. It's our job.” He said: “No offense, but we're already 7 patients behind, and who is ever going to allow us to do something like that?”
INTRODUCTORY COMMENTS BY THE MODERATOR
Edward L. Schor, MD
Foundations, like government agencies, by and large operate to promote the common good. Foundations are established through provisions of the tax laws with the expectation that they will be accountable to the public.
Local and regional funders, including state governments, are more likely to fund a service project, whereas national funders are more likely to be interested in research and policy. You don't go to the hardware store looking for groceries, and so you have to have a sense of what each of the funders' agendas are.
Presumably, the governmental funders are required to keep their funding process transparent. Private foundations have more options in that regard. Some will keep their processes hidden; others are much more open about them.
There is not an endless pool of money from which we're drawing, nor do we sit at our desks and write checks. We spend much more of our time trying to get an understanding of the fields in which we're operating, figuring out who's doing good things and what the issues are.
The panel members have been asked to respond to a series of 5 questions and then respond to the audience's questions.
I'm going to have people introduce who they are in conjunction with the first question.
QUESTION 1: What kind of funding organization do we come from, what kind of things do we typically fund, and how can someone find out about the mission?
Jennifer M. Rosenkranz
I'm Senior Program Officer with the Michael Reese Health Trust here in Chicago. I'm here representing conversion foundations. Conversion foundations result from the sale of a nonprofit hospital, health system, or health plan when it converts from nonprofit to for-profit. Grantmakers in Health has surveyed ∼165 of these conversion foundations around the country in ∼38 states with assets of $16.4 billion. So if you consider that foundations have to give away 5% of their assets per year, that's approximately $800 million in payout each year. Most of them do fund in a limited geographic area.
Clarita Santos, MPH
I'm with the United Way Metropolitan Chicago. Our focus area is mainly Chicago and its suburbs in Illinois. Some of the programs that we fund are health and human service–focused with an emphasis on community building. The first thing that we would fund would be planning assessment to see what the needs are within the target population. The second phase of funding is a pilot program to determine whether your idea for a solution works. The third phase of funding includes the full project roll-out.
David Heppel, MD
I'm here with 2 of my colleagues from the federal government, Hani Atrash and Jane Martin. I represent the Maternal and Child Health (MCH) program. MCH has a funding mechanism that is similar to some other federal programs in which most of the money goes out to the states. A small amount of it, ∼15%, is held back for research and development; that's where the grants that I and my colleagues have direct responsibility for come from. But most of the money goes out to states. The states must match the federal funds, and the vast majority of states put in far more money than is needed: more than 3 state dollars to 1 federal dollar. Why is that important? Because when you're operating on the law of going where the money is, there's a lot of MCH money in your state and perhaps more than there is in the federal government. On the other hand, when you've heard about 1 federal agency, you've heard about 1 federal agency. There's a great deal of variety.
John R. Lumpkin, MD, MPH
I'm Senior Vice President and Director of the Health Care Group at the Robert Wood Johnson Foundation [RWJF]. We are 1 of the largest philanthropies in the health field. Our endowment is approximately $8 billion. We try to base our philanthropy on a logic model and also a belief that we can leverage our funding to try to make some fundamental change. We look for various areas in which there seems to otherwise be a lack of development. We have 9 strategic objectives ranging from nursing retention to decreasing childhood obesity. The best place to see what we're interested in is to look at our Web site, www.rwjf.org.
I'm Assistant Vice President for the Commonwealth Fund. We're a foundation of relatively modest size. One program area is in improving the quality of health care for underserved minority populations, with a particular focus on doctor-patient communication and health literacy. Another [program area] is designed to improve the quality of developmental services and preventive health care overall. We have a Web site, too: www.cmwf.org.
QUESTION 2: How do funding organizations determine giving patterns, goals, and objectives?
Every year I have to develop a program plan that goes before the executive team at our foundation for review. Then, our grant making is a process of finding a match between your needs and interests and our objectives.
With the conversion foundation, in general, there are some differences. When a conversion happens, the attorney general of the state has to sign off on the agreement and how the conversion happens. In some states, they have gotten very involved in what kind of grants will be awarded, which came out of some scandals that happened in different states where people walked away with large sums of money. The Michael Reese Health Trust went through a community health needs assessment that involved leaders in the community; it involved educating our board about different issues and having people from the health department come in and speak to the board. We have 2 grant-making programs. One is responsive: it responds to letters of inquiry and requests that come in from the community. So within that program, we do not have specific populations targeted. It's broad. The responsive program is a way for us to learn what's going on in the community, find out who the leaders are, and who's doing great work. Our other program is proactive and has initiatives that we help to develop related to larger systemic issues that need to be addressed. I think a lot of the conversion foundations are responsive, but the trend has been, in foundations overall, toward more proactive giving in the past few years.
With the United Way, one of the trends that we are seeing is that there are more collaborations or partnerships with the community. So, for example, when we do a program looking at what outcomes will be funded during the next fiscal year, it's through community involvement, it's through focus groups, it's through qualitative surveys. For a more monthly type of feedback, we have committees, for example, a standing children's impact panel committee, to make sure that we are on target when we are looking at defining what our plans are.
There are 2 levels of answers. The way federal programs are supported is on the basis of legislation. So what the Congress tells us to do, we in the executive [arena] implement. At the state level, what the MCH programs do is based on not only what the federal legislation says but also what the state legislature says, which means that there are all sorts of influences that do occur. Sometimes, somebody's (accepted) good idea does not have an evidence base, and that's a negative. On the other hand, it does demonstrate the influence that individuals can have in this part of the process. So we check in with stakeholders. We listen at meetings to come up with goals and objectives, and ultimately, there is a strategic plan that we develop.
For each foundation, by checking on their Web site, they'll tell you exactly what it is that they don't fund. For instance, we don't fund services and we don't fund bricks and mortar. So if you want to build a hospital, RWJF is not the place to go. All those priorities, patterns, goals, and objectives are set by the board of directors of each foundation, and the staff of the foundation formulates that and brings it to the board. Our board tends to be strategic. They meet 4 times a year and want to know the big picture. They don't get involved in individual programs. But other foundations have different structures. Let me say that there is something on which all private foundations have a restriction: anything that can be perceived of as lobbying or being engaged in partisan political activity results in penalties from the Internal Revenue Service.
Last year there was some attempt to change the laws regarding foundation activities that made all foundations much more sensitive to these kinds of issues.
QUESTION 3: What are some things funding organizations look for or discourage when they're approached by people looking for funding, and related to that, particularly what kind of compelling information have we, as funders, received from pediatricians that have actually led to informing our funding decisions?
RWJF first looks at if the funding proposal or idea is consistent with our objectives. Second, is there good evidence for what's being proposed? Is there a good logic model? Does it actually make sense? Have you done the analysis of why you're recommending the change? RWJF is trying to look at systems changes and determine whether a project is new and innovative, and then we want to see the evidence that you as an organization, or you as the applicant, can actually do what you say you want to do. I've been on the other side of applying for grants, and I know that you get a letter of support from everybody that you can think of. We have to try to figure out if those are really people who are going to work on the project or just your friends who write letters. Generally, we develop our areas of focus by going to experts in the field, so many of our programs will reach out, particularly when they involve children, to the experts in the field, many of whom are pediatricians.
Well, how many of you have applied for grants? Would you raise your hands? Keep your hands up. Of those who've applied, how many have had to contort what you really want to do to fit what is in the grant? Can you put your hands down if that's the case? [Most hands down—laughter.] The point here is that the more you talk up front, the closer you're going to get an opportunity to write down what you truly want to write down. I'll be really concrete. In a couple of weeks, there will be something called an HRSA [Health Resources and Services Administration] preview, which will announce grants. You can get it at www.hrsa.gov, [search for] grants for 2005. I can guarantee you that there will be a grant announcement in that preview that has been generated on the basis of a conversation with a single individual. That's not at all uncommon. So if you talk at the beginning, it helps. The kind of compelling information that I get, it makes a difference. We do well in the federal programs if kids and programs get better. The way we learn about that is from what's going on in the real world, so the more we hear from you, the better off we are. I think, generally speaking, we're looking for something that is replicable. On the other hand, every 5 years the state MCH program has to put together a needs assessment and a plan of action. That happens to be coming up next year. It's starting right now and is due next July. The federal MCH program urges, requires the state programs to get input from interested parties. You can do this every year, because the plans are modified every year, but it is particularly important this upcoming year. Do you want to influence how a substantial portion of federal/state dollars are spent? This is the year to do it.
And it's easy. Call your state [MCH] director and say: “there are things I think you need to be aware of.”
I agree with some of the things you said. Call foundations to ask. Try to develop a relationship. Look at the Web site and the guidelines before you call. Once you've looked at the guidelines, you might call and ask: “You know, I'm trying to decide if I should submit for program A or B. Can you give me some idea of what might be a better fit for where you're headed right now?” A lot of times a program officer can give that kind of advice. The other way we use pediatricians is we have a proposal-review panel. On the panel, there are ∼60 people here in the city of Chicago who have expertise in the areas in which we fund. In addition to staff reading all of your proposals, we also have people in the community read them (our staff can't be expected to have expertise in every single area). The panel helps inform the decisions and recommendations that we give to our board. We also have a pediatrician on our board.
I want to emphasize that where foundations and agencies are more directive with regard to funding priority areas, the staff are likely to be very well informed and to have professional degrees in the field(s) in which they make grants and can be a resource to potential grantees. I'm a pediatrician, and we're funding in child health. David Heppel is a pediatrician. So there is that expertise. Often, though, particularly in local foundations, there's no one there who knows much more about health than what they experience going to the doctor themselves. You need to understand that may be the case and understand what information you need to provide to them. What seems totally obvious to you may never have passed through their minds.
QUESTION 4: How do pediatricians influence giving toward important child health initiatives and get involved with funding agencies? What roles can pediatricians play in that process?
They should be involved with committees, for example, our youth impact committee, because when it comes to decision-making, the committees have a lot of influence in where the money goes or what the focus of a United Way is. The second way is through the needs-assessment process. This is because oftentimes community assessments might be general and may not be able to see the specific cases that you see within your practice. So make sure that you are at those meetings where they are doing community assessment.
We all give away money for a living. We know we do that. [Laughter.] So when you contact us, we know that's why you're calling. [Laughter.] You don't have to beat around the bush or couch it as something else. It's perfectly acceptable to go to a local foundation and say: “You know, I want to be on your board” or “I want to be on your advisory committee because I'm passionate about these issues, and I'd like to see those issues addressed by your foundation.”
I would say that of my 4 colleagues here, the national foundations are probably the most difficult for individual pediatricians to get involved with. For instance, ours is a private foundation. Robert Wood Johnson II, who endowed our foundation, actually ran and operated the foundation before it became national, and it was his will that this foundation would predominantly have on its board former executives of the Johnson & Johnson Company. Most pediatricians don't fit in that category. [Laughter.] On the other hand, we do operate a lot through what we call “national programs,” and these will have advisory committees. Certainly if you have an interest, volunteer to be on an advisory committee: “Hey, I'm very interested in this area. Here are my credentials. Here's why I think I would be good on an advisory committee.”
AUDIENCE QUESTION: Is it better to be, shall we say, an insider? Once you're on the board, is it unfair to give a board member a grant?
Most foundations, I believe, will not give a grant to board members themselves or even advisory committee members. On the other hand, if what you really want to do is influence the direction of the funding overall and you're not looking for something for yourself, then being in an advisory capacity is fine. It's not just that the [Internal Revenue Service] is looking over our shoulder. We truly believe that we have an obligation to be very ethical in our work, and looking for conflicts of interest and trying to avoid them is 1 way of attending to ethics.
QUESTION 5: What are each of us planning to do over the next 3 to 5 years in terms of child health funding? Are there particular topic areas we are moving toward?
Our foundation does not have a specific 3- to 5-year program plan. We are looking more at responding to broader issues outside of just specific physical health, in terms of addressing poverty and violence. In terms of physician practice, we want to see that physicians are responding to issues within the family and steering people to the extra services and help they need. We are receiving more requests that address obesity as well.
We're definitely becoming more outcomes focused. One of our important topic areas is readiness to learn. What does it mean that kids are ready to learn? What are some of the indicators that you're measuring?
We've been supporting the medical home concept, and within that, the early childhood area and the comprehensive approach/systems approach to that. Mental health, both prevention and intervention, is another important topic area, as is oral health. But the most important thing is that we need to hear from you. Funding trends will be determined by what you and your colleagues say. Remember, the people who influence what we do, the legislators (particularly within the state), are very bright people, but they don't know about health, which means that they are often very interested in being educated.
I would say that the 2 areas in which we see us placing emphasis in relationship to children and their health are childhood obesity and the 8.5 million children who are not insured.
At the Commonwealth Fund, our focus is on improving the quality of well-child care, and we want to be working on some policy issues, including reimbursement.
AUDIENCE QUESTION: One critical question is that many pediatricians think that there are few supports for practicing urban pediatricians. How can people work together to try to find ways to sustain community pediatric work?
We like to see organizations working in partnership. If you want to start a new program in an area where we know there are already 3 or 4 community-based organizations doing that work, it's not likely that you're going to get funded. Find out what else is going on in the community outside the hospital institution.
I think there are 2 things. One is the willingness of the community to get involved and to see that it survives. Programs like [Community Access to Child Health] are a very big component of that. So then pediatricians are seen as part of the community, not as individuals who come in and want their way. The second is that we still have a reimbursement system in this country that makes no sense, and that becomes the job of your professional society. To the extent that you support your professional society not only with paying the dues but by being active, then you create the environment in which pediatricians and your academy can influence the decisions that are being made in Washington. And that's where a lot of the issues related to sustainability of pediatrics will have to be determined.
AUDIENCE QUESTION: Does the attorney general have to inform the public about conversion trusts?
I don't believe so. A lot of it, over the years, has kind of happened behind closed doors, and that's why you do have some uproar now.
AUDIENCE QUESTION: Do we have a preference for prevention and community-level work versus treatment and individual-level interventions?
Yes, I have a preference, but each funder may have a different preference. You have to do your research. We depend on you to be there when we want to write the checks, so don't be afraid to interact and try to find out what our preference is and where the fit is between your idea and our approaches to funding.
AUDIENCE QUESTION: Where does one go for funding for training?
Same kind of answer. You just have to do the legwork and find what foundations are funding and try to find a fit. On the other hand, you might find some foundations that are willing to be responsive to a new idea, even if it is not something they have funded in the past. If you have a good idea, pitch it, and maybe it will take off.
AUDIENCE QUESTION: How important is research versus implementation?
Again, it depends. John Lumpkin and I do more research for big demonstration projects; we don't implement services, whereas a local foundation is more likely to fund services.
You know, I would add that a good place to start in your local community is a regional association of grant makers. I know ours has a library that keeps a database on what foundations fund locally. Instead of having to go to each foundation individually, it's a good place to start to learn a lot about the foundations in that area.
You can also convene the foundations. There's no reason that the state chapter of the [American Academy of Pediatrics] couldn't identify all the foundations in the state and have a meeting and say: “What are you guys doing? What's your focus? How can we influence that?” I can't guarantee every foundation will show up, but I bet a lot of them would.
AUDIENCE QUESTION: Although collaborations are great, they require too much paperwork: will funders please standardize report forms?
No. [Laughter.] We tried it. It doesn't work. Everybody's got their own reports and it's very hard to influence.
AUDIENCE QUESTION: Are the United Way priorities the same nationally or different in each city?
It's different in each city and each state.
AUDIENCE QUESTION: If there's an RFP [request for proposal] and it states a dollar amount, up to $250000 per year for 3 years, should you ask for $250000 a year? $249999? Or, should you just ask for what you want?
If it's a $200000 grant or a $150000 grant, then it's much better to come in at that level than to come in at $250000, have us look at the budget and say: “they're just padding it; we're not really sure we can work with these folks.”
This may be my own philosophy, but I don't want anybody to underbudget, either. That is much harder for me to deal with down the road. So I don't want anyone to pad a proposal, but I don't want to see unrealistically low ones, either. Figure out what it's really going to cost to do the job right and ask for that amount.
If the cost is substantially different from the level given in the guidelines, that may be a good thing, because there may be extra money around (to fund other projects), but it is not worth contorting the cost of a project to make it look excessively frugal.
AUDIENCE QUESTION: Does it matter if an applicant is for-profit versus not-for-profit?
Absolutely. By and large, it's a whole lot easier for us to fund something through a nonprofit than it is to go through a for-profit process. That doesn't mean for-profits can't play a role, but maybe if you're a for-profit, you need to find a not-for-profit to ask for the money and run that through them to you as a contract.
AUDIENCE QUESTION: How important is the PI's [principal investigator's] background, experience, education, and so on in securing the funding?
It's very important. Credentials are less important than capability. Every one of us wants to make sure that whoever we're funding has the capacity to do what they say they're going to do. Track record is the best way we have of assessing that. If you've got this great idea but you've never worked in that area before, it's not likely to be funded.
COMMUNITY ACCESS TO CHILD HEALTH AND MEDICAL HOME NATIONAL CONFERENCE PANEL MEMBERS
The panel consisted of the following members: Bill Isler (not present; author, commentary) (President, Family Communications, 4802 5th Ave, Pittsburgh, PA 15213; E-mail: www.misterrogers.org); David Heppel, MD, FAAP (Director, Division of Child, Adolescent, and Family Health, Health Resources and Services Administration, Maternal and Child Health Bureau, Parklawn Building, 5600 Fishers Lane, Rockville, MD 20857; E-mail: ; Health Resources and Services Administration Web site: www.hrsa.gov); John R. Lumpkin, MD, MPH (Senior Vice President, Director Health Care Group, Robert Wood Johnson Foundation, PO Box 2316, M/S 2421, Princeton, NJ 08543-2316; E-mail: or email@example.com; Web site: www.rwjf.org); Jennifer M. Rosenkranz (Senior Program Officer, Michael Reese Health Trust, 20 N Wacker Dr, Suite 760, Chicago, IL 60606; E-mail: ; Web site: fdncenter.org/grantmaker/health); Clarita Santos, MPH (Director, Program Planning and Initiatives, Community Building, United Way Metropolitan Chicago, 560 W Lake St, Chicago, IL 60661; E-mail: ; Web site: www.uwonline.org; National United Way Web site: national.unitedway.org); and Edward L. Schor, MD, FAAP (moderator) (Assistant Vice President, Commonwealth Fund, One E 75th St, New York, NY 10021-2692; E-mail: ; Web site: www.cmwf.org).; Web site:
- Accepted December 22, 2004.
- Address correspondence to Edward Schor, MD, FAAP, Commonwealth Fund, One E 75th St, New York, NY 10021-2692. E-mail:
No conflict of interest declared.
- Copyright © 2005 by the American Academy of Pediatrics