No matter how much we in the world of philanthropy might like to wave a magic wand to fix all the problems with California’s health care system, there are limits to what we can do. We don’t have enough money to buy better health care for even a small percentage of Californians or to build a new system from scratch. What we can do is be a catalyst for change by supporting great ideas and innovations that need help getting off the ground.

Here is a good example.

Recently, the University of California (UC) medical schools and Cedars-Sinai Hospital won a $9.9 million grant from the U.S. Department of Health and Human Services to solve some very important riddles: Why do similar patients at different hospitals in the same system have such wide variations in the care they receive toward the end of life? Are seniors getting the kind of care, and the amount of care, that they want toward the end of their lives? And how can we determine what care is necessary for extending life and what care is excessive, both in the toll it takes on our elders and the unsustainable cost burden it adds to our health care system?

We know from the Dartmouth Atlas of Health Care (the Foundation is one of several funders) that similarly ill patients at UC Los Angeles spent 85.8 days in the hospital (44% of that time in the intensive care unit) and had 38.5 physician visits in the last two years of their lives, while at UC San Francisco, similar patients spent only 61.5 days in the hospital (25% of those in the ICU) and had 25.9 physician visits. No one disputed the facts, but no one could explain the difference without knowing more about individual cases. Did more care translate into more lives saved, or did the more intense treatment fail to extend the lives of patients? In other words, was the variation in treatment warranted?

CHCF played a catalyzing role in finding answers to these questions in 2005 when we brought together researchers at the Dartmouth Atlas and leaders at the UC hospitals to explore the findings. By providing a space for participants to meet, understand the data, and articulate their questions, we aimed to open a dialogue to find answers to the questions around variation in treatment patterns.

"The Dartmouth Atlas research was pivotal in identifying and highlighting the significant problem of variation in care at the end of life," said Maribeth Shannon, director of CHCF's Market & Policy Monitor program. "But a solution required a roll-up-your-sleeves, get-deep-in-the-data effort that few hospitals are able to undertake on their own."

Of course, the reasons for variation are complex, but the two positions basically came down to these:

1. More care does not mean better care, or
2. More care can mean better care, in certain situations.

With CHCF's prodding and an agreement to fund early studies, all of the meeting's participants decided to find out what the answer was and how the difference in care could be rationalized or changed. Dr. Tom Rosenthal, chief medical officer at UCLA later told the New York Times, "We were inspired" by the meeting.

Following this meeting, CHCF supported a collaboration of researchers from the five UC hospitals and Cedars-Sinai (which has doctors affiliated with the UCLA medical school) in an effort to take a case-by-case look at data on heart failure patients and find out what was behind the variations in their care. CHCF provided funding to the research team and requested specific deliverables for them to report back on their findings.

It turned out that there was no bright-line finding; more care is sometimes better care. The difficult part is knowing in advance when more is better and when it is not. The group came to agree that a significant reason for the variation was the way each facility dealt with the most severely ill patients. For example, UCLA often took a much more aggressive approach to treatment of patients than did UCSF. Sometimes that paid off, but often it did not. The best approach, all of the participants agreed, was to have a culture that provided aggressive treatment when it was warranted and approved by the patient and family, and to make sure that patients and families were made aware of all the options available to them — including palliative care alongside curative care, when aggressive care was clearly unwanted or unwarranted.

The University of California/Cedars-Sinai coalition continues to work together on innovative approaches to better manage patients and was recently granted nearly $10 million from the Agency for Healthcare Research and Quality to continue making practical progress.

The strength of CHCF's role here was not in solving the problem, but in providing the spark and the support to bring disparate parties together, help build a structure to search for a solution, and apply the power of our resources to make it a reality.

So what did we learn?

• CHCF could not have fixed the variation problem at these major institutions, but by bringing people together we helped start the process.
• The leaders of our health care system generally have a strong professional interest in improvement — they need to be worked with, not yelled at.
• Sometimes a little bit of well-placed funding can result in a big payoff.

We think this is what being a catalyst is all about.