Over the past decade, increasing capital investment in technology, rising operating expenses, and declining reimbursement rates have stressed the financial viability of healthcare institutions. Intensifying competition, new market entries, and growing expectations from consumers and payers have heightened concern in these outcomes. As a result, the consolidation of healthcare institutions has accelerated (Brown et al., 2012; Guerin-Calvert & Maki, 2014; Zuckerman, 2011). In 2018 alone, 803 mergers and acquisitions and 858 affiliation and partnership announcements were documented (Lagasse, 2019). The pressure to enter a strategic alliance has been especially felt by rural healthcare institutions. Their closure in many communities would essentially eliminate readily available access to healthcare services (Arduino, 2015; Holmes, 2015; Noles et al., 2015). Given this concern, the Center for Rural Pennsylvania (CRP) in 2015 awarded a grant for research on rural health alliance activity initiated to sustain community-based services. This opportunity led to a CRP-funded research project titled “Exploring Health Care Alliances in Rural Pennsylvania” (Kimmel & Sarcone, 2017). At the time, regional healthcare alliances in rural Pennsylvania were not comprehensively documented.
Questions as to how these alliances influenced rural healthcare capacity and performance were the foci of our research. We defined alliances as voluntary agreements among two or more healthcare institutions to include both nonequity-based and equity-based arrangements. The survey identified 22 separate instances of alliance formation involving healthcare institutions in rural Pennsylvania counties. The structure of the cooperative ventures ranged from informal collaborative arrangements sealed with a handshake to formal equity or near-equity arrangements represented by full-asset mergers, member substitution agreements, and superparent organization structures. From the available cases, five health institutions were studied. Selection of each case was based on the geographic location of the institution, the characteristics of the community served, the partner chosen, and the type of alliance achieved. The five hospitals and health systems studied were the Laurel Health System (LHS), Wayne Memorial Health System, Penn Highlands Healthcare, Shamokin Area Community Hospital, and Tyrone Regional Health Network.
Several interrelated measures, employed to document change in operational and financial capacity, were relied upon to assess the impact of each alliance (Table 1). Although all five health institutions demonstrated positive outcomes related to alliance efforts, an analysis of the LHS alliance revealed substantive positive outcomes across all four measures (Table 2).
Table 1 -
Definition and Measures of Rural Community Health Capacity
|Definition of rural community health capacity
| The volume and distribution of medical resources (institutions and providers) collectively providing health services for residents within a defined geographical area. Capacity size and scope are defined by determining the overlap of all healthcare institutions’ and healthcare providers’ primary service area footprints and by documenting evidence of routine and regular interaction among the identified providers.
|Measures of rural community health capacity
| 1. Evidence of increase in rural community healthcare capacity
| Documentation sources: Pennsylvania Department of Health and Pennsylvania Department of Labor and Industry statistics; hospital annual reports, press releases, interviews with key stakeholders, and facility tours.
| 2. Evidence that increased rural community health capacity is based on documented community health needs
| Documentation sources: Community health needs assessments required and conducted by each institution included in the study, the Pennsylvania Department of Health’s Health Status Indicators for Pennsylvania Counties and Health Districts report, and interviews with key stakeholders.
| 3. Evidence that increased rural community health capacity represents rural healthcare best practices
| Documentation sources: National Rural Health Association; Health Resources and Services Administration; Robert Wood Johnson Foundation; Commonwealth Fund; Pennsylvania Office of Rural Health (PORH); guidance provided by PORH staff throughout the course of the study.
| 4. Evidence that increased rural community health capacity relates to improvements in healthcare service quality (clinical and patient satisfaction), accessibility, and/or provider institution financial condition
| Documentation sources: Pennsylvania Cost Containment Council Reports (The Impact of Healthcare-Associated Infections in Pennsylvania, The Hospital Performance Report, The Potentially Preventable Hospitalizations in Pennsylvania Report, and The Hospital Financial Analysis Report) and Hospital Consumer Assessment of Healthcare Providers and Systems data.
Table 2 -
Laurel Health System Postalliance Outcomes
||Meets Documented Need
||Represents Best Practices
||Improves Services and/or Finances
|Susquehanna Health System (SHS) established a cancer center in the LHS service area, meeting a community health assessment need.
|SHS invested in a new primary care center in the Laurel Health System (LHS) service area, meeting a community health assessment need. The federally qualified health center accepts patients regardless of ability to pay and integrates physical and behavioral health services.
|LHS, in collaboration with SHS, introduced specialist office hours at each primary care center. In addition, a new hotline improved communication between LHS primary care providers and SHS specialists.
|As part of SHS, LHS participated in an accountable care organization to improve costs, quality, access, and patient experience.
|LHS accessed SHS operational and financial resources and capabilities, thus improving the financial condition of LHS through efficiencies and expanded services. The alliance also served to discourage further competition from a rival health system.
Represents success in achieving outcomes associated with the measure.
Reflecting on the differences in success among the five health institutions led to the following question: Why are there differences in success? Fortunately, this line of inquiry could be pursued because study data detailed each institution’s governance and management structures as well as alliance-related decisions and actions.
From our reexamination of the qualitative data for this article, a pattern emerged of complementary and interconnected strategic decisions and actions common to institutions experiencing relatively greater alliance success than others in the study. The decisions and actions are organized here into four related themes of commitment: (1) collaborative leadership, (2) purposeful partnership, (3) coordination, and (4) progress. Organizational capabilities underpinning identified decisions and actions within each theme are also provided. For each organization, these capabilities include the competency to manage within and across organizations, the wisdom to take the long view, and the discipline to focus on results that align with the mission. The LHS case study illustrates decisions, actions, and underlying capabilities within each theme.
The literature on interorganizational relations is represented in numerous professional and academic disciplines. The cooperative organizational forms described in the interorganizational relations literature are often interchangeably referred to as partnerships, networks, collaboratives, and strategic alliances. Organizational theories applied to provide a rationale for interorganizational relationship development include resource dependency (Pfeffer & Salancik, 1978; Selsky & Parker, 2005), ecological analysis (Hannan & Freeman, 1977), and institutional theory (DiMaggio & Powell, 1983). Literature on strategic alliance development commonly addresses the related topics of alliance integration and alliance life cycles. The health management literature is populated with alliance integration research (Butterfoss et al., 1993, 1996; Conrad et al., 2003; Dowling, 1995; Francisco et al., 1993; Gamm et al., 1998; Hasnain-Wynia et al., 2001; Mitchell & Shortell, 2000; Roussos & Fawcett, 2000; Song, 1995).
Throughout the research, common factors influencing the level of alliance integration include its purpose, intensity of the alliance process, and the resulting alliance structure (Gadja, 2004). Variability in alliance integration was evident in our study. In contrast, the study revealed a common pattern of decisions and actions associated with the life cycle of an alliance. Numerous models detailing the evolution of alliances are described here (Bailey & Koney, 2000; Miles & Snow, 1992; Ring & Van De Ven, 1994; Thorelli, 1986), including contributions from healthcare scholars (D’Aunno & Zuckerman, 1987, 1990; Zuckerman et al., 1995). These models consist of defined phases beginning with issue identification and membership commitment, progressing through the implementation of agreed-upon strategies, and concluding in some cases with termination (Bailey & Koney, 2000; Miles & Snow, 1992).
For the CRP-funded study in 2015, the qualitative research design relied on both primary and secondary sources of data. Primary sources included open-ended, structured interviews with key stakeholders. Secondary data included publicly available data on community social, economic, and health status characteristics, and hospital operational and financial performance.
The findings in this article rely on a reexamination of transcripts of 34 interviews —approximately 800 pages of transcribed data. Given the extensive literature on strategic alliance formation, a deductive approach was initially pursued (Babbie, 1991; Crabtree & Miller, 1999) in the analysis of the text. The four-phase models of strategic alliance development put forth by Zuckerman and colleagues (1995) and Bailey and Koney (2000) were relied upon to compose the initial coding structure here.
As themes emerged separate from those supported by predefined codes, a hybrid approach was adopted relying on both deductive and inductive analysis (Elo & Kynga, 2008; Fereday & Muir-Cochrane, 2007). Three of the resulting four themes presented in this article mirror those within frameworks offered by Zuckerman and colleagues (1995) and Bailey and Koney (2000). A fourth theme on collaboration presented here is not fully captured in existing alliance life cycle models.
The following four themes are ordered by the sequence of observed activities. For each theme, decisions and actions, along with underlying organizational capabilities that characterize successful alliance formation, are described.
Commitment to Collaborative Leadership
Given ongoing pressures to transform the American health system, healthcare institutions can no longer assume future success based solely on individual effort. Health system transformation aimed at increasing consumer and payer value requires meaningful professional and institutional collaboration (Austin et al., 2016;Van Vactor, 2012). A deeper understanding of the underlying social and environmental factors influencing health further necessitates collaboration across economic sectors.
Alliance-initiating healthcare institutions must proactively position themselves to be valued partners in expanding collaborative networks. Institutions with superior capability to manage within and across organizations willingly take on a shared leadership position to create value through greater integration and coordination of essential health (physical and behavioral) services and social services in their immediate communities. Collaborative community outcomes are enhanced through the creation of shared governance and management structures, which increase efficiency and allow creative approaches to service delivery designed to maximize value (Alfero et al., 2014, 2015). As a result of these efforts, a healthcare institution seeking alliance arrangements beyond its immediate service area positions itself as an equal in any newly forming alliance arrangement and better prepares its community to manage the resulting change.
Commitment to Purposeful Partnership
An institution’s capability to think and act strategically epitomizes a commitment to purposeful partnership. These activities are characteristically completed during the emergence phase described by Zuckerman and colleagues (1995) and defined as the assembly phase by Koney and Bailey (2000). As stated by Austin and colleagues (2016), strategy efforts should yield a portfolio of initiatives that allow for timely responses to varying scenarios, given the uncertainty of the healthcare environment. With a strategic alliance as one scenario, disciplined healthcare organizations can reduce risk by methodically addressing a series of questions to ensure the right partnership match.
The questions addressed mirror a comprehensive approach to strategy formulation offered by Hambrick and Fredrickson (2001). To start, successful institutions first identify a desired market position that enables them to sustain services in their community. With a clear sense of their desired market position, alliance-seeking institutions must then address a series of related questions: What are the characteristics of the ideal partner? When should a prospective partner be approached? How should a final agreement be structured?
As consideration of an alliance continues, successful institutions project ways in which they will be able to differentiate postalliance offerings to attract and retain patients, consider the path and timing of alliance integration, and most importantly, they consider the return on this strategic action measured by their ability to meet their mission.
Commitment to Coordination
Commitment to coordination aligns with those tasks completed during the transition phase described by Zuckerman and colleagues (1995) and defined as the ordering phase by Koney and Bailey (2000). As noted in the healthcare management literature (Bradley, 2016; D’Aquila et al., 2013), the real work begins after the agreement is reached. During this phase, successful alliance-initiating healthcare institutions integrate individual organizational structures and processes at multiple levels in ways that engender trust and create an environment for the allied organizations to meet individual and mutual strategic goals. In this way, commitment to coordination may be viewed more broadly as commitment to the implementation of agreed-upon alliance strategies. As summarized by Arduino (2015) and Beer and Eisenstat (2000), organizations that capably implement strategy are characterized by a leadership team that clearly communicates a unified strategy without competing priorities, creates an environment for effective vertical communication, invests in down-the-line leadership skills, and ensures coordination of decisions and actions across functions, business units, and organizations.
Commitment to Progress
Commitment to progress represents tasks associated with the maturity phase described by Zuckerman and colleagues (1995) and reaffirmed by Koney and Bailey (2000) in their description of a performing phase. At this point in an alliance, efforts transition from planning to performance. During this phase, alliance-initiating healthcare institutions seek to sustain core services, strive to expand offerings, and, cognizant of the increasing complexity and risk of the operating environment, attempt to mitigate uncertainty by participating in new finance and service delivery mechanisms made possible by the alliance. Throughout this phase, successful alliance-initiating health institutions maintain discipline by focusing on initiatives whose outcomes align with mission, address identified community needs, and meet “best practice” standards.
LAUREL HEALTH SYSTEM: AFFILIATION THROUGH MEMBERSHIP SUBSTITUTION
A Brief Case History
The story of the LHS, summarized in Table 3, begins in 1987 when the Soldiers and Sailors Memorial Hospital (SSMH) in Wellsboro, Pennsylvania, completed a strategic plan and initiated actions to ensure long-term survival. Hospital leaders envisioned the institution as the backbone of a care system bringing continuity to the delivery of health and human services in its community. The SSMH community health governance model was subsequently recognized as an innovative way of maximizing limited health and human services resources within a rural community (Zuckerman, 1998).
Table 3 -
Summary of Key Laurel Health System Events and Strategic Alliance Themes
||Soldiers and Sailors Memorial Hospital completes a strategic plan that envisions the hospital as the backbone for a community health and human service alliance.
||Laurel Health System (LHS) forms as a holding company offering inpatient, ambulatroy healthcare, and social services.
||LHS completes a strategic plan outlining scenarios that would trigger efforts to pursue a strategic alliance.
||Facing increased direct competition, LHS initiates a formal partnership search.
||LHS merges with Susquehanna Health System (SHS) through the execution of a membership susbstitution agreement.
||LHS senior administrator leads 20 separate work groups composed of employees from each organization to integrate LHS with SHS.
||LHS increases primary care resources and specialty care services within its service area and participates in an accountable care organization start-up.
The first opportunity to realize the SSMH vision occurred in 1988 when a not-for-profit health and human services organization in the county—North Penn Comprehensive Health Services (North Penn)—approached the hospital to discuss a possible affiliation. To further pursue their shared vision, the two organizations formerly affiliated in July 1989, creating LHS as a holding company to oversee North Penn, the hospital, and hospital-related ventures.
While the hospital continued to achieve financial and clinical successes, it became clear to the administrators and board members that major changes in the local and national healthcare marketplace were well underway. As early as 2005, with other small, rural hospitals affiliating with larger systems, LHS board members began discussing the idea of affiliation. However, they were not certain if it was yet needed. LHS brought in consultants and conducted a strategic plan in 2005 and then again in 2009. An outcome of the 2009 strategic plan was the development of a list of “trigger mechanisms.” These were criteria established that would initiate LHS efforts to form a strategic alliance with a regional health system. The trigger mechanisms related to service quality, finances, recruitment, and competition. Realization of any one of these would commence a partnership search.
In 2010, a large regional health system immediately north of the LHS service area began to compete with LHS with the assumption that it would eventually absorb LHS. The hostile initiative prompted LHS to begin a formal alliance exploration. Despite its long run of success, the increased competition led LHS to merge with the Susquehanna Health System (SHS) in September 2012. The merger, completed through the execution of a membership substitution agreement, allowed LHS to sustain its core operations and unwind relationships with North Penn as required in the agreement. In addition, as a result of the merger, LHS improved the availability of primary care services, broadened the scope of specialty services in the community, and exploited an opportunity to participate in an accountable care organization (ACO). Today, as a result of SHS’s decision to enter a strategic alliance in 2016, LHS is part of the University of Pittsburgh Medical Center (UPMC).
Illustration of a Successful Health Alliance
The four themes of a successful healthcare alliance identified in Table 3 are illustrated in the LHS case excerpts from Kimmel and Sarcone (2017) that follow.
SSMH’s commitment to collaborative leadership was first demonstrated in the development of a community health and human services network positioned to better manage the risks of an increasingly challenging operating environment. This commitment to collaboration, as described by an LHS senior administrator who retired following the merger of the two organizations, was the key to LHS success within its immediate service area for well over a decade:
What made it work was partnership. So, the whole affiliation, Laurel Health System, was a partnership of entities. It was a partnership of the boards of directors, all focused on doing what’s in the best interest of the community. It sounds kind of trite, but that’s really what made it work.
The formation of LHS resulted from a commitment to purposeful partnership evidenced by the strategic planning process undertaken by SSMH in 1987. Despite near-term success, the board of directors and senior management staff of the newly formed organization remained vigilant of changing competitive dynamics by completing the formal strategic planning exercises in 2005 and 2009. As evidence of commitment to a purposeful partnership process, the most significant product of the 2009 strategic plan was the development of the list of trigger mechanisms that would initiate LHS efforts to form a strategic alliance with a regional health system. The retiring LHS senior administrator later recalled the board’s deliberations and actions, working to ensure LHS had a strong bargaining position in any future negotiation, and preserving LHS services within the community:
The board said, “OK, we understand. We’re financially stable. So, we’re looking at 3 years, maybe as long as 5 years. Things won’t deteriorate so badly that we can’t survive. But when will we know? When’s the right time? We don’t want to wait until we’re a fire sale, because then we’ll have no say in what’s going on.” So, as part of our strategic plan, we developed a list of indicators.
In the end, the trigger mechanisms defined four separate but related scenarios in service quality, finances, recruitment, and competition. Realization of any one of these would commence a partnership search. Overt competitive pressure from the large regional health system soon activated a formal search process. LHS invested a year in developing a request for proposal. As later recalled by a senior administrator of the eventual affiliating organization, LHS leadership was clear on what it sought in a partner:
Proximity (because geographic relevance is important for an organization our size), culture, and community connectedness.…Those were the three main things that were attractive to us.
These characteristics were echoed in the retiring LHS senior administrator’s remembrance of partnership requirements:
Every affiliation that was successful was successful because of common cultures. In every one that failed, it was because they had competing cultures. We said, “We’ve got to affiliate with somebody who is as close as possible, who understands rural community medicine, who understands rural culture.…an organization that is committed to serving community as we are.”
In 2012, LHS found the partner that met its requirements and agreed to merge with SHS through the execution of a membership substitution agreement. Once the agreement was finalized, LHS’s continued desire for a successful partnership was demonstrated in its commitment to coordination. This began with a strategic vision agreed upon by alliance leadership. Developed during negotiations, the vision served as the basis for organizational integration and plan implementation. As later observed by one senior administrator of the affiliating organization (who was promoted from LHS administration), the ability of the CEOs of the partnering organizations to commit to a common strategic vision set the alliance up for success:
This sounds soft and fluffy, but the first thing is leadership. You read about it, you write about it, you teach it…but when you live it.…This affiliation happened because of leadership: Leadership on the part of the former LHS senior administrator, leadership on the part of the senior administrator of the affiliating organization, and failed leadership by our other suitors. So, it was dramatically obvious to me the importance of leadership—having those two leaders set good vision and goals and work collaboratively, honestly, upfront.
Continued success, however, required more than structure. It required a process for effective vertical communication. Immediately following the formal agreement signing, the retiring LHS senior administrator postponed his departure date to assume direct responsibility for organizational integration, departing upon its successful implementation. As the retiring LHS senior administrator noted later, the process began with a concentration on clinical care services but soon encompassed all organization functions:
We put a structure in place so that as soon as the papers were signed, we could start the integration process. We set up work groups and we decided to do the clinical work groups first. I think there were 19 or 20 different work groups.…It worked because we all worked together in a small community. There was better communication, better coordination.
Over a 20-month period extending into 2014, the retiring LHS senior administrator led the work groups, ensuring clear and accurate communication from leadership to staff within and across organizations.
The efforts of leadership to create a common culture across the organizations and to establish structures and processes aligned with the culture, positioned the alliance to achieve service-related strategic goals. The commitment to progress on behalf of LHS was revealed in multiple ways. In response to LHS community assessment priorities, SHS honored its commitment made during the negotiation to invest in a new outpatient facility in Mansfield, Pennsylvania, and a cancer center at the Wellsboro hospital. The alliance prioritized efforts to increase access to medical care specialists and recruit primary care physicians for Tioga County in response to the LHS community needs assessment. To support overtaxed local volunteer emergency medical services (EMS) units, SHS established a paid EMS unit in the community. Finally, the partnership with SHS created an opportunity for LHS services to participate in a new model of healthcare provision and financing: On April 15, 2013, SHS committed to ACO participation by joining other central Pennsylvania healthcare providers to form River Health ACO to improve the cost, quality, access, and patient experience for residents of central Pennsylvania.
Through a series of decisions and actions that led to an alliance with SHS, LHS leadership effectively addressed growing competitive pressures and advanced services in the system’s community. These activities led to positive outcomes reflecting critical capabilities developed by LHS senior management and board members. LHS attributes aligned with common prerequisites identified in contemporary healthcare research on alliances, including mergers (Campbell, 2008; Chesley, 2020; Keane et al., 2016; Manas, 2011; Schulte, 2011). These prerequisites include clarity of purpose, diligence in selection, cultural compatibility, and focus on integration.
LHS leadership’s ability to manage within and across organizations resulted in the formation of a collaborative community service network. The capability to provide responsive community service advanced the network’s reputation and positioned it as a credible partner for future expansion.
The pursuit of a regional alliance was not taken in haste. As a result of its strategic leadership capabilities, LHS leadership was able to identify a desired long-term market position and carefully institute a plan to achieve that desired position. Following the formation of the regional alliance, LHS’s interorganizational management capability was the source of the knowledge and skills to create value for its community through the effective integration of regional resources. Finally, deep knowledge of the community, paired with a commitment to meet the identified needs of its residents, instilled LHS leadership with the discipline to pursue results that align with the mission.
The impact from political, economic, social, regulatory, and technological trends, coupled with a population health approach to care, ensures the continued consolidation of healthcare services in the American healthcare system as exemplified by LHS, now a part of SHS. Furthermore, as a result of SHS’s decision to become part of UPMC in 2016, LHS—which was independent in 2012—became part of a globally recognized $19 billion healthcare system. As a condition of the merger, UPMC committed to invest $500 million in the newly named system, UPMC Susquehanna, to enhance the quality and expand the scope of services provided in Lycoming and Tioga counties.
Although only fully supported by one case study, we believe the insights gained from an intensive review of rural healthcare alliances are transferable. Commitments to collaborative leadership, purposeful partnership, coordination, and progress thematically represent a series of critical decisions and actions required to achieve strategic alliance success. The organizational capabilities of strategic leadership and interorganizational management expertise serve as the foundation for these decisions and actions. Successful alliance-initiating organizations employ key organizational capabilities throughout the multistage alliance process, aware of the critical decisions and actions in each stage that collectively must be implemented to advance their mission.
This research was made possible through a grant from the CRP.
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