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BUSINESS FORUM Vol. 27, Issue 1 | 1

Business Forum is dedicated to improving the effectiveness of business in contemporary society. We provide a forum for fresh ideas, impactful research, and possible solutions to business challenges. We strive to close the gap between research and practice and enable evidence-based business management.

Our peer-reviewed articles address specialized and interdisciplinary issues of interest to business practitioners. We accept manuscripts from all domains of business, usually themed by a particular journal issue. We also publish reviews of books and digital materials of interest to our audiences as well as important insights shared by business and civic leaders.

Business Forum is published semiannually as an educational service of the College of Business and Economics at California State University, Los Angeles. As such, papers addressing economic development in our region, or useful to its business managers or for the public good are especially welcome.

Editor-in-Chief Marianne James, Ph.D., CPA, CMA, Cal State LA

Editorial Board Members Andre S. Avramchuk, Ph.D., CGEIT, Cal State LA

Vickie Coleman Gallagher, Ph.D., Cleveland State University Tyrone Jackson, Ph.D., Cal State LA

Xiaoquan Jiang, Ph.D., Florida International University Michael R. Manning, Ph.D., Benedictine University

Robert Marley, Ph.D., CPA, University of Tampa

Managing Editor Xiaohan Zhang, Ph.D.

Digital Works / Book Review Editor Shirley Stretch-Stephenson, Ph.D.

Copy Editors Rhonda Albey and Masood Khan

Issue Editor Andre S. Avramchuk, Ph.D.

Cover design by Pablo Martinez

ISSN: 0733-2408 Publisher: College of Business and Economics, Cal State LA

5151 State University Drive, Los Angeles, CA 90032 Phone: 1-323-343-2942

Email: [email protected] https://businessforum.scholasticahq.com

BUSINESS FORUM Vol 27, Issue 1 | 2

TABLE OF CONTENTS

Editorial ……………………………………………………………………………………………………………………………………………3 Andre S. Avramchuk

Adapting to an Evolving Healthcare Environment ……………………………………………………………………………..5 Cástulo de la Rocha

Cal State LA’s Mind Matters Initiative: Making a Difference ……………………………………………………………..7 Jillian Beck

ARTICLES

Pixels and Patients: Using Technological Innovations to Reduce Healthcare Costs and Improve Health Outcomes …………………………………………………………………………………………………………………8 David R. Weinstein Lonnie S. Barish Micah P. Frankel Addressing Employee Burnout Through Mitigation of Workplace Stressors ………………………………………..17 Portia Jackson Preston Fast Food, Supermarkets, and Obesity in the Inner City: A Study of Food Access and Health in South Los Angeles ……………………………………………………………………………………………………………………………………….24 Tom Larson Deborah Compel Larson Who Did the Affordable Care Act Help and Who Did It Fail? ……………………………………………………………..33 Zhen Cui Devika Hazra

Lessons from the Healthcare Funding Challenges at Konkola Copper Mines in Zambia? …………………….39 Mwadi Kakoma Chakulya Francis Wambalaba Barbara W. Son Being Intentional About Workplace Mindfulness Programs ………………………………………………………………..48 Carol Blaszczynski

BOOK REVIEW

The Gene: An Intimate History by Siddhartha Mukherjee, M.D. ………………………………………………………..54 H. Rika Houston Call for Paper Submissions and Reviewers …………………………………………………………………………………………57

Sponsors ……………………………………………………………………………………………………………………………………………58

BUSINESS FORUM Vol. 27, Issue 1 | 3

HEALTHCARE CURRENTS: A SPECIAL ISSUE FORUM

It is an exciting time at the Business Forum, a peer-reviewed, scholar-practitioner journal published by the College of Business and Economics at Cal State LA. The journal provided scholarly advice and application to business practice since the mid-1970s and is now renewed in a modern print-online format. Our articles have always aimed to advance business practice through application of research or theoretical synthesis of information relevant to business. This Healthcare Currents issue is not an exception, as we highlight an array of interesting topics from reviewing healthcare technology advancements that contribute to reductions in costs of care to helping managers understand wellbeing and mindful practices at work.

We open with two vignettes setting a practical context for the articles. The President of AltaMed Health Services Corporation shares how his company handles healthcare industry changes and leads the way into technological and service innovation in the underinsured Southern California communities and beyond. The “Mind Matters” initiative in the second vignette showcases one of the wellbeing programs that engender positive change in how work-and-study community members empower themselves with knowledge about compassionate engagement and managing stress. Echoing previous research on compassion and change (e.g., Avramchuk, Manning, & Carpino, 2013; Worline & Dutton, 2017), both vignettes illustrate the need for leaders to take their organizations further on a path toward social responsibility and human thriving.

The main Articles section begins with a review of technologies for monitoring and supporting patient care remotely. David Weinstein, Lonnie Barish, and Micah Frankel lead us on a fascinating journey into innovative market solutions targeting improvements in preventive care and therefore increasing its quality while reducing overall care costs. The quality-versus-costs dilemma (Bradley & Taylor, 2015) is central in the healthcare management field, and most articles chosen for this special issue try to tackle it in some practical way.

Addressing healthcare costs from a workplace angle, for example, Portia A. Jackson Preston synthesizes the literature on workplace stressors and shares evidence-based recommendations for dealing with employee burnout. Tom Larson and Deborah Compel Larson then take us outside of the workplace and into a South Los Angeles community to demonstrate through their research how the food deserts in urbanized environments coexist with the obesity epidemic and other healthcare cost drivers among our local population, including its working-age segment.

Among the key currents in our healthcare field is the set of monumental changes due to the enactment and ongoing implementation challenges of the Patient Protection and Affordable Care Act of 2010 (ACA). Zhen Cui and Devika Hazra have examined the associated positive and

EDITORIAL

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negative impacts on healthcare cost coverage and provide interesting, original statistics on who the ACA helped and who it failed in this regard. Their research gives insight into the issue of health insurance for the self-employed and suggests policymaking implications for healthcare coverage of part-time employees in the United States.

Mwadi Kakoma Chakulya, Francis Wambalaba, and Barbara W. Son bring into the spotlight an increasingly important, global view on employee healthcare financing through a unique case of Zambian copper miners. The authors’ survey research illuminates the nuances in employee attitudes toward paying for healthcare costs, producing potentially useful lessons for the unionized miner workforces in particular and labor-management partnerships in general. We then close with the article by Carol Blaszczynski that harnesses and showcases the power of workplace mindfulness through a synthesis of literature and current organizational practices. The author presents a compelling business case for mindfulness programs in different work settings and across employee and management job levels. The article furthers the encouragement from several authors of this special issue to build organizational communities for a sustainable workplace and a healthy society.

Finally, H. Rika Houston reviews The Gene: An Intimate History, a book by Siddhartha Mukherjee, that helps us to “challenge and reimagine preconceived notions of health and wellness” (Houston, 2018, p. 54). As we struggle to reconcile business imperatives with societal priorities (Rosenthal, 2018), there are paradigm shifts emerging to affect the core of what we know about our struggles, passions, and nature. The Business Forum journal aspires to bring our audiences fresh perspectives on how to work effectively and organize efficiently yet continue to live with wonder about a better world filled with creativity, innovation, and purpose. The Healthcare Currents issue attempts to deliver on this hefty promise.

Andre S. Avramchuk Issue Editor

References

Avramchuk, A. S., Manning, M. R., & Carpino, R. A. (2013). Compassion for a change: A review of research and theory. In A. B. (Rami) Shani, W. A. Pasmore, R. W. Woodman, & D. A. Noumair (Eds.), Research in Organizational Change and Development, Vol. 21, pp. 201-232. Bingley, U.K.: Emerald. Bradley, E. H., & Taylor, L. A. (2015). The American health care paradox: Why spending more is getting us less. New York, NY: PublicAffairs. Houston, H. R. (2018). The gene: An intimate history by Siddhartha Mukherjee, M.D., Business Forum, 27(1), pp. 54-55. Rosenthal, E. (2018). An American sickness: How healthcare became big business and how you can take it back. New York, NY: Penguin. Worline, M. C., & Dutton, J. E. (2017). Awakening compassion at work: The quiet power that elevates people and organizations. Oakland, CA: Berrett-Koehler.

BUSINESS FORUM Vol. 27, Issue 1 | 5

If you’ve been paying attention to what’s happening in Washington, D.C., you know that change is, ironically, a constant in health care. This includes new policies from our nation’s capital as well as the medical needs of our communities. Over the last several years, AltaMed Health Services has adapted to these changes and has forged

itself as a leader in ensuring access to health care and preventive services. Whatever happens in Washington, we are dedicated to continuing our nonprofit mission of providing quality health care without exception to each and every person we serve.

In more than four decades of operation, our key to success remains our focus on serving our local communities, particularly the underinsured. This has helped AltaMed grow from one storefront neighborhood clinic, staffed by volunteer physicians who treated 11,000 patients a year on a five-figure budget, into a $600 million health care provider with nearly 2,700 employees, delivering more than one million patient visits annually.

One of the hurdles we faced in achieving this growth was adapting to a state health care market that moved from a fee-for-service model to a managed care system. To remain competitive, we had to shift from operating as a grant- driven organization to a market-driven one with the ability to provide contracted Medi-Cal, Medicare and commercial health care services to every HMO in the region.

The Affordable Care Act (ACA) proved to be both a challenge and a growth opportunity. When the ACA was enacted, it was a victory for health care advocates across

the nation. It also became a game changer for community clinics. It enabled us to receive reimbursement for much more of the care we provided, because more patients now had private insurance or began to qualify for Medicaid because of its expansion. Community clinics like ours were able to use federal grants to expand facilities and add services, such as dentistry, urgent care or mental health care. Many clinics that once spent years in the red, barely able to keep their doors open, are now finally breaking even because of the ACA.

Patients who became insured as a result of the new legislation were now able to visit the doctor without the fear of unexpected medical costs. They have the security of a known co-pay and deductible, and can plan accordingly. In the case of Medicaid patients, they have the security of knowing that lack of income will not get in the way of their need for medical care.

At AltaMed, we have traditionally treated and prepared ourselves to act as safety net to a largely low-income demographic that would otherwise have very limited options for receiving medical care. Close to 185,000 of our patients – approximately 70 percent – currently rely on Medicaid for coverage across Los Angeles and Orange counties. Our ratio of Medicaid patients is significantly higher than the Medicaid coverage rate across California, as approximately one-third of California residents under 65 are on Medi-Cal.

We also have more than 50,000 patients who do not qualify for traditional coverage. These are patients who rely on our sliding fee scale and the fee-for-service model.

The implementation of the ACA forced us to increase the number of facilities we offer, to expand our capacity to serve more patients, improve and manage our operational costs, and ensure that we consistently deliver the best possible outcomes for our patients. Adjusting to the law was a difficult, two-year effort, but it helped move

Adapting to an Evolving Healthcare Environment By Cástulo de la Rocha

Cástulo de la Rocha is President and Chief Executive Officer of AltaMed Health Services Corporation, the largest nonprofit Federally Qualified Health Center in California in the nation. A social architect, Mr. de la Rocha has changed the faces of the communities AltaMed serves by expanding a sustainable and innovative model of health care delivery to provide access to quality care for millions of underserved patients. Accredited by the Joint Commission as a Patient Centered Medical Home, AltaMed is home to nearly 2,700 employees, provides care to approximately 300,000 patients, and delivers more than one million patient visits annually across nearly 50 medical, dental, HIV and PACE sites in Los Angeles and Orange counties.

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AltaMed from the bottom quartile in performance to being ranked among Kaiser Permanente, CareMore and others as a top health care provider.

If Congress repeals the ACA, California could lose $20 billion annually in federal funding for Medicaid expansion and insurance subsidies, leaving 7.5 million Californians without access to affordable insurance coverage. It will be a dark, dark day in this country’s history if we suddenly terminate coverage for the 22 million Americans who now receive some kind of benefit through the ACA.

Although plans for a replacement continue to be discussed in Congress, they just aren’t good enough. Many of the previously proposed plans have included potential cuts to Medicaid, which would largely affect the working poor and elderly. Getting rid of the individual mandate that all legal residents must be insured would likely mean that young, healthy people would stop buying plans, and insurers would once again be footing the greater part of the bill to cover people with higher medical expenses. That would lead to increased premiums and out-of-pocket costs for those who do continue to purchase insurance. By one estimate, 10 percent of those living in Los Angeles, Fresno, Kern, San Bernardino, San Joaquin and Tulare counties have received benefits under ACA. Some of these regions are represented by Republicans and have large numbers of Republican voters who’ve taken advantage of the ACA’s benefits. This is also true of many of the key states Republicans carried in the November election.

In 2015, U.S. health care costs reached an all-time high of $3.2 trillion, partly due to millions of Americans gaining coverage through the ACA. Employers, small businesses and chambers of commerce have to take a more active role in the debate over affordable health care. In particular, we have a significant stake in serving the Latino market where there are significant numbers of unemployed and working poor. Washington has floated many proposals, including health care spending accounts and tax credits. We have to become actively engaged to ensure that whatever policy Republicans and Democrats pass will continue to provide access to affordable health care for the maximum possible number of people. The consequences of not instituting a policy solution that keeps health care affordable would create an undue burden for working-class Americans.

And though we have seen ideas floated around, like expansion of tax-free health savings accounts or selling insurance plans across state lines, the best way to increase access to health care is yet to be determined. That said,

AltaMed will continue working closely with Covered California to identify the greatest need for coverage that remains in our state, and we will continue to offer one-on- one assistance at our health centers to ensure that no one who qualifies in our community is left without coverage. We will continue to operate until changes are solidified, and we will do our best to continue advocating for those who are still seeking coverage assistance.

The effect that the ACA has had on operating budgets, revenue and margins has forced some providers, like Aetna and United Healthcare, to leave the program. On a local level, we’ve seen Anthem Blue Cross exit the Covered California market. However, since the ACA became law, health care cost increases have been in the single-digit range, compared to previous increases of 12 to 20 percent. To contain future health care costs, doctors, hospitals, clinics and pharmacies will need to move away from a fee-based system, reliant on volume, to a value- based system with a capped monthly rate for services.

Across the spectrum, we all share responsibility for managing health care costs. As employers, we need to monitor and continually evaluate the care our employees receive and work with insurers to better manage those costs through wellness and other programs. Both employers and individuals have a role to play in choosing providers that deliver the best performance. Lastly, employees need to become more informed consumers and demand the information that will help them make decisions about their health care.

Health care will soon resemble the consumer market in that breakthrough innovations are being driven by data and technology. Providers that leverage data and technology to engage their patients will be the winners. For AltaMed, it means we have to use more strategic technology to deliver cost-effective, high-quality medical care. We’re already using electronic medical records in our back offices, and electronic prescription management and telemedicine in the clinical setting. Where technology will be especially helpful is connecting bilingual psychologists, cardiologists, dermatologists and other specialists with our patients. That’s a major challenge for providers, but advances like smartphone apps and remote medicine will help us meet patients’ needs anywhere and anytime. In order to stay relevant, we have to keep up with the times and continue to listen and meet the ever- changing needs of the communities we serve.

BUSINESS FORUM Vol. 27, Issue 1 | 7

Cal State LA’s Mind Matters Initiative: Making a Difference By Jillian Beck | Cal State LA News Service

The goal of the Mind Matters initiative at California State University, Los Angeles is to integrate inner well-being into the framework of University life as a means of supporting student success.

Cal State LA President William A. Covino and First Lady Dr. Debbie Covino created the Mind Matters initiative in 2013 to provide resources and programs to help students navigate the demands of academic excellence, family responsibilities and jobs. The President and First Lady realize that without inner well-being, there is no academic success.

The Mind Matters initiative comes at a time when college students nationwide are experiencing high levels of stress, including problems caused by sleep deprivation and anxiety about adjusting to university life.

“Now, perhaps more than ever, we need to ensure that our students understand the importance of caring for their inner selves,” President Covino said. “And we are providing them with ways to do so.”

To help ensure student success, additional counselors have been hired for the Student Health Center, doubling the number available to assist students. Space was renovated in the center to accommodate the additional counseling and workshops and activities were added to promote physical and mental well-being.

The number of peer health educators on the Student Health Advisory Committee (SHAC) has also expanded to more than 50 students. These volunteers help educate students about health and wellness issues.

Mind Matters programs include Well- Being Wednesdays, which promote inner well-being by encouraging a campus culture based on compassionate

engagement and mutual support. Mind Matters and SHAC volunteers, Well- Being Ambassadors and the new Mind Matters eagle mascot, Welly, promote inner well-being on the Main Walkway on Wednesdays with materials that reinforce the values of care and compassion.

More than 440 faculty, students and staff, including the President’s Leader- ship Team, have been trained in Mental Health First Aid, an eight-hour course that teaches participants how to identify, understand and respond to signs of mental illnesses and substance use disorders. The training provides skills needed to reach out and provide initial help and support to someone who may be developing a mental health or substance use problem or experiencing a crisis. On Well-Being Wednesdays, those trained in Mental Health First Aid wear green “We Care, I Care” buttons.

The Mind Matters initiative also features a speaker series, providing students, faculty and staff with insights on compassion, inner well-being and time management.

The engaging speakers have included Los Angeles Times columnist Steve Lopez and Rev. Gregory J. Boyle, S.J., founder of Homeboy Industries.

The Mind Matters Town Halls have been of great value to the campus commu- nity, complementing the civic-learning research Cal State LA students carry out in their classes. During the gatherings, students have created action plans for the health and well-being of the University community. Town halls are a proven practice that can contribute to student success and degree completion. More than 2,000 students have participated in Mind Matters Town Halls, and another 2,500 are expected to participate in the 2017-18 academic year.

BUSINESS FORUM Vol 27, Issue 1 | 8

A R T I C L E S _________________________________________________________

PIXELS AND PATIENTS: USING TECHNOLOGICAL INNOVATIONS TO REDUCE HEALTHCARE COSTS AND

IMPROVE HEALTH OUTCOMES

David R. Weinstein Extropy Health Solutions

Lonnie S. Barish

WellSpring Pharma Services

Micah P. Frankel California State University, East Bay

SUMMARY: Advancements in remote monitoring technologies provide new opportunities to mitigate the growth of healthcare costs while improving patient health outcomes. These technologies have the promise to positively impact a patient’s health by producing and contributing additional, valuable and timely “health information pixels” to the picture of a patient’s clinical profile. In this article, we review how the use of remote monitoring and support technologies to gather data, digitally connect patient data to healthcare teams, and generate actionable messages may further contribute to addressing the key dilemma of improving healthcare quality while reducing healthcare costs.

Introduction

The United States continues to grapple with significant challenges posed by the magnitude of healthcare costs and their year-over-year rate of growth. For example, family deductibles under the Affordable Care Act averaged over $12,000 for 2017 bronze plans, while average premiums rose over 20% from the prior year (Mangan, 2016). Average healthcare spending in 2016 was over $10,000 per capita in the United States. These numbers are projected to rise by another 50% between now and 2025, so even just a 1% reduction in actual healthcare spending growth rates will have a significant impact on absolute costs (Kamal & Sawyer, 2017). Advancements in remote monitoring technologies provide new opportunities to mitigate the growth in healthcare costs while improving patient health outcomes. These technologies have the promise to positively impact a patient’s health by producing and contributing additional, valuable and timely “health information pixels” to the picture of a patient’s clinical profile. In this article, we review how the use of remote monitoring and support technologies to gather data, digitally connect patient data to healthcare

BUSINESS FORUM Vol. 27, Issue 1 | 9

teams, and generate actionable messages may further contribute to addressing the key dilemma of improving healthcare quality while reducing healthcare costs.

Medication Adherence

One area targeted by these new technologies is poor medication adherence. The World

Health Organization defines medication adherence as “the degree to which the person’s behavior corresponds with the agreed recommendations from a healthcare provider” (Jose & Beena, 2011, p. 155). Poor medication adherence is a growing concern for clinicians, healthcare systems, and other stakeholders (e.g., payers) because of mounting evidence that it is prevalent and associated with adverse outcomes and higher costs of care (Ho, 2009).

The statistics are staggering. Poor medication adherence costs the healthcare system nearly $300 billion per year in additional doctor visits, emergency department visits, and hospitalizations (Bresnick, 2015). Chronic diseases such as diabetes, hypertension, and hyperlipidemia (i.e., high cholesterol) affect one out of every 10 American adults (Chronic Disease Overview, 2017) and account for 86% of healthcare costs (At A Glance 2015, 2015). Poor medication adherence may affect 50% of all patients and increases the likelihood of a hospitalization by up to 134% for chronic diseases such as high blood pressure, diabetes, and high cholesterol (Chronic Disease Overview, 2017). In 2003, the World Health Organization identified medication non-adherence as a leading cause of preventable morbidity, mortality, and healthcare costs (World Health Organization, 2003).

Data Pixelation

Past efforts at improving medication adherence have suffered from “data pixelation,” the concept from computer graphics used to describe blurry digital images caused by a dearth of pixels—the information elements of these images. Data on daily medication dosing is rare. Physicians typically rely upon monthly prescription insurance claims created when patients pick up their medications at the pharmacy (Lam, 2015). Monthly data provide a fairly coarse view of the patient’s adherence behavior and are usually actionable only weeks or months after the fact. The metaphor of a low-resolution digital photo is striking; with their relatively few data points, monthly prescription insurance-claims data present a pixelated, under-informed view of the patient’s true medication adherence.

Consequently, physicians often make assumptions about medication dosing behavior which may not comport with the facts (Goldberga, Cohena, & Rubinb, 1998; Hulka et al., 1976; Rand & Wise, 1994). Generally, physicians tend to overestimate the level of their patients' adherence to therapy (Philips, 1996). “Non-adherence to medications reduces treatment benefits and can confound the clinician’s assessment of therapeutic effectiveness, and is thought to account for 30% to 50% of cases where drugs fall short of their therapeutic goals” (Wroth & Pathman, 2006, p. 478).

Let us consider a hypertensive patient who forgets to take prescribed blood pressure medication every other day. This poor adherence behavior produces two health risks. First, by not taking medication as prescribed, the patient’s blood pressure may remain above the clinical goal, impacting long-term health through increased risk of cardiovascular events (Green, Kwok, & Durrington, 2002). Second, in response to the patient’s continued high blood pressure, the physician may raise the daily dose of blood pressure medication. Consequently, if the patient

BUSINESS FORUM Vol 27, Issue 1 | 10

adheres more to the medication regimen in the future, the increased dose may create a risk of an undesired decrease in blood pressure resulting in lightheadedness or fainting (Victor, 2016). …

EJBO Electronic Journal of Business Ethics and Organization Studies Vol. 23, No. 1 (2018)

20 http://ejbo.jyu.fi/

Promoting Sustainability: The Effects of Workplace Mindfulness Training

Introduction

Mindfulness training is enjoying grow- ing popularity in work life settings, with the aim to increase employees’ mindful- ness level and thereby their well-being. Prior evidence suggests that higher mindfulness is associated with reduced stress (Ciesa and Serretti, 2009) and bet- ter recovery from work (e.g. Hülsheger, Land, Depenbrock, Fehrmann, Zijlstra and Alberts, 2014). Mindfulness can be defined as non-judgmental, moment-to- moment awareness which can be culti- vated through formal meditation and informal practice in everyday life (e.g. Kabat-Zinn, 2003). Trait mindfulness refers to how mindful individual tend to be and act in daily life. Mindfulness is constituted of various facets, such as non- reacting, observing, acting with aware- ness, describing and non-judging experi- ences. Of these, non-reacting, defined as the ability to step back from and not be overwhelmed by distressing experiences, is an important contributor to employee well-being (Malinowski and Lim, 2015).

Three broad streams of mindfulness research exist. First, correlational and cross-sectional research explores asso- ciations between mindfulness levels and other factors (e.g. Malinowski and Lim, 2015). Second, diverse intervention stud- ies examine the effects of various types of mindfulness training, w

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