Mapping Stakeholder Relations: Lack Of Access To Affordable Healthcare In Pittsburgh
Assignment #2: Mapping Stakeholder Relations
Carnegie Mellon, Transition Design Seminar 2023
Team Diversity: Luis Garcia, Parrish Andre, Ariba Asad, Mary Priyanka Jacob, Emilie Zhou
Wicked problems live within us. They are not external entities but slurries of misaligned agendas between groups of stakeholders. Understanding the similarities and differences between stakeholder hopes and fears is essential to understanding the wicked problem. For this exercise, we mapped the hopes and fears of three groups of stakeholders and how they agreed and disagreed.
Unfortunately, the timeframe of this class does not lend itself to extensive interviewing, so for the purpose of learning, we only did secondary research on a limited set of stakeholder groups. We also admit that our group’s perspectives and biases would influence our statements. However, the importance of this step cannot be understated. Our mapping is nowhere near the necessary depth and breadth to attack such a complex problem.
Our Process
To better understand which groups are involved and affected by the lack of affordable healthcare in Pittsburgh, we began by brainstorming different stakeholders of this wicked problem. In order to start thinking about all the groups involved, we brainstormed groups across a wide range of power and influence regarding the wicked problem. We listed smaller subgroups under four broader categories, consisting of groups that are most adversely affected by the wicked problem, groups with a lot of power and privilege that may or may not care about the wicked problem being solved, groups that have the leverage to help solve the problem, and groups that might be benefiting from the problem and do not want to see it solved. In addition, we also brainstormed possible mindset characteristics for each of the main stakeholder groups. We found this was a risky exercise as we all have our own biases and can never fully predict another group’s mindset. Consequently, proper research and interactions with real stakeholders would be necessary to build a more comprehensive understanding of stakeholders’ interactions.
After mapping stakeholders on a power spectrum, we identified three groups we believed would have the most polarization and tension. We selected UPMC, insurance providers, and lower-income families as the three stakeholder groups because they represent groups who have different amounts of power on the problem and groups that are all affected very differently by the wicked problem. UPMC represents a group benefiting from the problem and who might want to avoid seeing this wicked problem solved. This group primarily focuses on UPMC leadership and those who put UPMC’s interests first. Insurance providers represent a group with some power and leverage to help solve the problem. They often work with hospitals and patients to determine what healthcare costs should be covered. Like UPMC, they may also put their financial interests first. Lower-income families represent a group that is adversely affected by the wicked problem as they are marginalized and treated unfairly in society. They have different access to opportunities, services, and care than those with higher incomes. As a team, we brainstormed fears, concerns, hopes, and desires that each of these three stakeholder groups could have in the context of our wicked problem. Then, we use different colored lines to connect different thoughts across the groups to find areas of conflict/opposing agendas, areas of agreement/similar agendas, and complex/ambiguous relations. By exploring how thoughts and interests across the different stakeholder groups could be connected, we developed a more robust understanding of how our wicked problem is involved in people’s lives.
Understanding our stakeholders
This process allowed us to build a more robust understanding of the multiple dimensions of this wicked problem. By mapping the fears and concerns and the hopes and desires of these three stakeholders, we unveiled critical aspects that show the daily economic, political, and social factors people encounter. Understanding the stakeholder dimension of this wicked problem also gave us clues to think about interventions that can address the lack of healthcare access in Pittsburgh. Identifying the common struggles and hopes of this wicked problem is a starting point for the people involved in the wicked problem to initiate change, especially when finding consensus is the hardest part of a collaborative effort.
The following section presents the main insights from each stakeholder we focused on for this assignment.
UPMC
Most sources that focus on UPMC show their constant emphasis on growth and avoiding problems with the stakeholders they interact with. We found that one of their primary concerns is the potential actions that clients may take against them, which often makes UPMC practice defensive tactics against lawsuits. Moreover, UPMC justifies the high costs of services because of the “high quality” and the constant investment in technical services.
On the other hand, one of the major hopes of UPMC has to do with its public image and reducing its operations costs. UPMC’s mission, vision, and values focus a lot on aspects related to its reputation, such as “shaping tomorrow’s health system,” “providing outstanding patient care,” and “advancing excellence and innovation throughout health care.” At the same time, we found multiple articles that showed UPMC’s efforts in realizing the principles above and strategies to strengthen its reputation and hence its overall power.
Learning more about this stakeholder showed us how feedback loops can tremendously impact the complexity of a wicked problem. In this case, significant investments and strategies to improve reputation accentuate the organization’s power, allowing them to pull more resources for even higher investments and strategies to grow. This cycle continues to benefit only a few, leaving many others in a disadvantageous position and with fewer possibilities to access healthcare.
Lower Income Families
Our research shows that this stakeholder group mainly hopes for some action from several stakeholders. For example, and perhaps the most evident one had to do with their hope and trust in politicians that would advocate for their needs and to pass laws that can support their access to healthcare. We found that this stakeholder strongly relies on the community around them by engaging with community or healthcare centers that advocate for their needs. Although some of these initiatives are positive as they increase the awareness of proper medical care, they also raise the question of why people need to look elsewhere to get what stakeholders such as UPMC should be supporting. Moreover, these preliminary insights also indicate that a wicked problem of this kind will require action at a higher level, such as those of the government, to achieve significant change.
On the other hand, our findings indicate the main fears and concerns connected to a lack of trust in the system and the frustration of rising medical costs. We found that accurate information related to healthcare is quite challenging to access and that, paired with the high costs of medical services, creates a “lack of autonomy” among individuals. This is particularly interesting and another potential area to explore further since this could indicate why people chose to find support or develop initiatives such as those of community centers. Finally, a major finding was that people are afraid of how the monopolization of the healthcare sector continues and their lack of control over that.
Insurance providers
A non-surprising finding for this stakeholder was their constant search for growth and expansion of their business. At the same time, they hope to cater to the city’s different economic classes with the government’s help and continue to improve their hold on Pittsburgh by providing subsidized insurance to big institutions such as universities. On the other hand, our research indicates that there could be some fear from these stakeholders of initiatives such as the Affordable Care Act (ACA) or the American Rescue Plan Act (ARPA) that could potentially reduce their profits.
This stakeholder is particularly challenged when thinking of potential interventions that could address this wicked problem, mainly due to how it could affect them and change their way of thinking and doing things until this day. However, these preliminary insights could be a starting point for more profound research that can shed light on potential interventions from other stakeholders, such as government agencies, to regulate and support change that can benefit less privileged groups concerning healthcare.
Mapping interconnections and interdependencies
The complexity and interconnected nature of a problem are what make it wicked. Access to affordable healthcare in Pittsburgh with a range of stakeholders affected one way, or the other is positioned within the same complex network. Our three selected stakeholders relate to one another in the same complexity, and in some cases, it has been identified that the fears of one group are the hopes and desires of the other.
The interconnectedness among various fears and hopes is represented through red and green lines, where red represents opposing views, and the green represents an alignment in the hopes within the stakeholder groups under study. Another kind of relationship that does not fall into these two categories has been identified in a few cases and is represented by black dashed lines. These are complex or ambiguous connections and are, therefore, more difficult to understand and resolve and, in some cases, exist between the hopes and fears of the same stakeholder group.
To understand the red line (opposing view) connection, a prominent example in the mapping is $440 million in profits earned by Highmark after COVID-19, while low-income families suffered job losses and instability in housing and jobs, with a huge impact on finances. Highmark hopes to continue earning more while the impacted group struggles financially. A green line (common goal) connection can be understood through the example of the impact of inflation on both UPMC, who fear that lowering the cost of healthcare services will affect the quality of care, and low-income families, who fear for unaffordability of the lowest priced silver plan premium the cost of which has been increased by 4%. Both groups are suffering due to medical inflation. The black line (complex) connection can be understood through the example of health insurers who hope to ease reimbursement and reduce their operation expenses by bringing many clinics into the network. At the same time, they fear that having too many hospitals and clinics will lower their standard of care.
Conclusion and Reflections
As rightly stated by our professors, this is one of the most challenging and necessary exercises to solve complex problems. Through this mapping, we considered our three most crucial stakeholders in the buckets of “most powerful and unwilling to resolve” (UPMC), “medially powerful and susceptible to opinion change” (Insurance providers), and “quite helpless and hoping for a resolve” (Lower income families). We had listed at least five stakeholders previously but had to downsize our list and information collected due to time.
We looked at the hopes of both UPMC and lower-income families for lower healthcare costs, but with differing agendas; one wants lower medication prices for larger profits, while the other wants a healthier life. Another issue that was mapped was the impact of Covid-19, which increased revenue for insurance providers and hospitals while putting a hole in the pocket of lower-income families, creating a very unhealthy and unsustainable landscape. We also observed that insurance providers and UPMC would appreciate a bigger population in Pittsburgh and, if possible, a richer gentry. However, both groups need more infrastructure to handle such situations in the present scenario. The hope for larger margins for UPMC and insurance providers goes directly against the wish for accessible and affordable healthcare from lower-income families. We also observed many ambiguous relationships between hopes and fears, both inter- and intra- stakeholder, especially in our stakeholder group that is assumed to be “sitting on the fence,” the insurance providers.
During our discussions for the exercise, we noticed our own personal and shared perspectives and biases shading the facts we were writing out from online research. This was especially noticeable in the ease with which we could fill out hopes and fears for the two extreme groups (UPMC and lower-income families), whereas filling out the same for insurance companies was very hard and had a lot of ambiguous relations within itself; clearly showing that human perspective just omits a large number of stakeholders who are hidden; and are usually most crucial to make or break wicked problems.
Despite the constraints, we have mapped our stakeholders as best possible, with as much conscious objectivity and responsibility to our wicked problem.
A copy of our mapping exercise can be accessed here.
References
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