Antony Chiang is a pretty sought-after guy. Less than a month into his new job leading the Dogwood Health Trust — which is poised to spend $50 million to $75 million a year to dramatically improve health outcomes and health equity in 18 Western North Carolina counties and on the Qualla Boundary of the Eastern Band of Cherokee Indians — Chiang, 51, spoke to Xpress in an exclusive conversation for this fall’s nonprofit special issue.
Before we dive into what’s on the horizon for you and Dogwood Health Trust, let’s take a moment to look back at your previous position as founding president of the Empire Health Foundation in Spokane, Wash. What aspects of your 10-year leadership of Empire are you proudest of?
I’m going to answer that on two levels. At the highest level, what I’m most proud of is helping, in partnership with the founding board, to write the DNA of an organization that fundamentally cares about moving the needle — and moving the needle on health equity. Neither one of those is a given.
I think when most people ask that question, what they mean is, are we proud of the reduction of the uninsured from 17% down to 3%? Yes, amazingly proud of that. Are we proud of reducing the number of kids entering foster care by about 15% this year so far, toward a 50% goal? Absolutely proud of that. Reducing out-of-school suspensions by 64% in three years at the lowest-income high school in Spokane? Absolutely proud of these different initiatives to the point that, because of my first answer, it’s hard to choose. Sixty percent increase in primary care physicians being trained in the region. What’s nice is I can just rattle these off.
For me, it’s about how we created the DNA of Empire’s approach to the work. Both our community partners and the board now expect that from the staff. It’s not OK to just shotgun the money out: We have to think about our toughest issues and how to change them permanently.
What drew you to the opportunity at Dogwood?
The main thing that’s driven my career decisions has always been asking the question: Will this new opportunity allow me to have more impact and make a bigger difference than the one that I’m potentially leaving? So I looked at the incredible passion and readiness of this board — especially over DEI [diversity, equity and inclusion] and health equity — and an opportunity to, again, build an organization from scratch.
People label me a startup person, and I do love startups. I find it exciting to build, so certainly a huge factor was the opportunity to start something.
But I have to give a lot of credit to this board: I would not be here if it were not for the passion of this board. As you may have seen looking at the work at Empire Health Foundation, a lot of incredible things are happening there. The potential had to be even higher here for me to leave.
Like Dogwood Health Trust, Empire came into being as the result of the acquisition of a nonprofit health system by a for-profit company. Over 10 years, you more than tripled Empire’s effective assets. How was that possible?
It just recently went up by $20 million. We were able to enforce some charity care covenants with CHS, the equivalent of HCA — a publicly traded hospital system that had acquired the nonprofit health system that had created the Empire Foundation. After some 2 1/2 years of litigation, and going into the trial stage with an extremely strong position, CHS settled, and part of that settlement was adding $20 million effectively to the endowment.
Additionally, when we began to have early wins on the impact work — reducing childhood obesity early wins, or reducing the uninsurance rate early wins — that’s very appealing to co-investors. So we were able to attract even more funding to the region. When I left, Empire Health Foundation was governing or managing about $70 million per year, about 90% of which was other people’s money, both public and private.
Going back to the first part of your answer: At Dogwood Health Trust, you are charged with overseeing Gibbins Advisors, the independent monitor for the transaction. How will you approach holding HCA accountable for the commitments it made as part of the deal to acquire Mission Health?
Aside from Dogwood’s well-defined legal and contractual roles overseeing the independent monitor, I would say more generally that we have a vested interest in honoring the legacy of the nonprofit system to ensure that the covenants are upheld. And to do so in a way that not only are we representing the community’s interests, but we are also doing so with good stewardship in partnering with HCA.
Because the reality is that HCA will, in running Mission, represent the single largest health care provider in this region. How could we be an effective health foundation without partnering with the largest health care provider in the region? And yet it’s a dual relationship: We also need to hold them accountable for what they committed to.
The independent monitor, which we did not have in eastern Washington, gives a wonderful platform for that dual role. I’m pleased that the choice was approved by the attorney general, and I’m looking forward to working with Gibbins as independent monitor. There’s a lot of wonderful structure that we didn’t have in eastern Washington, and so Empire Health Foundation had to wear all the hats at the same time, which was much more challenging than I think it’ll be in this situation.
Believe me, I just got done with three years of litigation — we will absolutely do whatever is necessary here at Dogwood [to hold HCA accountable], but [we will] have a structure where it’s not about personalities, it’s not about, “Well, we don’t want to offend so-and-so because we’re partnering with them on such and such,” which is a real possibility. Here, we have someone else to say, “Here are the standards, here’s what’s in the contract. We see a yellow flag.”
Will the independent monitor look back at the moves HCA has made since the transaction closed?
What’s the outlook on hiring for the foundation?
We will need to build a team. It’ll be a lot of fun: I love building teams!
From a governance point of view, what will this board decide are the key priorities to tackle? And how many? Staffing up to tackle three key issues is very different from staffing up to tackle six or 12.
How we approach the work will be really critical. For example, we already know we have one strategic initiative, which is addiction — the commitment to the state for $25 million over five years. A Philanthropy 1.0 approach would be: Let’s write a $5 million grant check to the state. That would fulfill our obligation.
Say it takes 10 minutes to write that check. But will it create the kind of results the community’s hoping for around opioid deaths and community prevention and all the different things? Very unlikely. Instead, we want to build trusted relationships in 18 counties with law enforcement, first responders, public health, K-12 — whoever the key partners are who will help us both in substance abuse prevention and in preventing opioid deaths.
When you think about what it will take to replicate and scale up best practices, it requires high engagement.
Tell me more about your approach to grant-making.
Oftentimes a foundation will do what I call 1.0 grant-making or Philanthropy 1.0. It’s fine, it serves a purpose, but it’s shotgunning the funding out there. It’s a great way to be popular, but not necessarily a great way to resolve long-standing social issues. Philanthropy 2.0 is where usually larger foundations come up with a big strategy — what they call a theory of change. They write a bunch of checks and hope that their theory is correct. At the end of five years, you have that inch-thick binder to see whether it did or did not happen.
Philanthropy 3.0 is really thinking through how to move the needle on something — specifically, health equity — and how to be sustainable. It doesn’t just wait around and see if it happens, but tracks the goal in real time, literally week by week or month by month, and then course-corrects and adapts along the way.
So my hope, the board’s hope, is that we will deeply collaborate with all of the partners in the region to do systems change and to achieve a different outcome for our community members.
It would be folly to think that Dogwood could somehow do it all on its own. If any one organization could, for example, reduce the number of kids entering foster care, by all means, that organization would have hopefully already done it. It’s not that simple. If any funder that had already been here could write a $100,000 check or a $500,000 check or even a million-dollar check and have erased that educational attainment disparity for African Americans, wouldn’t somebody have written that check?
Can you just write a check and solve our toughest social issues? You can’t. You have to do it in collaboration, and you have to do it in very meaningful ways that are not about numbers served or some of these other more traditional metrics. What are the root causes of why it is that way? Can we tackle that root cause?
How are you taking care of your own health and wellness as you’re transitioning into this new role? And how are you modeling that for your team?
As the CEO of a health foundation, the phrase “You have to walk the talk” is literal, not metaphorical. Are we encouraging walking meetings as opposed to sitting meetings? We did them all the time in Spokane. All our desks were adjustable, and I would say staff mostly stood at their desks. Can we be a role model in terms of benefits and wellness? What are we doing to incentivize wellness here?
It’s actually a wonderful motivator to have this role — the accountability. So it’s all the things that you would expect: lots of physical activity, lots of time with my kids. My mom has meditated for 50 years, but I just picked up meditation about a year ago. I have a very dedicated, faith-based and spiritual life. Just like we’re approaching the work of the foundation, I think of health as multifaceted. There’s the physical exercise and getting enough sleep and brushing your teeth. But is your relational health where it should be? Is your emotional mental health where it should be? Is your spiritual health, if you have such faith or leanings or inclination, is that where it should be? So in the same way that I look at the impact work in a multipronged system, I try to think about my own health more broadly than just my physical health.
Did anything surprising come out of Dogwood’s three community listening sessions in October?
We tried to design them in a way so that at least 50% of the session was engaging with the community members that attended. I asked people to write down the number of communities that we should go out to in the first year on substance use and addiction. The lowest was one and the highest was 19, but the spread was heavily weighted toward 19. When I asked individual community members, audience members, why they said that number, it made perfect sense: They wanted to make sure that Dogwood is being inclusive, that we are touching every community, not just focusing on Buncombe, for example. That’s really influencing us.
So people want to feel that everybody’s going to get something?
I considered it a spirit of inclusiveness: How do we design a series of bold strategic initiatives that touch the whole region and not just a couple of counties?
I also have to admit quite a bit of surprise at the closing reflections at each of the three locations. The courage to stand up in front of several hundred of your peers and say things along the lines of “I came in thinking one thing, and now I’m leaving thinking something totally different,” or “I came in thinking about my issue, and I’m now leaving thinking about the whole.”
This is my first couple of weeks in Western North Carolina, and folks are willing to be that authentic and that open. To me, that says these are community members who have invested 90 minutes of their time, come out of their way, and what’s on their minds is what’s best for the community over what’s best for me. And that is incredible. That was an absolute surprise.