Center for Studying Health System Change

he Greenville-Spartanburg-Anderson MSA is the largest metropolitan area in South Carolina, with about 884,000 residents.¹ It encompasses a five-county area in the "upstate" region of South Carolina and is approximately 100 miles southwest of Charlotte, North Carolina; 100 miles north of Columbia, South Carolina (the state capital); and 140 miles northeast of Atlanta, Georgia.

During the past 15 years, the MSA’s population has grown by about 1.2 percent annually, slightly faster than the U.S. average.² About 30 percent of the MSA’s employment is in manufacturing, nearly double the national average.³ Greenville County’s economy has been particularly strong, with annual job growth of 2.1 percent during the past 10 years. Its 1996 unemployment rate was 3.0 percent.⁴

Stimulated by national and international firms that have established and expanded their operations in the area, the regional economy has shifted from its heavy reliance on the textile industry to a more diverse manufacturing and service base. Greenville is attractive to businesses, in part because of its low labor and living costs and the absence of organized labor. However, the majority of new employment in Greenville County has been in the service sector. During the past 10 years, 2,700 manufacturing jobs were lost while 48,000 jobs were created in other sectors.⁵ In contrast, neighboring counties have a higher percentage of manufacturing jobs and higher unemployment rates, between 4.0 and 5.0 percent.⁶

The three major counties in the metropolitan area are Greenville, Spartanburg and Anderson, each with a city of the same name. Greenville County has approximately 38 percent of the MSA’s population, followed by Spartanburg with 27 percent and Anderson with 18 percent. The other two counties, Cherokee and Pickens, are predominantly rural. Greenville lies between Spartanburg and Anderson; the drive from downtown Greenville to either of these cities is approximately 45 minutes.

About 17 percent of residents in the Greenville metropolitan area are African American, compared with 12 percent nationally.⁷ There are few other ethnic minorities. Slightly more than 32 percent of the population has less than a high school diploma, and the average per capita income is about 15 percent below the U.S. average.⁸ Greenville is located near the "buckle" of the "stroke belt" in the Southeast, where the high incidence of stroke identified by researchers is only partly explained by demographic and other population differences.⁹ Gross mortality and mortality from cardiovascular disease in Greenville are also slightly higher than national averages.¹⁰ Infant mortality in Greenville is 17 percent above the U.S. average among white infants and 24 percent higher among non-white infants.¹¹ Poor nutrition, smoking and obesity were mentioned as behavioral risk factors that affect local health outcomes.

THE HEALTH CARE MARKET

There are three distinct sub-markets in the Greenville MSA, each dominated by one or two hospital systems. Some patients come to Greenville from outlying areas, particularly to Greenville County for tertiary care. Occasionally, highly complex hospital care is referred to Columbia, Charleston or out of state. Greenville’s hospital bed capacity is about equal to the national average, but it has 17 percent fewer physicians per capita.¹² Physician supply varies substantially, with the highest concentrations in Greenville and Spartanburg counties and the lowest in Cherokee and Pickens counties.

The region’s employers include a diverse mix of international and national corporate operations, state and local governments, other large local employers, such as the hospital systems, and small businesses. Many of the large employers have workers dispersed throughout the region. The hospital systems and physicians are predominantly local, although several organizations, including the Greenville Hospital System and Carolina Multispecialty Associates, are increasing their involvement regionally.

Most insurers that do business in Greenville operate on a regional or national basis. Blue Cross and Blue Shield of South Carolina, Greenville’s largest insurer, operates statewide. Most of the other managed care companies, like Aetna/U.S. Healthcare, Health source and Maxicare, are regional or national in focus. The new provider-sponsored networks are local in focus, although one, HealthFirst, is considering expanding to other areas of the state.

LEADERSHIP AND DECISION MAKING

Respondents described the Greenville community as highly religious, fiscally and socially conservative and distrustful of large bureaucracies such as government and big business. Greenville has not welcomed organized labor. The local Chamber of Commerce boasts that South Carolina is a "right-to-work state." Greenville is home to Bob Jones University, the largest nondenominational Christian university in the world. Respondents say the university has a strong influence on state and local politics. The area’s economic growth has created an influx of residents, including a grow-ing number of Europeans employed by international corporations such as Michelin and BMW. There is some "culture clash" between Greenville’s newer residents and those who have lived there for generations, according to respondents.

Several prominent political issues have important repercussions for local health care delivery. The Greenville County Council recently voted to close down the city’s public transportation system because of budget shortfalls, raising concerns about the closing’s impact on access to medical services for low-income residents. Neighboring Pickens County recently passed a law that requires health care providers to report drug-addicted pregnant women to the police for prosecution on child abuse charges -- raising a new barrier to prenatal care for some high-risk women.

Although 17 percent of Greenville residents are African American, this segment of the community reportedly has a limited voice in local decision making. Churches and community based-organizations have not been particularly active on health care issues, and there is little African American representation in the local physician community.

An informal network of local politicians and business leaders exerts substantial influence, according to a number of respondents. The community’s formal business arm, the Chamber of Commerce, is active in local legislative issues, and business leaders are well represented on hospital boards. The most important political institutions are the Greenville County Council and the 17-member legislative delegation of elected state officials who represent Greenville County. The council deals with local issues, while the legislative delegation meets regularly to discuss local issues related to state policy. Both the council and the legislative delegation were active in the debate over the proposed merger of Greenville Hospital System, Spartanburg Regional Medical Center and the Anderson Area Medical Center. This deal, which was referred to locally as the "AGS merger," was placed by the council on a Greenville County referendum.

The AGS merger was defeated in a November 1996 voter referendum by a 4:1 margin. The overwhelming defeat reflected a public perception that, in pursuing this merger, Greenville Hospital System would become less accountable to the community. Voters were also concerned that the merger would produce a large health care bureaucracy. These perceptions were fueled by a media campaign supported by opponents of the merger.

Respondents agreed that the major hospital systems are important actors in local health care decision making, but they did not offer any consensus about the influence of other organizations. Some respondents mentioned the United Way of Greenville County, which supported a community health assessment and has convened meetings with a broad range of participants to discuss local health care issues. United Way also worked with the Appalachia Public Health District Two to set health improvement goals for Healthy Greenville, a local initiative based on the national Healthy People 2000 agenda. The Greenville Medical Society has sponsored public forums to discuss community health care issues, but its most visible public activity has been to promote a "patient’s bill of rights" for managed care enrollees. In Anderson County, two groups were established to implement a community health improvement plan with the financial support of the Anderson Area Medical Center: Partners for a Healthy Community and the Anderson Alliance for a Healthy Future. The Greenville Taxpayers Association was also mentioned for its grassroots activism against the AGS merger.