Executive Summary
A. Focus of the Report
This report summarizes the results from the Mathematica Policy
Research, Inc. (MPR) evaluation of the National Health Plan Collaborative
(NHPC) to reduce racial and ethnic disparities, which is cosponsored by the
Agency for Healthcare Research and Quality (AHRQ) and the Robert Wood Johnson
Foundation (RWJF). The Collaborative began in July 2004 and ended in September
2006; the evaluation began in June 2005. A second phase is planned, but this
evaluation focuses on the initial Collaborative.
The Collaborative involved nine firms working to address
racial and ethnic disparities in health care that may exist within health
plans. The participating firms were large national and regional organizations
that covered millions of lives; over half of them sponsored health plans in
more than one location. The Collaborative's work focused primarily on disparities
that may exist among firms' commercially enrolled members. Participants in the
Collaborative agreed to focus on diabetes and to measure disparities using
common HEDIS measures. Several organizations supported the work of the
Collaborative—the two dominant support organizations are RAND and the Center
for Health Care Strategies (CHCS).
The evaluation sought answers to several questions:1
- How was the Collaborative structured, and what did it do?
- What did the Collaborative accomplish and how sustainable will these efforts be?
- Did the support provided by the Collaborative process contribute to firms' ability to make progress in addressing issues related to disparities, and how valuable did firms view their participation to have been?
- What can AHRQ learn about whether or how to engage in similar collaboratives in the future?
Drawing on a conceptual framework, we
sought to understand what the Collaborative did to help firms (1) support firm
leadership in building support for work on disparities; (2) collect or estimate
the race and ethnicity of their membership to better identify potential
disparities; (3) develop and test pilot interventions to reduce disparities;
and (4) communicate the outcomes of the work to others outside the
Collaborative. This summary focuses on what we learned; readers will find
additional detail on all of these activities within the text of the report.
B. Data Sources
This was a qualitative evaluation that involved little primary
data collection. We received Collaborative documents and sat in on the
Collaborative's telephone calls and meetings as a silent observer. We also
conducted three rounds of interviews with the lead staff of participating
organizations and a broader set of staff from among the nine firms. In round
two, we asked all participants to complete a "network feedback form" to support
a formal network analysis of the Collaborative. All 15 participants responded
to this request, although responses for some items were incomplete.
C. Findings and Conclusions
1. How Was the Collaborative Structured and What Did it Do?
From the start, the NHPC was structured as a learning
collaboration that convened participating firms through meetings and calls to
discuss activities in the area of disparities. Firms also received technical
assistance from support organizations.
The Collaborative involved several diverse organizations whose
interests and internal styles of operation differ. A key point of contention
for the Collaborative was how much to emphasize broad-based efforts to build
national and firm infrastructure for addressing disparities versus small-scale,
specific pilot interventions designed to reduce such disparities. The focus of
the Collaborative's work evolved over time, a factor important to understanding
its accomplishments.
A key focus of work was on developing insights into existing
disparities; RAND provided support to firms seeking assistance with geocoding
and surname analysis so that they could better learn about disparities in care
among racial and ethnic minority members with diabetes (and other conditions,
should firms elect to include them). The Collaborative also provided an
opportunity for firms to learn more about the activities of other participating
firms that are considered leaders in primary data collection efforts on race
and ethnicity.
The Collaborative also encouraged firms to develop pilot
interventions to reduce disparities and to focus on them during the
Collaborative's second year. At firms' request, such interventions were
defined broadly at the organizational, member, provider, or community level.
However, sponsor and support organizations appear to have encouraged relatively
small-scale interventions that could be assessed with HEDIS measures before and
after implementation. This model was more relevant to some participants—for
example, regional firms with relatively small total membership—than others.
Collaborative sponsors have engaged a communications contractor, GMMB, to work
with firms' communications staff on dissemination plans as the Collaborative
progresses.
The success of the Collaborative needs to be assessed in
context. For both sponsors and support organizations, work with large
commercial health plans around disparities was a new and risky endeavor, as
these organizations are complex and often difficult to understand.
Participants had varying views of the Collaborative's goal and therefore what
constituted success. Moreover, the scale of participating firms influenced
what they could accomplish. Firms' scale has proved both a major strength
(they touch millions of lives) and weakness (more barriers to change) for the
Collaborative.
In the first round of interviews, sponsors reported seeing
value in small steps that made disparities a more legitimate focus of quality
improvement work among firms. They also saw the value of small-scale efforts
that help firms understand information needed to measure disparities, and of
using the Collaborative to improve communication within firms to increase
support for addressing disparities.
2. What Did The
Collaborative Accomplish, And How Valuable Do Firms Perceive Their
Participation In It?
Despite adjustments to their efforts over time, the
Collaborative maintained the participation of all firms that were involved at
the start. Sponsors and support organizations can take pride in that outcome,
since many events could have shattered the Collaborative. To a certain extent,
it is not surprising that firms remained in the Collaborative—whatever its
demands, firms probably perceived the costs of participation as relatively low
in relation to the risks associated with dropping out. As one firm participant
remarked, "No one wants to be left behind. That's a strategic disadvantage."
Hence, although firms' continued interest is a positive sign, it is important
to look more substantively at the accomplishments of the Collaborative. The
main ones include:
- Increased organizational attention and commitment to disparities as part of the quality agenda for health plans.
- Firms' growing recognition that their ability to generate primary data on race/ethnicity is critical to making progress.
- Increased awareness among sponsor and support organization staff about how firms work, in ways that are relevant to understanding firms' contribution to disparities.
The Collaborative had less success in
sharing lessons about caring for patients in ways that reduce disparities and
applying that knowledge to alter care delivery. We summarize below the
findings on the Collaborative's progress in each area.
Organizational Commitment. All of the firms
participated with the support of their senior leadership, designated
well-placed senior staff to serve as liaisons, and involved their traditional
reporting structures to keep executives aware of their efforts. Thus, participants
in the Collaborative did so as official representatives of large organizations,
a factor that contributed to their ability to influence organizational
commitments to disparities. Most firms used their existing organizational
channels to address concerns related to disparities, but the Collaborative also
encouraged some firms to enhance their organizational structures to more
effectively deal with this issue, including creating disparities task forces
and the like. These structures—together with increased recognition of the
issue, generated partly by firms' participation in the Collaborative—should
sustain interest. While the Collaborative focused only on diabetes, firm
responses suggest that any insights firms gain about disparities are
influencing their thinking about care delivery in general.
However, there are challenges to sustainability, particularly
stemming from the environment and the instability within the industry. All
firms viewed the tight fiscal constraints imposed by the health care market as
influencing their decisionmaking, although some are better positioned fiscally
than others. Leadership turnover and change is also common in the industry.
Among national firms, for example, one had limited participation in Phase I
because of a merger and staff turnover, two others are now dealing with
turnover of the chief executive for their corporation. To the extent that firm
commitments have translated into permanent change—for example procedures for
data collection, or the inclusion of interventions in standard operating
systems—firms are likely to be better positioned to maintain the progress they
have made already.
Primary Data to Better Identify Disparities. As a
result of the Collaborative, firms are much more aware of the value of race/ethnicity
data in supporting quality improvement efforts targeting racial and ethnic
disparities. All but one of the firms now say the goal is to capture
race/ethnicity for all their members; the exception is capturing it for
selected patients in disease management programs. The geocoding/surname
analysis experience in Phase I was important in helping firms develop a
broader-based acceptance of the existence of disparities. It also highlighted
to firms what geocoding/surname analysis could do (general patterns) and what
it could not (member-specific identification to support interventions, or
identify patterns when residential patterns are not highly concentrated by
subgroups).
Despite the accomplishments, there remains a gap between what
firms have done and what they ultimately seek to do. For example, one leading
firm has primary data for only a small proportion of members, despite trying
for several years to collect them. Two of the firms committed to collecting
race and ethnicity data have not yet determined how they will do so, and a
third will not start until at least 2008, when its new IT system is in place.
Firms also face additional barriers. Because participating organizations are
large, even those that have data may not store it in a way that is accessible
for various uses across the firm.
Because of the time it takes to generate useable primary data
on race/ethnicity, some firms are planning to use geocoding/surname analysis
into the future to benchmark change by geographic area or further identify
locations for disparity-oriented interventions. While some tools will continue
to be made available to firms by RAND in Phase II, firms seeking individual
assistance from RAND will have to enter into individual contracts, as AHRQ will
not fund it. The transition poses a structural barrier to sustainability. In
retrospect, it could have been valuable to consider earlier how to
institutionalize firm capacity to deal with these issues, although firms seem
to be making their own arrangements.
Identification and Implementation of Interventions.
Firms' efforts to pilot interventions to reduce disparities generally took a
backseat to data collection. As firms gained insight on disparities, they
began to think more concretely about what they, as firms sponsoring diverse
health plans, could do to reduce disparities. By the end of the Collaborative,
seven of the nine firms had either completed or were in the process of
completing pilot interventions, and two were developing them. During this
evaluation, it was too early for most to know the outcomes of their
interventions; however, most thought their efforts created a framework and base
for future expansion and learning, and planned to continue related
interventions after Phase I ended.
Firm progress in pursuing interventions was challenging.
These challenges included: 1) uncertainty about how to begin, and how best to
intervene; 2) lack of data on race/ethnicity of particular members; 3)
implementing effective interventions that could leverage the diverse functional
systems in the firm and the split between corporate and regional
responsibilities; and 4) logistical issues, such as recruiting physicians to
participate in provider-based interventions.
The Collaborative led firms to view their work on disparities
as a part of their quality improvement effort, rather than an additional or
separate activity. This linkage allowed firms to create leverage to address
disparities. Still, firms were constrained by the tight fiscal environment in
which they operated and the competition for resources. The ability to build a
business case for working on disparities was viewed as important to getting
resources to address this and the quality improvement agenda in firms.
Enhanced Industry Knowledge in Staff from Sponsor/Support
Organizations. While not a stated objective, participation in the
Collaborative helped sponsors and support organizations learn more about large
commercial health plans. Although some key staff in sponsor and support
organizations were experienced in this area, others openly said they learned a
great deal about the industry through their participation in the
Collaborative.
3. Did the
Support Provided By the Collaborative Process Contribute to Firms' Progress in
Addressing Issues Related to Disparities and How Valuable Did Firms View Their
Participation As?
Overall Value. Firm responses to the network analysis
clearly paint a positive picture of the Collaborative overall, as an effort
that contributed to their goals. In the round three interviews, all of the
firms responded positively to a question about whether they viewed their
participation as worthwhile relative to its costs. Consistent with their hopes
at the start of the Collaborative, firms articulated this value as allowing
them to leverage firm resources, enhance firm awareness of disparities, fuel
internal efforts, and ensure momentum. Firms appreciated the sponsors'
willingness to provide resources to support their needs. The fact that the
Collaborative was sponsored by an important federal agency and a major health
foundation enhanced its credibility and provided added value in the eyes of
participating firms. Moreover, sponsors' decision to continue with a second
phase of the Collaborative (as discussed more below) takes advantage of
existing momentum, and the creation and institutionalization of disparities
task forces (or similar) by several participating firms improves chances for
longer-term sustainability.
Contribution of Collaboration. On a more concrete
level, however, firms did not appear to necessarily benefit as much from
collaboration as they might have, had they been willing to more openly share
information or had the Collaborative been better structured to facilitate
substantive learning, particularly with respect to evidence on reducing
disparities. The network analysis indicated that sponsor and support
organizations were seen as the "glue" that held the Collaborative together.
Although termed a Collaborative, there was much more communication between
firms and support organizations than from firm to firm. This finding was
included in the interim report (which was shared with all participants), giving
them an opportunity to consider it. From firms' discussion at the final Phase
I meeting, it appears that they agreed with this conclusion. To some extent,
limited sharing is a function of the culture of the firms and the markets in
which they operate. As one firm noted in our interviews, "It [communication] is
a double-edged sword. To learn, you have to tell." When AHRQ requested more
information on this to aid in planning Phase II, firms thought the more
specific focus of their work in the next phase (discussed below) would
facilitate better communication, as would the experience they had working with
one another and the trust developed during Phase I.
Also relevant to shared learning were the firm responses about
their biggest disappointment: the Collaborative did not address their interest
in knowing about "what works," especially in terms of interventions that might
reduce disparities. While some of this could be a reaction to the lack of a
solid evidence-based knowledge in this area, it appears that more could have
been done to connect firms with sources and people who could provide insight on
this issue and also to structure agendas so that they could learn more from one
another. The effort required of CHCS to coordinate the complex structure of
the Collaborative probably came at a cost in resources that could be devoted to
more substantive support in this area. The fact that many firms did not want
to focus on implementing pilot interventions may have further discouraged
attention to this content, which it appeared firms wanted even if they did not
want to use the Collaborative to talk about what they might do with the
information.
Contribution of Communications. The communications and
dissemination infrastructure was an important component of Phase I. While many
participating organizations agreed that there was relatively little to
communicate in the first phase, the communications work undertaken by GMMB was
important in presenting a standardized and consistent message externally about
the Collaborative. Moreover, much of the communications activity in Phase
I—such as the development of a logo and other NHPC materials and the
establishment of a core message—provides a foundation for Phase II, when the
Collaborative may have substantively more to report on its activities in the
area of reducing disparities.
Firm Requirements for Participating in the Collaborative.
The most contentious issues for firms were the structure and requirements the
Collaborative sought to impose. Reporting requirements were a particular
concern, and at least some firms viewed the cumulative number of requests from
sponsor-affiliated groups to be burdensome. At the final meeting of Phase I,
firms' rejection of externally imposed reporting requirements was explicit—they
said they wanted to be responsible for defining any measures of progress that
would be used in Phase II and were uneasy about ways in which efforts could be
monitored. While firms acknowledged that Phase I deadlines were valuable in
pushing their efforts forward, they felt that responding to standardized
reporting requirements provided more value to sponsors and support
organizations with contractual requirements than to firms themselves which were
not funded to participate in the Collaborative. This is consistent with the
fact that for firms, a major cost of collaboration was the demands made on the
busy senior staff whose involvement was essential in generating the stature and
commitment from firms that the Collaborative sought.
4. What can AHRQ
learn about whether or how to engage in similar collaboratives in the future?
The evaluation findings
provide insight both on issues relevant to future efforts with large firms
sponsoring health plans and, specifically, for Phase II of the Collaborative.
General Lessons. In designing an initiative similar to
this, with large firms sponsoring health plans, sponsors would do well to be
clearer from the start about the goals of collaboration. They should also be
sure that the goals are shared by all participants, and adapt participation and
structure accordingly.
Assuming a given set of goals, there are at least three generic
questions that warrant consideration:
- Who Participates? There are not many firms that
play a major role sponsoring health plans nationally or regionally. Those that
do meet this criterion are diverse in structure (ranging from quite centralized
to very decentralized), investment in quality improvement, linkages with
provider systems based on ownership or history, geographic coverage, and other
dimensions.
- What Model for Collaboration? There are a variety
of ways to structure a collaboration. Ultimately, the form chosen should
support the overall goals (neither these goals nor the structure seemed to have
been given appropriate consideration at the outset of the Collaborative). The
decision to have RWJF sponsor a support organization (CHCS) to complement RAND's work for AHRQ was a significant one that probably had more influence over the
Collaborative than has been recognized. The Collaborative was structured on a
model of traditional quality improvement work with smaller, less complex
organizations—typically providers or small health plans with strong links to
provider groups. Other structures may be more appropriate, depending on the
goals. For example, if the goal is to inspire firms to prioritize work on
disparities and to leverage firm scale to remove environmental barriers to
doing so, it might be appropriate to use a workgroup model that includes
politically savvy expert facilitators with deep knowledge of firms' workings—a
former chief executive officer (CEO) who is well respected by firms and has a
good grasp of public policy concerns, for example—and the support of consulting
content experts. The Learning Network or Laboratory that some participants
suggested could be another model.
- How to Leverage the Private Sector Effectively?
Working with large private sector organizations that function in highly
competitive markets is different from working with grantees beholden to the
sponsor and financially motivated to cooperate. Sponsors seeking to engage
large private sector organizations in group efforts should understand the
reasons (business, political, personal) that drive a firm to participate, the
constraints that are likely to limit their response, and the processes required
to link the external work within the Collaborative to the firm's infrastructure
and decisionmaking processes.
- How to Encourage Sustainability? Because Turnover
in staff can be anticipated, sponsors need to think about how change can be
institutionalized and instability within participating firms. The other side
of sustainability involves doing as much advance thinking as possible about how
to sustain work in firms after external support is over. AHRQ may want to
consider building more formal requirements for technology transfer into RFPs to
help leverage the work funded through AHRQ's support contracts.
5. Insights on the Next Phase of the Collaborative
To sustain attention on reducing disparities, sponsors have
decided to proceed to a Phase II for two more years. While many details remain
to be determined, the intent is to increase the specificity and clarity of
objectives in Phase II, with a focus on particular activities that firms agree
are important. While not all of the firms participating in the Collaborative
will necessarily be involved in each of the activities, the foci for attention
in Phase II are (1) developing approaches to primary data collection on
race/ethnicity; (2) collective work on ways to enhance language access at the
national and local market level; (3) developing the business case for work on
disparities, both nationally and within firms; and (4) continuing information
exchange both among participating firms and with other stakeholders (which
includes a communications component that builds on Phase I accomplishments).
While some might view the specific activities of Phase II as a
more narrow scope of work—and perhaps more constraining—than Phase I, the fact
that these activities were defined by participating firms, rather than sponsors
or support organizations, should improve buy-in in Phase II. Some firms
expressed discontent with being told what to do in Phase I. From our
perspective the more collaborative approach in Phase II—at least in determining
what activities to pursue—holds promise and allows firms more flexibility to
focus on those activities of greatest interest to them. Further, it is
beneficial to narrow the scope of work potentially of interest to firms when
resources and time are limited. Focusing attention on a limited number of
priority areas—while giving firms flexibility to participate in them or not—is
an efficient approach to generate substantive change.
Our evaluation suggests that extending the Collaborative will
be valuable to firms in sustaining and expanding the accomplishments to date.
As one participating firm observed, the Collaborative serves as "the external
cattle prod that keeps us moving." Moreover, by the end of Phase I, the
Collaborative appeared to be gaining momentum. Given the external pressures on
firms and the competition for resources, the Collaborative will encourage firms
to continue to focus on the area of disparities and provide a platform from
which they can share their experiences, successes, and, if they choose to,
failures. This alone will be valuable to firms seeking insight and support.
However, the challenges should not be underestimated,
particularly if Phase II success is to be measured in terms of concrete
accomplishments. While the plan for this phase may appear more concrete and
defined than that of Phase I, there are in fact many remaining ambiguities.
From our observations of the process through which the Collaborative chose
specific foci for Phase II works—primary data collection, language access, and
the business case—we believe it will take strong leadership to move participating
firms in a direction that is both useful to them and substantively clear and
feasible. After tasks are better defined, support organizations may also find
that they need to draw on additional expertise and organizations to achieve
specific goals, such as the use of expert facilitators (such as former CEOs) or
consulting content experts to lead collaborative sessions on particular topics
as necessary.
Sponsors and support organizations may need to be more
realistic about what they can accomplish with their own resources and the
internal energy firms can devote to specific issues. On the one hand, keeping
all stakeholders engaged requires a broad focus because each firm has its own
priorities. On the other, to the extent that the focus is on collective
accomplishments rather than communications support to firms, only so much can
be done. Although there was a conscious effort to limit the number of
activities in Phase II, we are concerned that the successful completion of each
task may be complicated by defining these activities to include many
interrelated tasks. For example, some at this stage appear to have national
and market components (data or language access) and others national and
firm-specific estimates (in terms of the business case for work on reducing
disparities). The Collaborative will also have to invest in enhanced
information sharing and, potentially, strengthening the substantive content of
support. If many of the same staff (within firms and within the Collaborative)
are expected to support each of these things, there is a risk that none will be
done well.
We are also concerned that too high a share of the resources
available to the Collaborative have, in the past, been devoted to coordination
rather than substantive analysis linked to other external efforts and
scientific knowledge of the available evidence/state of the work in each target
area. For example, for the primary data collection activities of Phase II, the
Collaborative will need to identify how its efforts interface (if at all) with
providers and/or purchasers and how they relate to existing governmental
efforts at standardization.
Our recommendations for Phase II include developing more
targeted goals for each Phase II activity and encouraging an outcomes-oriented
(rather than process- and logistics-oriented) approach to Collaborative
meetings. Careful focus to targeted activities can help ensure that the
Collaborative's attention is not spread too thin or in too many directions.
6. Conclusion
In conclusion, the Collaborative has enhanced firms' interest
in effective interventions to measure and address disparities. However, there
remain many substantive issues about how to design and support such measures
and interventions, and many political, organizational, and market factors that
must be considered. We encourage participants in the Collaborative to
carefully assess priorities and lessons from Phase I as they continue to work
on the important issue of racial and ethnic disparities in health care.
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