Chapter II. Description of the Collaborative
This chapter describes the organizations sponsoring,
supporting, or participating in the Collaborative, what they said (in round
one) about their initial motivation to participate, the structure and content
of the Collaborative's work and future plans, and issues that bear on judging
the Collaborative's success. Readers seeking more insight into the origins of
the Collaborative will find a review of its historical development in Appendix
B.
A. Organizations Participating
in the Collaborative
AHRQ and RWJF cosponsored the Collaborative. AHRQ was the
overall convener and contracted with RAND to conduct an initial needs
assessment and to work with the participating firms to obtain and analyze
racial and ethnic data. RWJF contracted with and paid the supporting
organizations that provided guidance to the participating firms. CHCS was the
central support organization responsible for organizing the Collaborative
process and meetings, and for collecting firms' quarterly update reports
(although firms' response to this reporting
requirement remains incomplete). CHCS was also the main repository of the
documentation on the work undertaken by the Collaborative. Under subcontract
to CHCS, IHI provided a limited amount of support to the leadership team (i.e.,
the sponsors and organizations providing support to the Collaborative) of the
Collaborative as well as advice based on its extensive work in provider-based
quality improvement. In July 2005, RWJF entered into a contract with GMMB to
support the Collaborative's communications objectives. Although RAND's work
was initially viewed as distinct from that of the support organizations, CHCS,
RAND, and IHI staff worked together to support the participating firms.
The Collaborative originally comprised 10 firms, but
two—Anthem and WellPoint—merged during the first year of the Collaborative,
leaving nine firms. Five of these nine are large national firms that operate
health plans in many regions: Aetna, Cigna, Kaiser Permanente, United
Healthcare, and WellPoint; Kaiser Permanente is unique because it is built on
integrated delivery systems. Four are regional firms: Harvard Pilgrim
Healthcare of Massachusetts, HealthPartners of Minnesota, Highmark Blue
Cross-Blue Shield Organization in Pennsylvania, and
Molina Healthcare, Inc., headquartered in California. With the exception of
Molina, whose business is largely in Medicaid, these commercial firms offer a
variety of products geared to groups and individuals. Many also participate in
Medicare. Table II.1 summarizes the key characteristics of each firm.
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B. Collaborative Structure
The Collaborative was structured in ways consistent with many
such collaboratives. Over the period of a year, the Collaborative was to meet
in person three times in a general meeting. These collaborative meetings
occurred over a 21-month period: on September 10, 2004; March 17 and 18, 2005;
and June 20 to 21, 2006. In addition, the Collaborative held a final in-person
meeting on NHPC key principals in Chicago on September 15, 2006, to determine
the focus of Phase II. Table II.2 shows the activities and timeline for the
Collaborative.
Two main support organizations received contracts to support
the Collaborative's activities (RAND and CHCS). We summarize the way the main
support organization contracts were structured, the commitments sponsors
perceived the firms to have made to the Collaborative, the support provided by
the Collaborative for collecting racial and ethnic data and developing pilot
interventions, and the structure of support and plans for disseminating and
communicating results.
1. Support Organization
Contracts
RAND received two rounds of funding from AHRQ to support the
Collaborative. The first contract was awarded on November 30, 2003, for
assistance to begin in 2004. A second contract was awarded in spring 2005. Each
contract totaled $200,000 to $225,000 and, although each was intended for a
one-year period, they appear to have been extended to match the Collaborative's
flow of work.
The scope of work for the first year's contract called for
RAND to (1) recruit participants and convene the first meeting of the
Collaborative; (2) interview participants to assess their capacity, readiness,
and interest in working on disparities data (building on earlier interviews for
the California Endowment); and (3) adapt the tool developed by RAND with United
Healthcare as part of AHRQ's Integrated Delivery System Research Network
(IDSRN) to help firms start measuring disparities. The document RAND prepared to support the award envisioned that baseline measures of disparities for at
least some of the plans would be available during the first year and that AHRQ
would fund additional tool development and pilot projects. To facilitate
progress, RAND's work was to be complemented by a separately contracted
"learning organization" expert. Interventions would not be tested until after
the first year.
RWJF's contract with CHCS involved two years of funding (from
September 1, 2004, through August 31, 2006), for a total of about $500,000, a
portion of which was allocated to support from IHI. CHCS's project proposal
envisioned a mix of participants, including those serving Medicaid and commercial
markets, and work that would build on CHCS's Best Clinical and Administrative
Practices (BCAP) typology.4
CHCS expected challenges in applying the models they had historically used for
quality improvement in Medicaid plans to collaboratives involving firms based
in the commercial market because (1) the fragmentation
among purchasers in the marketplace made it challenging to harness their power
in ways that allowed health plans to send a consistent and effective message to
providers about the importance of quality improvement and disparities
reduction; and (2) their multi-location and product organization made focusing
the intervention more difficult. As CHCS expected, its approach to the
Collaborative departed substantially from the BCAP-like models originally
proposed because firms had different views of the Collaborative's mission and
their own needs; some perceived a need for less focus on small-scale
improvement than is traditionally the case in learning collaboratives.
2. Participant Commitments
and Motivation
Each participating firm in the Collaborative had its own goals
derived from its organizational context and priorities. In addition, many of
the key actors had been involved in nationally focused work to address
disparities (Appendix B). Based on the round one interviews, we summarize
their goals as follows.
Sponsors. For AHRQ, supporting the Collaborative was
consistent with the agency's emerging emphasis on the use of research to drive
quality improvements and the active involvement of users. AHRQ's history of work
on disparities and its new responsibilities for the National Healthcare
Disparities Report (NHDR) made the agency particularly interested in working
with health plans in a visible way to address perceived needs. Although RWJF
staff say that they view AHRQ as the dominant and driving partner in the
Collaborative, they also note that co-sponsorship of the Collaborative served
important internal needs. In particular, RWJF's new leaders had significant
interest in disparities, and involvement in the Collaborative allowed them to
move while internal plans for funding were still under development. In
addition, staff perceived that the foundation could work more actively with
health plans given their leverage over large populations.
National Firms. In our round one interviews in summer
2005, the national firms—Aetna, Cigna, Kaiser Permanente, United Healthcare,
and WellPoint—were not explicit about their objectives for participating in the
Collaborative. It appears that they were motivated by perceived needs, both
internal and external. They indicated they were using the Collaborative for a
mixture of purposes, including making changes in delivery and dealing with
political concerns. By allowing firms to work together, the Collaborative
could reduce the risks perceived in addressing issues related to disparities.
Some firms also felt that if they did not participate, they risked falling
further behind the rest of the industry. Negative perceptions resulting from
failure to participate were a concern for some of the organizations that were
industry leaders.
Our round one interviews with national firms suggested that
their interests focused mostly on developing organizational commitments to
improve data infrastructure for addressing concerns over disparities. Although
they might ultimately improve the quality of local care, organizations seemed
more interested in learning how to employ knowledge internally than sharing
what they were doing with other organizations. Nor were they interested in
taking small local steps to improve quality (by relying on the rapid-cycle
techniques that are a traditional part of learning collaboratives).
Regional Firms. While regional firms' objectives did
not necessarily differ from those of the national firms, the impetus for participation
was more distinct. Participating regional firms were typically large,
well-established organizations that wanted to use the Collaborative to expand
in areas they were already pursuing. Two of the four regional firms were
recruited through their ties to RAND staff. Compared with national firms,
regional firms found pilot interventions more relevant, although they were
constrained by limited resources and competing priorities. At least one looked
to the Collaborative primarily for insight on how to capture disparities data
for its members.
Support Organizations. The support organizations are
contractors that receive payments for carrying out a specified scope of work.
However, given that the organizations have earned high regard and face many
competing demands, their involvement also reflects particular organizational
and staff interests. RAND's interest in the Collaborative was a natural
outgrowth of its staff's earlier work on racial and ethnic disparities; Dr.
Nicole Lurie, who served in the Clinton Administration as a federal government
appointee in the area of racial/ethnic disparities, used her contacts and
experience to move the Collaborative forward. RAND staff were also experienced
in using geocoding and surname analysis to examine racial and ethnic
disparities through AHRQ's Integrated Delivery Systems Research Network
(IDSRN), in which it participated as a subcontractor on the Center for Health
Care Policy and Evaluation's team based at United Healthcare.
AHRQ and RWJF divided responsibilities, with RWJF responsible
for arranging for a support contractor to coordinate and guide the
Collaborative's efforts. Few organizations that are involved in guiding
quality improvement collaboratives are experienced with health plan (versus provider)
collaboratives. After considering a range of firms, RWJF selected CHCS because
although it works primarily in the Medicaid area, it is perhaps the only
learning organization with a history of work on health plan collaboratives.
RWJF and CHCS also have a history of successfully working together. RWJF asked
CHCS to involve IHI because the latter brought knowledge and recognized
leadership in provider-based initiatives. A key staff member at AHRQ familiar
with IHI's work with community health center-based collaboratives encouraged
the organization's involvement. The lead staff from CHCS and IHI had worked
together as senior staff at RWJF, which gave them a good basis for establishing
a partnership. Under the contract, CHCS is responsible for most activity; IHI
staff provide targeted, substantive support in selected areas. Firms
participating in the Collaborative may not necessarily distinguish between the
support IHI and CHCS provide, because of the way the two work together.
3. Firms'
Initial Commitments
From the Collaborative's inception, participating firms
struggled to varying degrees with how open to be about their internal processes
and concerns, whether to share data, and whether to commit to shared
activities. In an effort to secure clear commitments, AHRQ discussed an
agreement with firms in 2003 and again on July 8, 2004, when the major
organizational stakeholders—the sponsors, support organizations, participating
firms, and their affiliated trade associations—held a two-and-a-half hour conference
call to agree on how to proceed. An important area of discussion involved the
commitments firms were making to the Collaborative. The Memorandum of
Participation Principles stated that:
- Improving overall quality and reducing disparities are important
national and plan objectives. Participating plans will commit senior
leadership to attend three Collaborative meetings and intervening calls to
report on progress.
- Data are needed to assess performance and assess quality. Participating plans agree to obtain the necessary data to move forward,
with technical support from RAND as required.
- Workgroup measurement will focus on one or more accepted
evidence-based measure. Participating plans agree to the common
measurement expectations they define for the Collaborative.
- The workgroup will balance efforts to achieve consistency
of measurement with flexibility reflecting varied plan market conditions.
- The workgroup will balance its efforts to share data, pilot
designs, and results with requirements for maintaining privacy,
confidentiality, and proprietary interest.
Participants also agreed that
disparities in diabetes can provide a starting place for mutual work and that
they would build on existing measurement efforts and thus involve HEDIS
measures. Firms were not asked to formally approve or sign the memorandum.
The way the final two principles dealt with consistency versus flexibility and
sharing versus proprietary interest suggest that some lack of consensus about
what firms would do existed from the start.
4. Support Activities
During Phase I of the Collaborative
In addition to structuring and leading formal meetings,
learning organizations supported the Collaborative in Phase I by providing
assistance to firms by telephone. Several rounds of such calls were completed.
While CHCS originally hoped to group firms for joint assistance calls, it found
that firms preferred communicating separately. The calls were important for
documenting activity, as firms provided only limited detail in their progress
reports, which were often missing information or submitted late. To coordinate
their support to the Collaborative, key staff from each support and sponsoring
organization participated in periodic conference calls—termed operational
workgroup meetings—convened by CHCS. Firms were supposed to submit quarterly
progress reports to CHCS. Compliance was spotty and CHCS ultimately put less
emphasis on this activity, asking firms instead to prepare slides and other
tools for briefing others in the Collaborative about their progress. As
highlighted in the framework, the Collaborative structure could help firms
advance their ability to deal with issues of racial and ethnic disparities,
support overall firm and leadership commitment to addressing racial/ethnic
disparities, and help firms better measure and assess disparities and take
action to address them. Ultimately, the Collaborative can generate learning
about disparities that can be shared with those in the Collaborative and
others.
Measuring Disparities. In the Collaborative's initial
year, most firms' focused on developing insights into disparities within the
firm. RAND provided support for geocoding and surname analysis of firm data on
members with diabetes, thereby helping firms to generate estimates of racial and
ethnic disparities.5
RAND recognized that firms had limited internal data on the racial and ethnic
composition of their membership and that data improvements would take time (see
Chapter IV). To that end, RAND formed a workgroup that appears to include all
firms except the two that were already getting needed data. The hope was that
developing such data would reinforce firms' sense that disparities were a
problem warranting attention. While there was less active support to firms in
collecting their own racial and ethnic data, geocoding/surname analysis helped
firms appreciate the value of such collection and spurred them to consider how
primary data could be collected. The Collaborative set up sessions for firms
to learn about member organizations' work—particularly, that of Aetna, whose decision to capture member data was an important impetus for the
Collaborative, and HealthPartners, whose affiliated clinics actively collect
racial and ethnic data from patients who seek care. Support organizations also
requested firms to submit common measures based on HEDIS diabetes indicators;
however, firms did not prioritize this effort and response was varied (Chapter IV).
Intervening to Reduce Disparities. From the inception
of the Collaborative, firms disagreed about how much effort should be spent in
developing and testing specific pilot interventions to reduce disparities. The
organizations brought in to support the Collaborative were experienced in this
area—one of the two AHRQ senior staff guiding the Collaborative's development
had experience working with community health centers, and was very interested
in pilot interventions. Round one interviews revealed an uneven interest among
firms in testing pilot interventions. Support organizations reported a "push
back" from firms to following a traditional learning collaborative model,
especially with respect to using tools developed by CHCS and IHI for Medicaid
plans or provider groups. Firms wanted to pursue strategies that made the most
sense to them. Some perceived small scale pilots too narrow an approach,
unnecessary given their existing investments in quality improvement, or
inappropriate to the extent they had a provider emphasis if they perceived
their health plan's strength favored member-based interventions. CHCS
responded by clarifying that pilot interventions included a variety of
activities: data collection/refinement, provider- and member-directed
strategies, community-based strategies, and work on organizational assessment
and capacity building. At the first group meeting, plans presented details of
their existing initiatives. Many indicated that future intervention would
follow the results from geocoding and other data analysis, an approach
consistent with RAND's original concept that interventions would begin in Year
2.
In the second year of the Collaborative, firms further
developed their interventions, some of which were new, while others built on
existing activity (Chapter V). As complex organizations with several
ongoing activities, firms did not distinguish Collaborative-specific activity
from other firm work.6
Because many of the activities and interventions were not initiated until late
in the Collaborative, most are ongoing, and there is limited information thus
far on their impact. Firms said that these activities would, for the most
part, continue after the formal end of Phase I of the Collaborative.
Building Communication and Dissemination Infrastructure. Although communications was not a part of the initial Collaborative
infrastructure, the need to disseminate information about the Collaborative and
what it was learning was always an important goal. To support that goal, RWJF
entered into an 18-month, $160,000 contract with GMMB in summer 2005. The
contract called for GMMB to coordinate all public communications related to the
Collaborative. Since then, GMMB developed relationships with the
communications staff at each firm, developed a logo and other material to
create an identity for the Collaborative, and hosted the National Health Plan
Collaborative Roundtable Briefing to publicize the work of the Collaborative
(Chapter VI). Currently, GMMB is drafting a Phase I report on NHPC
activities, which will include a "call to action." While it is likely that
communications will have a more substantial role in Phase II of the
Collaborative, to date, RWJF has not yet decided exactly how that function will
be handled and where the focus will lie.
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C. Context for Judging the
Success of the Collaborative
The Collaborative involved nine diverse firms whose interests
and operational styles needed to be coordinated. Because the Collaborative's
model of engagement was new to many participants, the tools for structuring the
Collaborative had to be developed. In view of participants' varied
interests, support organizations found that they had to modify their proposed
strategies substantially. A key point of contention involved whether to
emphasize broad-based efforts to build national and firm infrastructure for
improved measurement of disparities or specific interventions designed to
reduce such disparities and, if so, on what scale. Because of participants'
varying views on this subject, the goals of the Collaborative were not
necessarily well defined or interpreted the same way by all participants.
In today's environment, firms face a wide range of competing
demands—for example, two firms in this study were involved in a merger, and
another two were dealing with recent and severe financial stress. Leadership
changes are common, and the market continues to pose challenges for all firms.
In our interviews, we typically heard that work on disparities was a high
priority for quality improvement, but that each firm's ability to proceed
depended on a range of considerations and market demands.
Initial interviews with senior leaders at AHRQ and RWJF
revealed that both organizations were aware that participating firms cannot
always influence care delivery directly, although they are responsible for
millions of covered lives. Sponsor interviewees saw value in the
Collaborative's ability to influence such organizations to make disparities a
more legitimate focus of quality improvement work, to understand the value of
relying on information to measure disparities, and to motivate "silo"
components of firms to talk with one another. That is, the Collaborative's
scale means that even small effects may be influential in enhancing work to
address disparities in ways that will potentially affect many people.
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