Chapter III. Firm Perspectives on Disparities and Commitment to the Collaborative
This chapter describes the relationship between the
Collaborative and participating firms' commitment to the issue of racial and
ethnic disparities—one of the four main outcomes of interest to this
evaluation. The conceptual framework views gaining and enhancing such
commitments as a critical first step in collaboration. (Go to the top boxes in
Figure III.1.) For the most part, the findings in this chapter are based on
what firm staff reported in the second round of interviews. However, at the end
of the chapter, we discuss how participating in the Collaborative influenced
the firms' overall perspectives and focus on disparities.
A. Overview of Key Findings
Firms said that they decided to participate in the
Collaborative for a variety of reasons, including the national importance of
racial/ethnic disparities, their interest in learning about the issue, their
perception that collective action might be more efficient than individual
action, and their ability to use participation to gain internal leverage or
address more "mundane" organizational goals. The firms that participated in
the Collaborative did so with the support of senior leadership. In fact, the
senior leaders of each organization monitored the Collaborative's progress,
which reflects the importance of the issue to the firm. In most firms, buy-in
to the Collaborative or work on disparities appeared relatively concentrated
among senior leaders. Because such leaders set the tone and agenda for an
organization, this was by no means a trivial achievement. However, support
from leaders did not necessarily mean that the buy-in carried over (at least
during the study) to the many operational or geographical units within these
complex organizations.
The Collaborative is not the
only way in which the nine firms address disparities. Some had work that
preceded the Collaborative; others said their participation put the issue more
firmly on their radar screens. Firms with ongoing initiatives on disparities
viewed the Collaborative through the lens of those pre-existing activities
within the firm that defined the short-term organizational priority. Some
firms said that the Collaborative was only one of many external efforts
involving disparities.
Firms cautioned that their ability to invest in the
Collaborative's activities was constrained by a variety of organizational
considerations. The effort firms were willing to invest in part reflected the
degree to which they viewed the Collaborative's focus as aligned with their own
agenda and needs, and the degree to which they could balance work across
competing objectives. For this reason, they urged that their organizational
commitment should not be judged solely by the resources invested in the
Collaborative.
The overall effect of the Collaborative on commitments to
reducing disparities appears positive across all firms, although it is hard to
quantify. Firms reported that rather than changing their perspectives on
disparities, the Collaborative increased the visibility of the issue within the
firm. However, in the case of a few firms with major organizational changes or
strong competing commitments, it seems unlikely that these firms would have
continued their work to reduce disparities had they not participated in the
Collaborative. The fact that the firm would be judged externally (by the
Collaborative) based on what they did enhanced the priority of action within
each firm. The Collaborative was also viewed by many firms—especially those
with the least prior focus on disparities—as enhancing the breadth of
knowledge, interest, and commitment to work in this area across the firm. For
the most part, such work was regarded as an integral part of quality
improvement.
Return to Contents
B. Why were Firms Participating?
The firms in the Collaborative became involved through a
variety of routes (Appendix B). Many of the national firms had been
involved in earlier collective activities around disparities, thus making their
participation in the Collaborative a natural next step. A few firms had
established leadership positions in the field such that their involvement was
inevitable and expected. Some became involved by circumstance—for example, a
connection with one of the sponsors or support organizations.
While participants' histories and particular interests varied,
our interviews point to five major reasons behind firm interest in the
Collaborative (Table III.1). Typically, more than one reason drove firms'
interest.
First, disparities are an important national issue. Hence,
firms saw work in this area not only as "the right thing to do" but also an
important business consideration to ensure that the products they offered
addressed the increasingly diverse needs of the populations they sought to
serve. Many firm leaders had been heavily involved in other national efforts to
address disparities.
Second, working collaboratively rather than individually was
viewed by firms as efficient both in communicating information and in gaining
political support for shared objectives that require broad-based consensus—such
as standardized methods of capturing race and ethnicity. Collective work also
provided a certain amount of "cover," protecting firms concerned with adverse
legal or other consequences associated with collecting data on the racial and
ethnic characteristics of their members.
Third, firms believed a Collaborative was a good way to find
out more about disparities and how to measure and to reduce them. They also
wanted to understand what others were doing and benchmark their own activities
against emerging national practice.
Fourth, some firms or staff had internal goals that could be
advanced by participating in the Collaborative. All of the firms in the
Collaborative are complex organizations with competing interests. Senior
executives with an interest in reducing disparities participated in the
Collaborative in order to enhance firm commitment to and support for the
issue. Sometimes, especially in smaller organizations, mid-level staff with a
strong interest in the issue championed firm participation.
Fifth, more "mundane" considerations made participation
attractive. Some firms perceived that they got involved because their
participation was solicited by AHRQ, a request that was hard to decline.
Participation could advance firm objectives—for example, create an image of the
firm as a national player—or have the additional value of documenting work
consistent with the firm's nonprofit status.
Return to Contents
C. What did Firms Hope to Achieve?
Interviewees from firms said that it is inappropriate to look
at a firm's involvement in the Collaborative in isolation from its other
ongoing work in disparities and elsewhere. While our analysis suggests that
participation may have enhanced firms' commitment to addressing disparity
issues, firms noted that the Collaborative's leaders should not assume that the
Collaborative generated initial concern for the issue or was the only source of
motivation. The participating firms were large companies that were involved in
many collective activities, including work on disparities through their trade
associations, quality alliances, and other coalitions.
Organizational context influenced firms' perceptions of what
they hoped to gain from participation in the Collaborative. For example, firms
that perceived themselves as already heavily invested in quality improvement
might see fewer gains through learning from others or undertaking pilot
interventions; for them, the Collaborative often made it easier to capture
racial and ethnic data on members. A firm whose business was heavily based
around racial/ethnic minorities perceived that it had more to share than learn,
and was comfortable with that. There were several firms with existing internal
initiatives to address disparities, and they perceived that following up on
these priorities took precedence over new projects that might be spurred by the
Collaborative.
The context of the Collaborative also influenced the resources
firms could or wanted to make available to Collaborative activities. All of
the firms involved in the Collaborative invested heavily in quality improvement
and disease management, though their strategies varied, and some placed more
emphasis on these areas of concern than others. In addressing disparities,
they sought to build on these ongoing structures and strategies (as reflected
in their approach to data collection and pilot interventions) rather than
initiate new activities. In many instances, firms faced major organizational
constraints on the resources available for participation in the Collaborative,
particularly when dealing with challenges such as mergers, emerging from
bankruptcy, or multiyear efforts to reconfigure their entire information
systems platform.
In sum, our interviews suggest that each firm participating in
the Collaborative wanted to be involved in the meetings and communications with
one another and perceived that doing so would have important benefits for it
and its work on disparities. Beyond that, firms had their own agendas and
priorities, all of which influenced their capacity to support the
Collaborative's work and their interest in doing so with specific projects.
These differences were apparent from the start of the Collaborative and were
important in understanding firms' evolving responses to the requests of the
Collaborative. The core principles stated by AHRQ in its Memorandum of
Participation appeared more central to AHRQ staff than to the firms
participating in the Collaborative. (None of the firms interviewed mentioned
the principles explicitly when discussing their involvement in the
Collaborative.) By agreeing to participate in the Collaborative, firms may have
agreed to a limited statement of goals, but were more likely to feel that they
were agreeing to work together to share information on disparities and use it
in ways that would be valuable within their organizations.
Return to Contents
D. How was Firm Leadership in the
Collaborative Positioned Within Each Organization?
Senior staff members led each firm's work within the
Collaborative, reporting to senior managers in different locations at the top
of each organization. Below, we review how firms positioned their linkages to
the Collaborative and the implications for communications and reporting. We
then discuss the implications of the leadership and communication structure for
work on disparities throughout the firm. Some firms were more forthcoming
about their internal operations than others. We avoid presenting details that
would reveal aspects of internal operations that firms likely regard as
sensitive and not publicly shared.
1. Organizational Location and Communication
In all cases, a firm's lead contact for the Collaborative was
a high-level senior executive with direct access to senior firm leaders.
Leaders varied across organizations; linkages to clinical leaders were more
common than linkages to other leaders or the CEO. In addition, some lead
contacts delegated day-to-day responsibility for work with the Collaborative to
other staff in the organization. Such delegation appeared to increase in the
second year of the Collaborative as firms took on more activity under pilot interventions.
Table III.2 describes some of the ways each firm structured
its participation in the Collaborative. In four organizations, lead contacts
reported to the medical leadership; in two other firms, lead contacts had dual
reporting lines, involving both clinical leadership and health plan
administration. In organizations where the lead reported to the CEO, the lead
or CEO was a physician. In the one instance where the lead reported to an
administrative executive in charge of marketing, the lead contact was selected
because of extensive work with vulnerable populations; the lead receives
support from a clinical staff member from within the organization. The
differences in placement of liaisons to the Collaborative
reflected internal characteristics of how different firms worked and did not
appear to have hindered external efforts at collaboration, especially when all
firms' liaisons had stature, seniority, and access to top leadership.
The work of the Collaborative appears to have been well
communicated within the top leadership circle. All firms in the Collaborative
kept at least some of this circle informed about the Collaborative, and some
did so for a wider group. Leads regularly briefed the person(s) they report to
about the Collaborative, and the latter seemed to sign off on key decisions.
The leads reported to staff who often reported directly to the CEO and sat on
major executive committees of the organization. In some firms, the
Collaborative lead periodically briefed the executive leadership on the
initiative, sometimes at length. Three firms had established ongoing
organization-wide taskforces or groups to support their disparities work, at
least two of which formed before the Collaborative; lead staff from the
Collaborative were actively involved in such taskforces. In each of the other
firms (and perhaps these three as well), the degree of reporting on the
Collaborative varied with the relevance of the Collaborative to other
activities underway in the organization. Communication was broader in firms
where the Collaborative was directly helping to drive the agenda than in firms
where it was not being used that way (perhaps because the organization was
already moving in a given direction to address disparities at the time the
Collaborative was formed). A few firms seemed to have more limited
communication on the Collaborative with senior leadership because the work of
the Collaborative did not closely match perceived leadership needs. In these cases,
disparities might still be important, but not in a way that the Collaborative
could or would address.
2. Organizational Complexity and the Implications for Communication
It appears that a relatively small circle of individuals from
all or at least most firms knew about the Collaborative, although a broader set
of people may be included in a firm's disparities work. Those involved in the
Collaborative are high-level managers who helped drive organizational
priorities. Thus, their participation in and support of the Collaborative were
likely to influence firm behavior. However, broader communication and support
for strategies that addressed disparities were necessary if firms were to
eliminate racial/ethnic disparities. Several reasons probably explained why
knowledge of the Collaborative might not be more diffused throughout the firms.
First, the firms are large, and it takes time to share
information and develop buy-in across the organization. It was notable that
the Collaborative—or at least the issue of disparities—was on the radar screen
of at least some of the top leaders of participating firms.
Second (and as discussed later in this chapter), clinical
interests defined the focus of early work of the Collaborative and thus these
leaders were more aware of the Collaborative. The business sides of the
organization—finance, marketing—have interests in the issue of disparities but
frame the issue differently or do not place the same priority on this work
without a push from senior leaders. Firms that had been involved most
extensively in addressing disparities created cross-organizational structures
to engage diverse components of the organization in supporting work to resolve
disparities.
Third, the least centralized firms had a harder time implementing
change. At least two of the national firms, for example, were heavily
decentralized in assigning responsibility for care delivery and
decisionmaking. Despite national firm leadership's encouragement of
consistent national strategies, tensions between national and regional
interests and priorities remained. Thus, even if both central and regional
leaders agreed that disparities were an issue, each level may have had its own
perspective on the primary actions to take; moreover, communications between
central and regional efforts (or across regions) may have been incomplete.
Thus, one firm moved much more slowly and cautiously in developing
interventions than its national leadership might have wished, while another
concentrated most of its early work in a state within one of its three core
regions where support for such intervention was strongest.
The challenge of broad-based communication and buy-in was an
issue for most firms, not just the largest or the least centralized. Most
firms reported many steps between policy and execution. When firms took
concrete steps toward implementation as part of the Collaborative—whether data
collection, geocoding/surname analysis, or piloting interventions—additional
staff were likely to become aware of the Collaborative. Nonetheless, given the
scale of the firms in the Collaborative, such diffusion takes substantial time,
and small-scale pilots were likely to touch only a small number of staff in the
organization. The challenge, therefore, was to maintain the interest of senior
leaders who set the tone and focus for an organization and to support a broader
agenda that aimed not just to test change but also to introduce it across the
organization.
Return to Contents
E. What were Firms' Perspectives on Disparities?
A focus on disparities took many forms within the
participating firms. Indeed, the challenge for top leaders was to harness for
mutual benefit the interest in disparities as conceived across the operational
units of each firm. This section examines three ways in which disparities were
relevant to firms; these emerged in our round two interviews.
1. Firms as Employers and Large Organizations
The nine firms participating in the Collaborative were large
organizations employing many people. Both legal requirements and internal
interests meant that the firms were becoming increasingly attuned to the
diversity of their workforce. Each firm wanted to understand its workforce and
make certain that firm policies were culturally appropriate. Several of the
organizations employed diversity officers whose main interest was in workforce
diversity. We interviewed some of these officers and found that they think
about disparities largely from the perspective of human resources, with little
or no involvement in the organization's care delivery or quality improvement functions.
A few firms built on their role as an employer to support
their interests in disparities and work with the Collaborative. Given that
firms purchased health care for their employees, they were positioned (albeit
not without challenges) to capture self-reported employee race and ethnicity
data. As employers, the firms also stood to benefit from improved health
outcomes resulting from interventions intended to reduce disparities. Firms
also stood to generate good will by providing culturally appropriate care.
Thus, the firms' role as purchaser with a large workforce provided an
opportunity for some to target initial work on disparities within a subset of
the commercial population—firm workers and dependents covered by the health plan.
Firms also viewed reducing disparities as an important part of
their role in working within the community or broader environment. For
example, one large firm was proud of its work in supporting nursing
scholarships and a leadership academy to further diversity in the workforce. A
regional firm emphasized its CEO's involvement with other influential business
and political leaders in a coalition pushing for coordinated regional economic
development that could reduce the area's socioeconomic disparities. Another
proudly cited its effort with community colleges in 17 states to raise
certification rates for bilingual students seeking medical careers. Several
participants in the Collaborative noted that their internally funded foundations—while
typically not involved in the Collaborative—supported broad-based
community-focused efforts relevant to the issue of disparities. In at least
one case, the firm aimed to link its member-focused strategy for diabetes to
community-based interventions targeting these broader goals through work in
local pharmacies.
2. Disparities and Firms' Quality Improvement Agendas
The round two interviews showed that interest in disparities
was linked more closely to quality improvement than to any other firm function
and disparity initiatives tended to fall under the purview of the
organization's clinical leadership.
Each of the firms in the
Collaborative saw quality improvement and reducing disparities as related, but
differed in how they conceptualized the relationship. In their comments on
this issue, some firms seemed to describe tension between the two concepts,
noting that disparities, especially in health care outcomes (but also in health
care processes), were influenced by a far broader variety of factors than firms
could influence—for example, socioeconomic status and environmental health
behaviors. In fact, some firms were concerned that efforts to address
disparities would leave them overly accountable for outcomes beyond their
control. When we asked senior leaders to comment on the relationship between
reducing disparities and improving quality, their responses suggested that
there were at least two views of how disparities relate to the quality agenda
(Table III.3).
One view held that reducing disparities translated into
high-quality care through concern with providing culturally appropriate care.
Such a definition led to an interest in training providers, making interpreters
available, and implementing other initiatives that enhance care systems'
ability to meet user needs. A related view was that disparities are an example
of a more general need for market segmentation to identify variables that
differentiate people so that each group's needs can be met.
These views can be distinguished from another view that
focused less on variables that differentiate people's characteristics and more
on means to address the distribution of outcomes in improving quality. From
this perspective, raising average quality was critical; the disparities in
outcomes were less relevant than the fact that some outcomes are unacceptably
low, regardless of the amount of disparity. Those with this view were probably
more comfortable with quality improvement initiatives targeting areas of low
performance than with race- or ethnicity-focused initiatives. Firms that
appear to put more emphasis on quality improvement in positioning their
products and plans were more likely than their counterparts to hold such a
view.
We think that there is a link between a firm's view of
disparities and the strategies they pursued to address them—including, for
example, a focus on clinical versus social factors, the importance firms attached
to capturing race/ethnicity data on all their members, and how they allocated
their investments in quality improvement.
3. Disparities as an Opportunity or Threat to Marketing
Most firms explicitly stated that they wanted their membership
to grow over time. Stagnant membership is almost always a problem because
those who are continuously enrolled inevitably age and use more care. Unless a
firm is able to attract new members, it may experience adverse selection and/or
find its products priced out of the market. In addition, many firms viewed
growth as an important business goal that could satisfy investors or reinforce
other organizational goals.
Firms were particularly sensitive about reporting racial and
ethnic information, particularly for African Americans, among whom a history of
discrimination has led to high levels of distrust. Health plans often perceive
that collecting racial or ethnic data before enrollment is illegal or will be
viewed negatively by policymakers concerned that such data would lead to
discrimination; our interviews uncovered evidence of this perception. In almost
all cases, firms that did collect racial/ethnic information emphasized that it
was voluntary. In approaching members for information, the firms sought to use
sources that enrollees would regard as trustworthy and likely to use the
information for the member's benefit. For example, firms tended to regard
provider requests more favorably than plan administrative requests because
patients might regard the former as more in their self-interest.
Yet, despite barriers to collecting racial and ethnic
information, we found that marketing departments were very interested in using
such data to enhance their success. Marketing staff used a different language
from that of staff involved in quality improvement. Our interviews indicated
that marketing staff saw their mission as member service. They viewed racial
and ethnic subgroups as market segments to contact. They also indicated that
membership was more likely to grow if they could show that interested members
would know or be shown how to use health plans' systems. In the words of one
marketing director, "'Ethnic marketing' is to marketing what disparities is to
quality improvement." Firms that invested in addressing disparities said they
did not do so for marketing purposes, but recognize that their investments
allowed them to convey to purchasers their interest in serving all the diverse
members of their workforce.7 They said employers were more interested in a firm's capacity to respond to employees in different languages, for example, than in the finer nuances of quality improvement. They felt these interests would grow in importance as the
United States population became more diverse. At the same time, they also
said that "rates, product, and network" were dominant in driving the employer
market and that only the most progressive employers were directly concerned
with the issue of disparities.
Return to Contents
F. What Effect Did the Collaborative Have on Firm Commitments to Addressing Disparities?
Because our evaluation began midway into the Collaborative, it
is not possible to judge in full how firm perceptions changed over the course
of the entire Collaborative. However, in our round three interviews, we asked
firms' lead contacts and senior executives for their thoughts on this issue,
and whether the Collaborative had any particular adverse effects on the
commitment to reducing disparities. Eight of the nine firms participating in
the Collaborative were part of this final round of interviews.
As lead contacts and other senior executives noted, their
firms were aware before the Collaborative of disparities and the importance of
addressing them. Yet the issue was more important to firms at the end of the
Collaborative.
The shift was particularly striking in firms with the least
emphasis on disparities before the Collaborative. One large national firm said
that while its perspectives on disparities did not change, such perspectives
were "more diffusely known throughout the organization," with staff aware that
further quality improvement meant addressing disparities. Another firm, which
integrated disparities into their disease management program after the start of
the Collaborative, noted, "This is not 'side of the desk' stuff anymore.... It's
incorporated into the way we do business and not a project or a pilot
anymore." One firm that was already working on disparities said that its work
would have gone a bit slower without the Collaborative. As another regional
firm put it, "No one wants to be left behind." Even those that did not
acknowledge any direct influence of the Collaborative described changes that
seemed to derive from the work of the Collaborative—for example, starting to
look within their minority populations at subgroups, taking steps to begin
collecting primary data on members' race/ethnicity.)
As discussed further in Chapter VIII, firms typically expressed a desire for the Collaborative to continue beyond Phase I. Even though most felt that they would progress on their own, external collaboration
reinforced these efforts and helped firms' efforts continue, despite the many
competing priorities.
Return to Contents
Proceed to Next Section