Chapter VIII. Accomplishments, Sustainability and Insights for Phase II
A. Main Accomplishments and Their Sustainability
At the start of our evaluation, a participant suggested that
the Collaborative would be a success if the firms all were still participating
at its conclusion "They all stayed," another participant observed at the end
of the Collaborative. Sponsors and support organizations can take pride in the
fact that the Collaborative remained intact despite several events that could
have shattered it. Yet, to a certain extent, it is not surprising that firms
remained in the Collaborative—firms tended to perceive 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." While firms' continued interest in
the Collaborative is a positive sign, it is important to look more
substantively at the effort, what it accomplished, and how sustainable these
activities will be.
The previous chapters have provided considerable detail on
what was and was not accomplished through the Collaborative. We have drawn
four major conclusions about what the Collaborative has accomplished with
respect to reducing racial and ethnic disparities. These are:
- Increased organizational attention and commitment to disparities
as part of the quality agenda for health plans.
- Growing recognition among firms that collecting primary data on
member race/ethnicity is critical to making progress.
- Limited progress in learning more about how to alter care for
patients in ways that will reduce disparities and especially in applying
knowledge to alter care delivery.
- Increased awareness among diverse staff from sponsors and support
organizations about how firms work in ways that are relevant to understanding
their contribution to reducing disparities.
We discuss each of these below.
1. Organizational Commitment to Addressing Disparities
Members of the Collaborative participated as official
representatives of large organizations, which contributed to their ability to
influence organizational commitments to disparities. 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.
Most firms used their existing organizational channels to
address concerns relating to disparities, but the Collaborative also encouraged
some of them to enhance their organizational structures to more effectively
deal with disparities. Before the start of the Collaborative, two of the five
national firms had modified their structures to help foster attention to
disparities—one had established a firm-wide disparities taskforce reporting to
the CEO, the other a Cross-Cultural Care and Services taskforce under medical
leadership. The Collaborative reinforced these structures. Using the
Collaborative as an impetus, a third created an informal mid-level staff
workgroup that sought to develop support for and initiatives addressing
disparities. Of the four regional firms, two formed interdepartmental
committees/taskforces to address disparities and culturally and linguistically
appropriate care, and at least two had briefed or planned to brief their Board
of Directors on progress in meeting disparities objectives. Another
institutionalized its disparities work by moving it from its "incubator"
research and development department to its Office of Medical Affairs.
These structures—together with firms' increased recognition of
disparities issues, via their participation in the Collaborative and other
factors—should sustain interest. While the Collaborative focused only on
diabetes, firm responses suggest that insights about disparities in diabetes
care are influencing their 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.
For example, one national firm's participation in Phase I was limited because
of a merger and staff turnover, two others are now dealing with CEO turnover.
Such turnover has the potential to reduce organizational knowledge of the
Collaborative's work, slow decisionmaking, and modify priorities. Firms whose
commitments have been translated into permanent change—for example, in data
collection procedures or standard programming—are likely to be better
positioned to maintain their progress, although further progress may be more
challenging. Because not much as been publicized about the Collaborative to
date, the cost of slower progress may not be as high as it would be if external
expectations were higher. This could change as plans to increase awareness of
the Collaborative become implemented.
2. Primary Data to Better Identify Disparities
As a result of the Collaborative, firms more strongly believe
that primary race/ethnicity data are important in supporting quality
improvement efforts that take into account the diversity in their enrollment.
All but one of the firms now say their goal is to capture race/ethnicity for
all members, and the latter firm is capturing it for selected patients in
disease management programs. The geocoding/surname analysis experience in
Phase I played an important role in helping firms develop a broader-based
acceptance of the existence of disparities. It also highlighted to firms what
geocoding could do (general patterns) and what it could not (member-specific
identification to support interventions, or identify patterns of disparities
when residential patterns are not highly concentrated by subgroups).
Despite what has been accomplished, there remains a large gap
between what firms have done and what they ultimately seek to do. For example,
one leading firm still has member race/ethnicity data for only a relatively
small proportion of members, despite several years of concerted data
collection. Two of the firms committed to collecting race and ethnicity data
have not yet determined how to do so, and a third will not start until at least
2008, when its new IT system is in place. Firms seem to have an easier time
collecting data on small subgroups of enrollees—those who visit portals or are
in disease management—than obtaining more universal data for their entire
enrollment, or sufficiently complete data in geographical areas to calculate
rates and proportions (which is essential to geographic analysis). Most firms
appear to feel it necessary to capture such data via their employer groups or
from members, because working with providers will be difficult. Even those with
affiliated providers face data collection challenges absent a strong push from
management. Furthermore, because organizations are large, those that have data
may not store it in such a way that it is accessible to other divisions and
people within the firm. Phase II will prioritize supporting firms in primary
data collection but the challenges—technical, organizational, and
political—should not be underestimated.
Because of the time it takes to generate useable primary data
on race/ethnicity, some firms plan to use geocoding/surname analysis to
benchmark change by geographic area or further identify locations for
disparity-oriented interventions. Firms used RAND support and methods in Phase
I. While RAND will continue to make some tools available in Phase II, firms
seeking individual assistance will have to enter into individual contracts with
RAND, as external resources to support this are not available. The transition
poses a structural barrier to sustainability. At least one firm has purchased
its own software and plans to continue internal efforts, although it remains to
be seen whether issues of consistency arise. Three others have or are
considering contracting with RAND for some ongoing support or training to
complement their internal efforts. In retrospect, it could have been valuable
to consider earlier how to institutionalize firm capacity to address these
issues, although firms seem to be making their own arrangements.
3. Limited Progress in Identifying and Implementing Interventions
During Phase I, firms made at best limited progress in
modifying their care processes with the goal of reducing racial and ethnic
disparities. Pursuit of interventions to reduce disparities took a back seat to
data collection efforts for most of the Collaborative. As firms gained insight
on disparities, they began to think more concretely about what they, as firms
sponsoring health plans in diverse ways, 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 in the process of developing them. Consistent with the Collaborative's
focus, all of these interventions targeted primarily race/ethnic minority
members with diabetes; four firms focused on Hispanic members and the others
other subgroups. Most pilots were small, although size varied, and the
approaches differed markedly across the firms, as described in the report. At
the time of this evaluation, it was too early for most firms to assess the
outcomes of their interventions. Still, most perceived that these pilot
programs created a framework for future expansion and learning, and planned to
pursue related interventions after the end of Phase I.
Firm progress in pursuing interventions was challenging for a
variety of reasons. First, firms were uncertain where to begin, citing
uncertainty about how they best could intervene to fill the gap. Second, firms
were constrained by lack of data, as many interventions require knowing the
race/ethnicity of particular members and most require at least an ability to
geographically target. Third, the scale and complexity of firms created
challenges to implementing effective interventions that could leverage the
diverse functional systems in the firm and the split between corporate and
regional responsibilities. Fourth, logistical issues, such as recruiting
physicians to participate in provider-based interventions, were a challenge.
Perhaps the Collaborative's most significant contribution to
care delivery was that it increased firms' awareness of the role disparities
play in the quality improvement agenda. By the end of the Collaborative, firms
typically saw this connection, rather than viewing addressing disparities as an
additional or separate activity. Still, firms were constrained by the tight
fiscal environment in which they operated and the competition for resources.
Firms viewed building a business case for working on disparities as important
to securing resources to address the issue, as well as for quality improvement.
4. Enhanced Industry Knowledge in Staff with
Sponsor/Support Organizations
Although some key staff in sponsor and support organizations
felt that their experiences in the Collaborative were consistent with their
understanding of firm behavior, others openly acknowledged that they learned a
great deal about the industry through the Collaborative. In most cases, the
latter group of participants had more experience with provider-based
organizations (or government research) than with complex health financing
organizations like those in the Collaborative. These organizations were
surprised by the severe limitations in available race/ethnicity data and the
challenges in collecting it, as well as the organizational and other barriers
within each firm and between it and the provider community. Conversely,
participants were positively impressed with the interest and commitment to
quality improvement among firms participating in the Collaborative. They also
came to understand why many firms preferred member interventions to those
focused on providers, as well as the reasons that progress was slow and efforts
typically long-term. (Although they were not necessarily convinced that the
trade-offs between this kind of focus and others made sense.) As a result,
sponsors and support organizations developed a greater understanding of why
firm goals typically relate more to policy changes than to changes that
actually benefit patients immediately and directly. However, many still viewed
provider-based organizations as more immediately relevant to reducing
disparities.
Contribution of Communications. The communications and
dissemination infrastructure was an important development in Phase I of the
Collaborative. While many participating organizations agreed that there was
relatively little to communicate in the first phase, GMMB's communications work
was important in presenting a standardized and consistent external message
about the Collaborative. Moreover, much of the Phase I communications
activity—the development of a logo and other NHPC materials and the
establishment of a core message, for example—has provided a foundation for
Phase II work, when the Collaborative may have substantively more activities
and result to report.
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B. Future Plans for Phase II
To encourage continued attention to concerns over disparities,
sponsors have decided to proceed to a second phase for an additional two years.
The support infrastructure will be streamlined with a single contract (from
AHRQ) to CHCS, with RAND serving as subcontractor. (RWJF will continue to be a
co-sponsor and responsible for communications.) While many details are yet to
be determined, the intent is that the Phase II objectives will be clearer than
those of Phase I, with a focus on particular activities that firms agree are
important. Not all of the firms participating in the Collaborative will
necessarily be involved in each Phase II activity, but the foci for attention
in Phase II are to be:
- Development of approaches to primary data collection on
race/ethnicity.
- Collective work on ways to enhance language access in the
national and local markets.
- Creation of the business case for work in this area, both
nationally and within firms.
- Information exchange, both among participating firms and with
other stakeholders.
- Communications related to the accomplishments of Phase I.
Details defining these objectives are
still being developed, as are agreements with plans on how success will be
measured.
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C. Insights Relevant to Phase II
The Phase I experience suggests that continuing 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." Given the external
pressures on firms and the competition for resources, the Collaborative will
encourage firms to continue to focus on disparities and provide a platform for
sharing experiences, successes, and, if they choose, failures. This alone will
be valuable to firms seeking insight and support.
However, there remain significant challenges to a successful
Phase II, particularly if success is to be measured in terms of concrete
accomplishments. While the activities firms have agreed to pursue in Phase II
may appear more concrete and defined than those of Phase I, that clarity is to
some extent misleading. While topic areas for Phase II have been defined, many
details remain unclear and significant effort will still be required to drill
down into the details of each topic. Moreover, from our observations of the
process through which the specific areas of focus (primary data collection,
language access, and the business case) were defined, we believe it will take
strong leadership to move participating firms forward in a direction that they
take ownership of and find useful, and that also makes progress on work that is
both substantively and operationally clear and doable. The fact that firms
themselves decided on Phase II activities—even though they require additional
definition and specificity—likely increases the extent to which firms feel
invested, at least at this stage. However, commitment will carry the work only
so far, unless it can be leveraged to develop, implement, and succeed in
specific substantive accomplishments.
In seeking clarity, sponsors and support organizations need to
be realistic about what they can accomplish with the resources they have made
available and those that firms can generate internally. On 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 broad, collective
accomplishments rather than a process focused mainly on supporting
communications among firms, only so much can be done. Although a conscious
effort was made to limit the number of explicit activities in Phase II, there
may be a natural tendency to handle differences of opinion among Collaborative
members by expanding the scope of efforts to include all ideas instead of
making strategic choices among competing priorities. As we read the scope for
Phase II, such "scope creep" is reflected in defining goals to have national
and market components (primary data, language access). Similarly the work to
define business case for reducing disparities has been defined broadly at both
the macro and firm business levels—referred to in Collaborative discussions as
"Big B/little b" needs (each of which has its own set of complicated
measurement and design issues). Beyond the specific objectives of concern to
the task force, the Collaborative will have to invest in enhancing general
information sharing and perhaps strengthening the substantive content of
support in a number of areas. If these tasks all tap the same resources from firms
and support organizations, there is a risk that none may be done well.
We also are 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 work in each area.
For example, in focusing on primary data collection, the Collaborative will
need to identify how its efforts interface (if at all) with providers and/or
purchasers and how they relate to existing efforts at standardization, such as
Office of Management and Budget (OMB) or state requirements regarding
collection of racial/ethnic data.
Because sponsor and support organizations have urged us to
provide as much insight as possible on what we suggest with respect to Phase
II, Table VIII.1 describes the areas we see as most critical in shaping Phase
II, recognizing that there are a variety of relevant perspectives that can be
brought to this task. These recommendations focus on developing targeted goals
under each topic area in Phase II (including an outcomes-oriented approach to
Collaborative meetings and conference calls) and not allowing the focus in each
area to become too diffuse over time, which could result in less interest on
the part of individual firms and/or in the Collaborative as a whole trying to
move in too many different directions.
In conclusion, the Collaborative has enhanced firm interest in
effective interventions to measure and address disparities. However, there
remain many challenges in designing and supporting such measures and
interventions, and many political, organizational, and market factors to
consider. We encourage participants in the Collaborative to assess their
priorities and lessons learned from Phase I as they continue to work on this
important issue.
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