Appendix B. Background on the Collaborative and its Origins

Growing Public Policy Interests in Health Disparities

Interest in racial and ethnic disparities in health care grew substantially in the late 1990s; at the same time, interest in quality improvement was on the rise (Table B-1).  In 1998, late into his administration, President Clinton appointed Dr. David Satcher to the posts of Surgeon General and Assistant Secretary for Health.  Satcher brought with him an interest in the disparities issue that would ultimately result in disparities emerging as one of the two goals for Healthy People 2010.  At about the same time, John Eisenberg, then head of AHRQ, was asked to head an HHS interagency work group on quality.

When AHRQ was reauthorized late in 1999, the legislation called for preparation of an annual National Healthcare Quality Report and an annual National Healthcare Disparities Report beginning in 2003.  That same year, Congress also requested the Institute of Medicine to prepare a report on racial and ethnic disparities in health care.  The Office of Management and Budget (OMB) had already issued revisions to its classification of racial and ethnic data that were slated to go into effect in 2003.  The National Committee on Vital and Health Statistics and, specifically, its Population Subcommittee began to examine the implications for data collection and analysis, both within and outside the private sector.

Although the transition from the Clinton to the Bush Administration resulted in some shift of emphasis, the push for reporting on quality and disparities was already well established.  Drs. Satcher and Eisenberg continued to serve early in the Bush Administration while Senator Frist's interest in the issues contributed to bipartisan appeal.

Industry Interest

While much of the discussion of disparities focused on federal data and initiatives, other public sector initiatives also examined the capacity of private sector providers and health plans to track disparities and participate in improvement efforts. For example, the National Committee on Vital and Health Statistics (NCVHS) examined issues associated with collecting disparities data in the private sector.  In 2001, Jack Rowe, who had recently taken charge at Aetna Health Care, decided that it was in the firm's interest to collect racial and ethnic data so that Aetna could examine disparities; the firm began to do so in late 2002, announcing the initiative publicly in early 2003. 

Industry interest in the Collaborative reflects a response to the release of national reports on disparities in 2002 (IOM) and 2003 (AHRQ) as well as an effort undertaken by other major national firms to position themselves to respond to Aetna's initiative.  In their drive for collaboration, firms started to look for a vehicle to address issues of disparities—a potentially sensitive concern—both collectively and within an environment that favorably addressed their antitrust, legal, and other concerns.

Networked Leaders. Many of those actively involved in the Collaborative today were engaged in both public and private efforts related to disparities and personally committed to the issue.  Dr. Lurie, now at RAND, worked for David Satcher as a Deputy Assistant Secretary of Health and was the point-person on disparities for much of the work in that office.  In this capacity, she also worked with AHRQ leaders, including then-director Dr. Eisenberg and Carolyn Clancy (then a center director and now head of the agency).  RWJF's current president, Risa Lavizzo-Mourey, also had been in the senior AHRQ leadership during the Clinton Administration.  She was Co-Vice Chair of the IOM committee on disparities and made disparities one of the new priorities at RWJF when she assumed leadership of the organization in the early 2000s.  John Lumpkin, who was brought in by Dr. Lavizzo-Mourrey to head the health care work at RWJF (where disparities was located), previously served as chair of NCHVS when it was dealing with the issue of disparities data.

Well-positioned individuals in the industry also had a long history of engagement in public policy issues and brought an active interest in the disparities issue.  The following are notable examples.

• Woody Myers, then executive vice president at WellPoint Health Networks, was a reviewer of the IOM report on disparities and came to his position at WellPoint after working on health benefits for General Motors and heading the New York City Health Department.  (After the WellPoint-Anthem merger, Dr. Myers left the firm.)
• Ray Baxter, head of community benefits at Kaiser Permanente, made reduction of disparities a priority when he joined the firm.  He was previously in a leadership position with Lewin Associates and had led the San Francisco Department of Public Health and the New York City Health and Hospitals Corporation.
• Jack Rowe, Aetna's president and CEO, started in 2000; he previously led the Mt. Sinai-NYU Health System in New York City, where he was active in public policy activities and served as a commissioner of the Medicare Payment Advisory Commission.
• Reed Tuckson, senior vice president of consumer health and medical care advantage for UnitedHealth Group (the parent company for affiliated health businesses), assumed his position in 2000 after working in senior positions at the American Medical Association and elsewhere.  He chaired IOM's Quality Chasm Summit Subcommittee and served in the late 1980s as the District of Columbia's commissioner of health.  (Dr. Lewis Sandy, currently executive vice president for clinical strategies at UnitedHealthcare, one of UnitedHealth Group's main business divisions, was previously executive vice president at RWJF.)
• Kathy Coltin, director of external quality and data initiatives at Harvard Pilgrim, served on the NCVHS Subcommittee on Populations and participated in its work to measure racial and ethnic disparities.

These historical connections pointed to the personal, as well as organizational interests and connections that helped shape the Collaborative.

Build Up to Collaborative

Exactly when the seeds were sown for the Collaborative is a matter of debate.  In any event, the process that ultimately led to formation of the Collaborative had its origins in the discussions that started in the late 1990s among overlapping sets of health plan representatives, government officials, and researchers. Clinton Administration official Dr. Lurie says that she, along with AHRQ leaders, grew concerned about the limited amount of data for documenting disparities within health plans. In response, they convened a meeting in mid-1999 (cosponsored by HHS and the Commonwealth Fund) with representatives of managed care plans, purchasers, and federal agencies.  HHS also cosponsored a 50-state study of laws regulating data collection (also funded by the Commonwealth Fund).  Ultimately, these activities and the underlying concern about disparities led firms sponsoring health plans—working with Dr. Lurie, who was by then at RAND—to request support from the California Endowment to help think through issues associated with addressing disparities (Bierman, Lurie, Collins, Eisenberg 2002; Lurie interview 2005).  During this period, RWJF funded the American Health Insurance Plans (AHIP) to survey health plans about their data on disparities (AHIP 2004). 

The decision to pursue a collaborative under AHRQ's sponsorship occurred in summer 2003.  In July of that year, AHRQ convened a meeting facilitated by Larry Bartlett of Health Systems Research that brought together members of the California Endowment, RAND, and a number of national and other firms sponsoring health plans.  AHRQ staff members say that the genesis of the meeting occurred when firms approached AHRQ for technical assistance in forming a collaborative and measuring disparities.  For the industry, collecting data on race and ethnicity raised a host of organizational issues and concerns about legal liability, marketing risks, and so forth.  Working collectively under the AHRQ umbrella was potentially attractive to firms seeking to minimize perceived individual risks.  RWJF senior staff also attended the meeting at AHRQ's invitation.  We have not interviewed staff from the California Endowment, but we gather that AHRQ's interest in the Collaborative allowed the California Endowment to reduce its involvement in the issue.

At the July meeting, attendees reached agreement on guiding principles for their work (Health Plan Learning Collaborative Agreement).  These principles state that:

• Improving quality and reducing disparities are inextricably linked.
• Improving quality and reducing disparities are important health plan objectives.
• Quality measurement and performance assessment is the foundation on which quality improvement is based. Plans cannot improve what is not measured.
• Performance assessment will focus on selected domains of clinical care to be chosen on the basis of national priority (e.g., IOM's 20 priority areas, as well as NHQR and NHDR).
• The Collaborative will build on existing quality measurement and performance assessment efforts whenever possible.
• The Collaborative will support consistency in quality measurement and performance assessment.
• The Collaborative will support strategies that improve quality and reduce disparities.
• The Collaborative will support flexibility in quality improvement strategies so that plans may intervene at the consumer, physician, or organizational levels.
• The Collaborative will foster an environment in which it can share its experiences with the broader health community.

AHRQ's commitment to the Collaborative was to provide technical assistance, information on evidence-based approaches to quality improvement strategies, and opportunities for dialogue and learning.

After the July 2003 meeting, AHRQ began to put in place vehicles and agreements that would operationalize support for the Collaborative.  In September 2003, AHRQ awarded RAND a sole-source contract to support the Collaborative in assessing needs and collecting and analyzing data; RAND's earlier involvement with plans on the disparities issue as well as Allen Fremont's work in measuring disparities involving UnitedHealthcare under AHRQ's Integrated Delivery System Systems Research Network (IDSRN) led to RAND's involvement.  RWJF agreed to cosponsor the Collaborative.  AHRQ and RWJF staff worked through spring 2004 to define their respective roles and responsibilities. Ultimately, they decided that RWJF would fund the learning organization, which comprised of CHCS and IHI, to help facilitate the process of collaboration; these arrangements were in place by spring 2004.  (The official contract with CHCS is dated August 25, 2004.) The first official meeting of the Collaborative took place on September 10, 2004.

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