Regional Health Improvement Collaboratives Needed Now More Than Ever: Program Directors' Perspectives

We are present or past program directors of 4 regional health improvement collaboratives (RHICs) in the northwest, north central, and northeast United States, among 16 programs supported by the Robert Wood Johnson Foundation’s (RWJF’s) Aligning Forces for Quality (AF4Q) initiative. In this article, we summarize our common

vision and describe how commitments are being shaped and implemented according to healthcare market forces among regions. The sustainability of these initiatives is influenced by regional and national forces that could challenge Americans’ ability to experience improved health outcomes and reduced costs of healthcare. Multi-stakeholder collaboratives that promote transparency and collaboration are needed nowmore than ever to improve the value of healthcare for patients and other purchasers.

Regional Context: Think Nationally, Act Regionally

The Network for Regional Healthcare Improvement describes RHICs as nonprofit organizations based in a specific geographic region that are governed by multi-stakeholder

boards to help their community identify opportunities for improving healthcare quality and value, and to lead strategies to address those opportunities.¹ It is estimated that over 50 RHICs are currently engaged in cooperative health improvement activities at the regional level, working with providers who collectively care for as many as 120 million people, or over 40% of Americans. As a result of the 2009 federal stimulus bill, analogous regional initiatives were undertaken in the federally supported Beacon Community Program. More recently, initiatives were supported by the Innovation Center of the Centers for Medicare & Medicaid Services.

The AF4Q initiative presented a unique opportunity for regional health improvement, with a common national vision articulated by the RWJF and adopted by the leaders of

these 16 regional collaboratives. The vision, largely supporting the Institute for Healthcare Improvement’s Triple Aim Initiative of better care, better health of populations, and lower per capita costs,² anticipated a future state with several complementary components. It includes: (1) multi-stakeholder collaboration across purchasers (public and private employers and union trusts), payers, providers, and patients; (2) regionwide public reporting of performance of all providers, including reporting of patients’ experience with their care along with metrics related to care quality and outcomes; (3) active regional provider partnerships in patient-centered quality improvement with a particular focus on reducing disparities in care; (4) consumers who are actively engaged in their health and healthcare; and (5) reformed delivery systems and payment mechanisms that reinforce each of these components.

In addition to the common elements of this vision, RHICs across the country are working to find local solutions to the following more or less universal challenges: (1) a primary care system that is under-resourced and undervalued to address the growing prevalence of chronic disease and an aging population; (2) rampant misuse of emergency care for nonemergent problems; (3) overuse of potentially avoidable care from hospitals, specialists, and procedures at the same time that needed care is too frequently lacking; (4) poor coordination of care for patients across providers and systems of care; (5) poverty and its socioeconomic effects on health and access to healthcare; (6) poor lifestyle choices; (7) increasing lack of health insurance; and (8) payment that encourages delivery of healthcare services (“volume”) without incentives for providing or choosing high-quality, cost-effective care (“value”). In this challenging landscape, the AF4Q RHICs serve as neutral conveners and brokers (ie, the Switzerland) in their increasingly competitive markets, embracing transparency and accountability for healthcare and outcomes throughout their regions.

In addition to these common national themes, the regions are influenced by their market histories and local forces, and by the shared influences of national markets and federal initiatives. Contexts vary across regions in several important ways. Some regions include significant rural areas with widely dispersed providers and stretched capacity, such as Western New York, Humboldt County (California), and statewide programs in Minnesota, Wisconsin, Oregon, and Maine,whereas other regions include urban and suburban areas with a higher density of large healthcare systems like Puget Sound (Washington), Cleveland, Detroit, Memphis, Kansas City, and Cincinnati. Market forces and RHICs in Puget Sound, Cincinnati, and Maine are influenced heavily by large employers and other purchasers, while RHICs in Cleveland, Wisconsin, and Humboldt County are driven largely by primary care providers.

Sources for provider performance measurement range from exclusive reliance on health insurance claims to virtually exclusive reliance on medical records. National health

plans with large local penetration dominate the insurance market in several areas. Minnesota is supported largely by regional plans, while other regions are influenced by a varied mix of highly competitive regional and national plans. In its funding, the RWJF has supported RHICs with pre-existing initiatives in Humboldt County, Minnesota, Puget Sound, and other regions, while new programs were supported in Albuquerque, Kansas City, south central Pennsylvania, and western Michigan. In Cleveland, a new program was supported in a region with a history of an employer-driven quality initiative that collapsed in the 1990s, leaving a long shadow.³

Each RHIC’s trajectory into healthcare reform is heavily influenced by these and other forces that have affected both the opportunities and challenges of their regions. We

offer several relevant observations from our experience to date. Regions with purchaser-led programs generally are moving more rapidly into utilization and cost-related public reporting, and to the creation of multipayer payment reform pilot studies. For example, Puget Sound, Cincinnati, and other purchaser-led RHICs have won multipayer support for implementing patient-centered medical homes to strengthen primary care. In Maine, where the largest purchasers are activated public employers, performance reports strongly influence public employers’ health benefit designs and are beginning to guide employees’ choices for healthcare providers. These and other purchaser-led collaboratives are advantaged in the cost arena because they are relatively mature programs that predated the AF4Q initiative and have the support of large employers to effect change. These forces alone, however, may not affect the necessary provider engagement or efforts to reduce disparities in health and healthcare.

RHICs with strong provider leadership generally favor medical records—based approaches to measurement. Partlyas a consequence, they are also more likely to have robust

quality improvement- and patient-centered primary care initiatives and focus on improving care for all of their patients, including those without insurance. For example, Cleveland’s electronic health records (EHRs)-catalyzed measurement⁴ has shortened the path to national medical home recognition, engaged provider practices to participate in regular daylong learning collaboratives that highlight improvement on trusted reporting of quality metrics, and accelerated the transition to EHRs among community health centers that were previously paper-based. EHRs and other medical records—based systems have also focused public reports on communitywide

disparities in quality by race/ethnicity, insurance, educational attainment, and household income,⁴ drawing the regions’ attention to population health. In Maine, which has

the triple strength of strong physician leadership, a hybrid approach to measurement, and public employer support, the RHIC used public reporting and strong quality improvement efforts to engage nearly a quarter of the primary care practices in the state in the medical home model.

Approaches to defining and engaging consumers were also influenced by regional forces. Several of the collaboratives have undertaken measurement and public reporting of their patients’ experience in ambulatory care, variably supported by the RWJF, health insurers, or providers themselves. In Puget Sound, where employers and union trusts actively drive public reporting and consumer engagement, the RHIC’s “Own Your Health” campaign influenced 1 large employer to refine its premium contribution strategy to encourage employees to select a high-performing delivery system, which reportedly saved $61 million over a 2-year period. In contrast, Humboldt County avoids overt consumer steering based on established public reports, in part because its provider-led program is located in a rural region with constrained provider capacity. Consumer engagement in Humboldt County was translated as patient activation in their care, with widespread dissemination of a diabetes self-management program.⁵

National Context: “There Are Forces That Are Aligned Against You”

The quote above was made by a representative of a large national health insurer to RHIC leaders gathered at a recent national meeting. It was accompanied by similar comments from other health plan leaders, including “We cannot do [data sharing and health payment reform] in 50 different ways,” and “We have guard rails up—you should be aware that there are certain things that are hard-coded into our systems.” In taking regionally shaped trajectories toward a common national vision, AF4Q communities are succeeding despite increasingly competitive and challenging markets. Global employers have decreasing local presence, competing in international markets and seeking to reduce their corporationwide payrolls and cost of benefits. Competition among insurers and resistance to local customization by national insurers inhibit regional multi-payer

approaches to transparency and payment that would best support provider change. Local competition with subspecialistdominated delivery systems continue their fee-for-service strategic plans while waiting for clear signs about whether future payment systems will reward value over volume.

Multi-Stakeholder Collaboratives Are Needed Now More Than Ever

If a national vision of value-driven, patient-centered care is to become a reality—one that results in better care, better health of populations, and lower costs—RHICs, such as those embodied by the RWJF’s AF4Q initiative, are a necessary part of the solution. Each collaborative represents a neutral common table for all stakeholders to discuss their unique concerns while recognizing their shared interests. Instead of promoting silos by payer and unmanaged competition that, like the tragedy of the commons,⁶ foster a race to the bottom, the AF4Q collaboratives foster common values, transparency, and the sharing of best practices. While the need to reform the current healthcare system remains a growing national challenge, it is clear that solutions must be identified and implemented locally, making the role of RHICs critically important, now more than ever. Individually, each region has the opportunity to become a healthier place to live and a better place to do business. Collectively, and particularly because over 40% of

Americans receive healthcare by providers in these regions, this may be a very good place to start.

Author affiliations: Better Health Greater Cleveland and Center for Health Care Research & Policy, Case Western Reserve University/MetroHealth Medical Center, Cleveland, OH (RDC); Puget Sound Health Alliance, Seattle, WA (SED); Stanford Coordinated Care and Stanford School of Medicine, Palo Alto, CA (AG); Maine Quality Counts, Manchester, ME (LML).

Funding source: This supplement was supported by the Robert Wood Johnson Foundation (RWJF). The Aligning Forces for Quality evaluation is funded by a grant from the RWJF.

Author disclosures: Dr Cebul reports board membership with Better Health Greater Cleveland, and grants and meeting/conference attendance with the RWJF. Ms Dade reports employment with the Puget Sound Health Alliance. She also reports grants and meeting/conference attendance with the RWJF. Dr Glaseroff reports grants and meeting/conference attendance with the RWJF. Dr Letourneau reports consultancy/advisory board membership with the Maine Health Management Coalition and employment with Maine Quality Counts. She also reports grants and meeting/conference attendance with the RWJF.

Authorship information: Concept and design (RDC, SED, AG, LML); acquisition of data (RDC); analysis and interpretation of data (RDC); drafting of the manuscript (RDC, SED, AG, LML); critical revision of the manuscript for important intellectual content (RDC, SED, AG, LML); and obtaining funding (RDC).

Address correspondence to: Randall D. Cebul, MD, Center for Health Care Research & Policy, R221 MetroHealth Medical Center, 2500 MetroHealth Dr, Cleveland, OH 44109. E-mail: rdc@case.edu.

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