After a Decade of "Social Investment," the Quest to Improve Healthcare Continues

PLAINSBORO, N.J.—A 10-year investment to improve the delivery of high-quality, cost-effective, equitable healthcare has given stakeholders more information than ever about both barriers and opportunities for change, according to the former administrator of the Centers for Medicare and Medicaid Services (CMS).

While the ideal healthcare system “remains out of reach,” according to Donald M. Berwick, MD, MPP, the ambitious work of Aligning Forces for Quality (AF4Q), funded by the Robert Wood Johnson Foundation (RWJF), offers insights for those who want to improve the health of their communities.

Today, The American Journal of Managed Care publishes a supplement on the lessons learned from the independent evaluation of AF4Q led by Dennis Scanlon, PhD, director of the Penn State Center for Health Care and Policy Research, and researchers at Northwestern University, the University of Minnesota, the University of Michigan and the George Washington University. This 10-year, mixed methods evaluation examined the AF4Q design and implementation across 16 regions, known as alliances, while the national healthcare environment underwent tectonic change, including the passage of the Affordable Care Act (ACA) in 2010.

Berwick served as special guest editor for the supplement, which is available here.

The AF4Q quest sought to improve the health and healthcare of 37 million people with the aim of providing models for widespread national reform. From a well check to major surgery, patients, providers, and purchasers all experience the complexity of a mammoth system with many moving and interrelated, yet often isolated parts. With AF4Q, RWJF sought to align five key “forces,” with the goal of improving healthcare and patient experiences, while reducing costs:

· performance measurement and reporting

· quality improvement

· engaging consumers in their health and healthcare

· reducing healthcare disparities

· reforming payment

The supplement features three guest commentaries and eight original research reports. Berwick described the evaluations detailed in the reports as “both quantitative, in nearly breathtaking scale, and qualitative,” including the summary by Scanlon and his co-authors. “Social scientists will for many years be mining the AF4Q experience for detailed lessons and ethnographic and political insights,” Berwick said.

“The philosophy and guiding principles that undergirded AF4Q and its alliances remain consistent and fundamental among [Regional Health Improvement Collaboratives] RHICs today,” said Elizabeth Mitchell, president and CEO, Network of Regional Healthcare Improvement. “Change in healthcare happens locally because healthcare is local. AF4Q allowed these local relationships to expand and deepen.”

Scanlon added, "Such change needs to happen locally, even in the context of significant federal policy changes, such as the ACA. Our findings from AF4Q provide insight into the important work happening locally to create better healthcare systems and the many challenges regions face when trying to make things better and more affordable.”

Key findings at the conclusion of AF4Q:

· Implementing and aligning activities across all five “forces” proved difficult for any one AF4Q community.

· While collaboration among stakeholders to improve systems is conceptually appealing, there are many challenges to sustaining regional relationships, though AF4Q highlighted some promising models.

· Over time, the AF4Q regions showed no major differences in improvement rates in quality and health measures examined, compared with control communities. However, all communities tended to trend towards improvement.

· Engaging consumers in reforming the system proved more difficult than expected, but the conversation has been elevated. The importance of transforming the system “by patients and for patients” is gaining traction.

· Sustaining quality and price transparency at the community level is challenging. Important questions moving forward include: Who will fund and produce this information, and who receives the most value from it?

· Disparities reduction activities proved challenging but happened with more intensity in communities that had long-established relationships with community groups representing diverse and underserved populations.

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