The National Health Plan Collaborative: Overview of Its Origins, Accomplishments, and Lessons Learned
During Phase I of the NHPC, participants increased their understanding of racial and ethnic disparities. They also got to know one another better and appreciate others' perspectives. In addition, they developed the trust that sponsors and support organizations have learned is critical to the NHPC's goals of collaboration and sharing. In Phase II, participants drew on that base of trust to pursue important shared priorities. Although the NHPC fell short of the ambitious goals originally set by sponsors, particularly in Phase I, it was successful in supporting what appear to be critical changes in structures and processes within NHPC firms.
Accomplishments in Phase I
Findings from the evaluation of the NHPC Phase I show that the Collaborative made progress toward some, but not all, of its objectives.4 The main accomplishments of Phase I included the following:
- Increased organizational attention and commitment to disparities as part of the quality agenda for health plans. Participating firms had the support of their leaders and typically used or developed internal structures to enhance their ability to address disparities. Such infrastructure is critical because, to sustain their efforts, participating firms must confront both a constrained fiscal environment and, in many cases, an unavoidable instability in leadership.
- Firms' growing recognition that their ability to generate primary data on race and ethnicity is critical to progress. In Phase I, the NHPC focused on helping firms to use geocoding and surname analysis as a proxy for primary data on race and ethnicity that could be used to assess disparities. The proxy information brought to light the disparities within the firms' plans and made them more certain that such primary data are critical in supporting quality improvement efforts targeted to members of racial and ethnic minorities. By the end of Phase I, all but one of the firms said that their goal was to collect such data for all their members; the remaining firm was collecting the information for the subset of its enrollees who participated in disease management. However, the NHPC also revealed a substantial gap between what the firms had done and what they ultimately hoped to do.
- Increased awareness among sponsor and support organization staff about how firms work in ways relevant to understanding the firms' ability to contribute to reducing disparities. This was not a stated objective of the NHPC, but through their participation, sponsors and support organizations gained important insights into working with large commercial health plans. Although some key staff in these organizations already had industry experience, others said that they had learned a great deal about the industry through their participation in the NHPC.
Room for Improvement
The NHPC's first phase had less success in sharing lessons about caring for and interacting with members in ways that reduced disparities and in applying that knowledge to care delivery. The time needed to generate data on disparities delayed the firms in focusing on quality improvement. Only in the last year of Phase I did firms start to concentrate on this area. By the end of Phase I, however, seven of the nine firms either had completed, or were in the process of completing, pilot interventions, while two were developing them.
By the end of Phase I, it was too soon to judge the effects of the NHPC's efforts, although most firms said they thought such work created a framework and basis for future expansion, and they planned to continue their efforts. Aside from data, barriers to progress included:
- Uncertainty over how to begin and how best to intervene.
- Challenges associated with gaining support for and implementing changes that involved a variety of organizational functions and responsibilities.
- Difficulties facing firms in gaining the support of their associated physicians for interventions that included a provider-based component.
The NHPC's Contribution
Firms saw the first phase of the NHPC in a positive light. Consistent with its initial hopes, the NHPC allowed firms to leverage their resources, enhance their awareness of disparities, fuel internal efforts to address disparities, and ensure momentum for these changes. The fact that the NHPC was sponsored by an important Federal agency and a major health foundation enhanced its credibility and added value from the firms' standpoint. Participants also acknowledged, however, that they did not necessarily benefit as much as they might have from Phase I of the NHPC, had they been willing to share information more openly. They also indicated that they might have benefited more if the NHPC had been better structured to facilitate substantive learning, particularly with respect to evidence on ways to reduce disparities.
Given the experience obtained from Phase I, we encouraged NHPC sponsors and support organizations to develop a realistic set of priorities for the second phase, heavily focused on supporting substantive change in a few areas of high priority to participating firms. Firms also asked (during our evaluation) for some organizational changes in Phase II to make the NHPC a more streamlined structure with fewer and more predictable demands on their time. This would allow them to fit the NHPC more easily into their ongoing work within their organizations
Based on our final evaluation report for Phase I, as well as other factors, AHRQ decided to sponsor a second phase of the NHPC. (RWJF also remained involved, although its Phase II sponsorship was limited to supporting communications through its contract with GMMB.) Phase II sought to reinforce the participants' focus on measuring and reducing disparities while supporting firms in making concrete progress in targeted high-priority areas.
Accomplishments in Phase II
In Phase II, the evaluation continued to focus on the organizational response to the NHPC. For example, there was interest in answering such questions as:
- Will firms continue to participate in the NHPC, and with what level of commitment? If there is leadership or staffing turnover, can firms manage to retain their interest in both the NHPC and addressing disparities overall?
- How will the inclusion of Humana and other potential new firms in Phase II affect the NHPC's ability to work together on its goals and outcomes?
- Has the focus on particular activities strengthened or weakened the firms' commitment to reducing disparities?
- Will firms continue to view the NHPC as valuable, and if so, why? Are firms collaborating with one another? How much sharing of information and ideas actually occurs?
At the end of Phase II, all firms were participating actively in the NHPC, although, as always, some were more active than others. Most notably, the majority of firms appeared to have made substantial progress in integrating and institutionalizing their disparities work into the mainstream of their organizations, as described in more detail below. Several firms' representatives characterized their Phase II disparities activities as having moved from the "corner of the desk" to a more central position. In addition, others in their organizations, including senior management, were paying more attention to this work. Moreover, months after the end of Phase II, members appeared to be either steady in their disparities work or on a path to expansion (based on our correspondence with firms in March 2009).
NHPC Role in Reinforcing Firms' Work on Disparities
The NHPC helped to motivate firms' work on disparities. Many NHPC participants noted that membership in the Collaborative provided the leverage needed to obtain senior management involvement and commitment to disparities work. One firm representative commented that "being a member on its own was valuable because it allowed more resources in [the health plan] to be directed to disparities work." A number of NHPC participants noted that learning what their competitors were doing regarding disparities kept them focused on this work. One firm's representative noted that NHPC participation, and the accompanying knowledge of other firms' activities, provided "additional credibility and motivation to what was being done [internally], especially for the far reaches of the organization."
Staff from another firm described Phase II as "critical.in terms of raising this issue to a new level in our organization." Another firm's representative noted that participating in the Collaborative "made us talk about our [disparities] activities and be a bit more transparent with other health plans regarding where we are." One member mentioned, however, that the Collaborative may have benefited from tighter linkages with other groups doing notable disparities work, such as the Institute of Medicine's (IOM) Roundtable on Health Disparities.
The increased focus on disparities is impressive in light of competing pressures, such as business concerns and merger activity in several NHPC firms during Phase II. In the words of one non-firm representative, ".despite major upheavals in the plans, things have remained standing" and, by some accounts, the disparities work of several firms has begun to flourish. Several potential challenges lie ahead, however, as discussed in this brief's conclusion.
Firms placing an increased priority on disparities also was reinforced by several changes in the external environment during Phase II. First, policy developments in California and Massachusetts garnered the attention of health plans. California's Senate Bill (SB) 853 required access to language services for patients, and Massachusetts State regulations required hospitals and health plans to collect data on patients' race and ethnicity. SB 853 had a large impact on health plans operating in that State, with one large firm reporting that it spent $1 million on translated documents for each translated language. Similarly, the Massachusetts policy has prompted increased activity in firms operating there.
One firm's representative noted that its accelerated activity regarding race and ethnicity data collection would not have happened without the Massachusetts mandate. Not surprisingly, national plans are particularly concerned about States regulating many different approaches to data collection and language access. Second, NHPC firms reported increased interest in disparities among both public and private employers, as evidenced by requirements included in requests for proposals eliciting bids for group coverage. Finally, several firms' representatives noted that the changing demographics in the United States (e.g., the growing proportion of Hispanic persons in the population) helped to make the business case for reducing disparities. These firms are likely to see a change in the composition of their future customer base.
Institutionalization of Disparities Activities
Disparities work also became more clearly institutionalized in many NHPC participating firms during Phase II. As one NHPC organization stated, "The plans have established a real infrastructure [internally].now it has roots." Moreover, this institutionalization of activities raised awareness within each firm and helped "connect the dots" between internal disparities activities.
Examples of institutionalization are available for most NHPC firms, but a few notable developments follow:
- CIGNA developed a cross-function group, the Disparities Council, which held its first official meeting in May 2008. Also, the firm announced the appointment of Dr. Collette Edwards to a new national medical director position with a focus on disparities.
- Highmark created a new health equity and quality area within its quality and medical performance management department; Dr. Rhonda Johnson heads this group.
- Kaiser Permanente (KP) added an equity metric to its "executive dashboard"; this is shared systematically with senior quality improvement leaders. KP's chief executive officer sponsored the development of a disparities Web site under KP's umbrella of sites.
- Molina created a new vice president position whose duties will include work to improve access to care, as well as creating and implementing programs to reduce identified health disparities.
- UnitedHealth Group developed an enterprisewide committee, the Multicultural Clinical and Business Advancement Team, in fall 2007.
- Several firms noted that disparities work has been institutionalized within their organizations via regular or semiregular presentations to their boards of directors on disparities activities.
- Many firms have pursued cultural competency training activities, with several targeting both clinical and nonclinical staff and some conducting training enterprisewide.
- Several firms began collecting patient self-reported data on race/ethnicity/language through online enrollment, creation of a data warehouse populated with information from hospitals and physician groups, interactive voice response systems,viii and electronic health record systems.
Increased Sharing and Trust
NHPC participants uniformly suggested that sharing and trust between organizations increased substantially during Phase II, both for the group and one on one.6 Firms' representatives indicated that sharing with and learning from others was not only a primary purpose but also a major accomplishment of Phase II. Furthermore, in contrast to the anticipated concern over the impact of expanding the NHPC to include new firms, the expansion appeared to have no effect on sharing and trust. The concern may have been eased in part because only two new firms were invited to join during this time. Although several key firm representatives participated throughout Phase I and II, a number of firms had staff turnover. Therefore, the trust that developed among NHPC participants seems largely at the organizational rather than the individual level.
All participants seemed pleased with the group's move over time toward a more open atmosphere and found the in-person meetings—especially the last in Phase II in July 2008—particularly open and informative. Many firms noted that learning from others about what activities worked or did not work helped them to anticipate challenges and avoid repeating mistakes. One firm's representative characterized Phase II as a "sounding board and repository for best practices." Sponsors and support organizations were particularly pleased that firms were picking up and using others' ideas and that all participants seemed comfortable with that approach.
Firms' representatives reported more active internal sharing of information regarding NHPC meetings and calls, in part because of the institutionalization discussed above. In the words of one national firm's representative, who shares NHPC information directly with an internal committee focused on disparities, "I can't say enough how helpful it is to bring back information on what other plans are doing." Another representative, who also regularly updates internal staff on NHPC activities, suggested that staff in his organization always are very interested in what other firms are doing.
Informal communication between firms also grew substantially during Phase II, representing a marked change from Phase I. Several NHPC members noted that informal communication (such as telephone calls) now occurs between firms, particularly for the last 6 to 8 months of Phase II. Moreover, whereas the support organizations had to facilitate these types of firm-to-firm interactions in Phase I, this usually was not necessary in Phase II.
NHPC as a Leadership Organization
The NHPC originally was conceived as a group of firms that were leaders in the area of disparities, or at least had a strong interest in reducing them. Since the NHPC's inception in mid-2004, many other efforts have emerged that focus on disparities. Several NHPC participants also have participated in forums, collaboratives, and other groups. While the field has grown, NHPC organizations still identify the NHPC as a leader in the field. Specifically, several firms involved in disparities work outside the NHPC say they now realize that the NHPC was in the forefront of disparities efforts. For example, several NHPC firms have worked with the Disparities Solution Center at Massachusetts General Hospital, and a few other representatives of firms served as faculty at a recent meeting of the group. According to a staff member of one firm, this work "has shown me how far ahead the NHPC is." Another firm's representative stated that the NHPC members "sometimes think that all health plans must be doing what the [plans in the] Collaborative are doing, but that's not the reality."
viii Some health plans use interactive voice response technology to conduct educational outreach calls to members about preventive services and other member communications. For more information, go to the NHPC toolkit's case study of Harvard Pilgrim's work in this area at http://www.rwjf.org/qualityequality/product.jsp?id=34018.