The National Health Plan Collaborative: Overview of Its Origins, Accomplishments, and Lessons Learned
VI. Lessons Learned
Collaboration With Large Firms Requires Understanding Their Organizational Context
The firms that participated in the NHPC are large, complex organizations. Change in these organizations typically occurs slowly, unless there is a strong directive from an organization's top leadership. Moreover, competing demands and pressures within each firm often slow progress, such as constraints on information technology resources and staff, budgetary pressures, staff turnover, and merger activity. In addition, as a group, participating firms vary substantially in their structure (centralized versus decentralized), culture, and geographic coverage. Therefore, firms were not able to take a single approach or intervention-as is sometimes done in quality improvement collaboratives involving smaller, less complex organizations-or move forward at the same pace. Yet participants successfully used the NHPC as a venue for sharing best practices, avoiding each others' mistakes, and pushing each other to continue progress.
Given the often slow and deliberative nature of organizations of this size and complexity, AHRQ's funding of Phase II appeared to come at a critical juncture. The end of Phase I finally saw a building of momentum on disparities work. Phase II saw the continuation of this work, its extension (beyond disparities in diabetes care to care for other conditions and preventive care), and, for many firms, its institutionalization.
Phase II also saw markedly different interactions between NHPC participants, with substantially greater trust and sharing of information. This development was particularly notable, given the competitive nature of the industry. Most firms perceived this sharing to be one of the most valuable aspects of the Collaborative. Finally, as in Phase I, firms perceived that AHRQ's sponsorship of the NHPC afforded them greater consideration internally, by signaling Federal backing of an important issue.
Setting Specific Goals Can Help Collaborative Focus, But Flexibility Also Is Valuable
Deciding on concrete goals and specific activities at the start of Phase II allowed participants to be on the "same page" from the start and appeared to make a difference in its success (relative to Phase I, in which activities were substantially less defined). These activities and related goals provided the group with focus. Moreover, letting firms decide on the activities and goals of Phase II gave them more ownership, in that they valued the activities and thus had a vested interest in completing them. (This is in contrast to the more prescriptive approach in Phase I in which sponsors and support organizations encouraged plans to develop small-scale pilot interventions whose success could be assessed via before—after comparisons of HEDIS measures—a step for which many were not ready.)
The NHPC was also relatively flexible in altering its activities and goals as needed in Phase II. By late 2007, the NHPC dropped the business case work when the group realized these efforts lacked clarity and were not going to be fruitful, given that development of the business case did not lend itself to a group setting of competitors. Similarly, in early 2008, the NHPC developed several new task forces and the group began to spread itself too thin across a range of activities.
Realizing this—in part based on this evaluation's formative feedback—the NHPC then prioritized its efforts toward disseminating its Phase II work and planning for the group's sustainability after Phase II. These midcourse corrections were important in keeping the Collaborative on track and focused on high-priority tasks that could be most productive by the end of Phase II.
Reaching Out to Other Stakeholders Might Have Brought Opportunities
While NHPC participants widely agreed that Phase II was successful in focusing, sustaining, and institutionalizing their work on disparities, one criticism we heard was that the Collaborative did not reach out to external audiences. For example, several firms felt that connecting with large employers or employer groups, such as the National Business Group on Health, would have been useful in Phase II, if only to get the perspectives of these audiences on disparities. Also along these lines, representatives from NHPC firms sometimes reported learning of other disparities groups or activities, such as the American Medical Association's Commission to End Health Care Disparities, and were surprised that they had not heard about them from the NHPC. The transition of the group to AHIP may offer new opportunities to engage other audiences.
Collection of Race/Ethnicity Data Among NHPC Firms Increased Substantially
NHPC participants made substantial progress on data collection efforts during Phase II. One of the most notable developments in this area was the recognition of the need for multipronged data collection strategies, particularly in light of the limitations of primary data collection. At the last Phase II meeting, several NHPC firms that had been collecting direct race/ethnicity data for several years reported reaching a plateau of 25 to 35 percent of members for whom they have collected these data directly. This limitation highlights the need for creative strategies for data collection and the continued importance of proxy methods.
Employers remain an untapped source of data and could become an increasingly important source if existing barriers were overcome, such as many employers' misperceptions about the legality of sharing employee data with health plans. In addition, data from providers such as physician groups and hospitals remain another important and largely untapped source. The mandate to collect race/ethnicity data in Massachusetts, however, may begin to move this approach forward, as hospitals and other providers are beginning to make arrangements with health plans to share patient race/ethnicity data.
The Public/Private Partnership of the NHPC Differed From Others AHRQ Has Undertaken
In recent years, AHRQ has increasingly worked with private organizations through programs such as Accelerating Change and Transformation in Organizations and Networks (ACTION), the Primary Care Practice-Based Research Networks (PBRNs), and other collaborations that may be more time limited (e.g., Partnerships for Quality) as a means to conduct rapid-cycle applied research and better link research to the operational settings in which it may be used. In contrast to these programs, the NHPC represented a different type of public/private partnership for AHRQ.
First, the NHPC was convened primarily as a collaborative. The firms participating in the NHPC were not grantees and received no direct financial support, although they benefited from in-kind support provided by the support organizations and the NHPC infrastructure. The voluntary nature of this kind of participation is inherently more ambiguous and challenging than that between funder and grantee. Firm "buy in" to NHPC goals thus was more critical to progress, because shared goals had to evolve rather than be mandated.
Second, the firms' lead participants were not themselves researchers and instead occupied operational positions within the firms. Their interest in pursuing disparities reduction was motivated less by a research interest than by how they saw the work benefiting their organization and its goals, and also because of the value they often personally ascribed to the work. In many cases, they were asked to participate in the NHPC by top firm leadership. As a result, firms' representatives in the NHPC were much more integrated into the executive leadership and operations of their firms than if they had been based in a separate research entity. However, their location and background within the firm also meant that they had many competing demands on their time and did not necessarily bring strong analytical grounding on literature-based best practices for measuring disparities and testing interventions.
Third, the NHPC offered AHRQ an opportunity to potentially influence health care quality on a much larger scale than its other partnerships to date, given that the NHPC covered 87 million lives by the end of Phase II. Because efforts were linked to top leadership in major firms within the industry, the NHPC had the potential to generate momentum that ultimately could change how health plans perceive, measure, and act on disparities. Such scale also has its challenges. Firms that participated in the NHPC, particularly the large national organizations, move very slowly and must consider change primarily from the perspective of their business and organizational needs. This type of partnership is less likely to result in dramatic breakthroughs and innovation than in the gradual accumulation of knowledge and shifts in orientation.
Challenges and Opportunities Lie Ahead
While many NHPC plans made strides in their disparities measurement and reduction activities in Phase II, plans, including some outside the NHPC, are likely to face some significant barriers in the future. The magnitude of the current economic recession may hamper work on disparities as other issues and concerns become higher priority. One firm's representative remarked, "In a market where companies are laying off workers and cutting budgets, it is uncertain who will pay attention to the issues the NHPC has been focused on, such as data collection, if it involves investing in health IT systems." In addition, most employers-the primary purchasers of commercial health coverage-are not particularly attuned to issues of health care disparities,10 and employer attention may fade even more in light of current economic considerations. In the current economic climate, a key focus likely will be on the potential for disparities reduction activities to improve health care quality while reducing costs.
Perhaps a key lesson from the NHPC is that such voluntary efforts enhance receptivity and infrastructure in ways that are important if firms are to effectively engage in initiatives to address disparities. However, such shifts are more likely to occur when the external environment reinforces them. The fact that states such as California and Massachusetts are now requiring firms to collect and report data (race/ethnicity in Massachusetts and preferred language in California) and enhance their language services (California) has moved such work much higher on the priority lists of firms subject to those requirements.
While the Obama Administration has not yet indicated how it will approach disparities, it clearly has endorsed substantial increases in funding for information technology that will be used to drive quality improvement. This provides a valuable opportunity to capture uniform data on race/ethnicity/language essential to many strategies for disparities reduction. For the most part, Federal efforts are directed at providers, not health plans, and privacy concerns are likely to constrain the ease with which information can be shared. However, such enhanced capacity, combined with external incentives to use it to enhance quality and reduce disparities, is likely to be critical to continued progress by health plans working on these priorities.
AHRQ's Investment in NHPC Resulted in Important Organizational Changes Within Participating Firms
As a Federal agency, AHRQ took a risk in supporting the NHPC by entering into a partnership with organizations it could influence but not control on an important issue (disparities) at a time when the health plan role and perspective still were unformed. In hindsight, initial expectations, at least from the sponsors, probably were unrealistic. The NHPC's work resulted in organizational change, but the impact of such change on people served by health plans is still not felt fully. Future progress is likely to be driven by external requirements as much as voluntary efforts. Yet the NHPC arguably paved the way for future change and helped to create a base that will support those efforts well.
Sponsors' limited support generated many times that investment among NHPC firms in staff and systems work on disparities. Through their work on the NHPC, firms also became more committed to reducing disparities and modified their organizational structures to institutionalize these concerns. The NHPC also enhanced communication and information sharing across firms in the industry and generated an increased appreciation across public and private partners about the complexity of participating firms and how they work. The partnership of the NHPC therefore can be viewed as a timely investment that generated knowledge, commitments, and channels of communication that will provide a valuable basis for building future work on disparities.