Chapter III. Firm Perspectives on Disparities and Commitment to the Collaborative
Evaluation of a Learning Collaborative's Process and Effectiveness to Reduce Health Care Disparities Among Minority Populations
This chapter describes the relationship between the Collaborative and participating firms' commitment to the issue of racial and ethnic disparities—one of the four main outcomes of interest to this evaluation. The conceptual framework views gaining and enhancing such commitments as a critical first step in collaboration. (Go to the top boxes in Figure III.1.) For the most part, the findings in this chapter are based on what firm staff reported in the second round of interviews. However, at the end of the chapter, we discuss how participating in the Collaborative influenced the firms' overall perspectives and focus on disparities.
A. Overview of Key Findings
Firms said that they decided to participate in the Collaborative for a variety of reasons, including the national importance of racial/ethnic disparities, their interest in learning about the issue, their perception that collective action might be more efficient than individual action, and their ability to use participation to gain internal leverage or address more "mundane" organizational goals. The firms that participated in the Collaborative did so with the support of senior leadership. In fact, the senior leaders of each organization monitored the Collaborative's progress, which reflects the importance of the issue to the firm. In most firms, buy-in to the Collaborative or work on disparities appeared relatively concentrated among senior leaders. Because such leaders set the tone and agenda for an organization, this was by no means a trivial achievement. However, support from leaders did not necessarily mean that the buy-in carried over (at least during the study) to the many operational or geographical units within these complex organizations.
The Collaborative is not the only way in which the nine firms address disparities. Some had work that preceded the Collaborative; others said their participation put the issue more firmly on their radar screens. Firms with ongoing initiatives on disparities viewed the Collaborative through the lens of those pre-existing activities within the firm that defined the short-term organizational priority. Some firms said that the Collaborative was only one of many external efforts involving disparities.
Firms cautioned that their ability to invest in the Collaborative's activities was constrained by a variety of organizational considerations. The effort firms were willing to invest in part reflected the degree to which they viewed the Collaborative's focus as aligned with their own agenda and needs, and the degree to which they could balance work across competing objectives. For this reason, they urged that their organizational commitment should not be judged solely by the resources invested in the Collaborative.
The overall effect of the Collaborative on commitments to reducing disparities appears positive across all firms, although it is hard to quantify. Firms reported that rather than changing their perspectives on disparities, the Collaborative increased the visibility of the issue within the firm. However, in the case of a few firms with major organizational changes or strong competing commitments, it seems unlikely that these firms would have continued their work to reduce disparities had they not participated in the Collaborative. The fact that the firm would be judged externally (by the Collaborative) based on what they did enhanced the priority of action within each firm. The Collaborative was also viewed by many firms—especially those with the least prior focus on disparities—as enhancing the breadth of knowledge, interest, and commitment to work in this area across the firm. For the most part, such work was regarded as an integral part of quality improvement.
B. Why were Firms Participating?
The firms in the Collaborative became involved through a variety of routes (Appendix B). Many of the national firms had been involved in earlier collective activities around disparities, thus making their participation in the Collaborative a natural next step. A few firms had established leadership positions in the field such that their involvement was inevitable and expected. Some became involved by circumstance—for example, a connection with one of the sponsors or support organizations.
While participants' histories and particular interests varied, our interviews point to five major reasons behind firm interest in the Collaborative (Table III.1). Typically, more than one reason drove firms' interest.
First, disparities are an important national issue. Hence, firms saw work in this area not only as "the right thing to do" but also an important business consideration to ensure that the products they offered addressed the increasingly diverse needs of the populations they sought to serve. Many firm leaders had been heavily involved in other national efforts to address disparities.
Second, working collaboratively rather than individually was viewed by firms as efficient both in communicating information and in gaining political support for shared objectives that require broad-based consensus—such as standardized methods of capturing race and ethnicity. Collective work also provided a certain amount of "cover," protecting firms concerned with adverse legal or other consequences associated with collecting data on the racial and ethnic characteristics of their members.
Third, firms believed a Collaborative was a good way to find out more about disparities and how to measure and to reduce them. They also wanted to understand what others were doing and benchmark their own activities against emerging national practice.
Fourth, some firms or staff had internal goals that could be advanced by participating in the Collaborative. All of the firms in the Collaborative are complex organizations with competing interests. Senior executives with an interest in reducing disparities participated in the Collaborative in order to enhance firm commitment to and support for the issue. Sometimes, especially in smaller organizations, mid-level staff with a strong interest in the issue championed firm participation.
Fifth, more "mundane" considerations made participation attractive. Some firms perceived that they got involved because their participation was solicited by AHRQ, a request that was hard to decline. Participation could advance firm objectives—for example, create an image of the firm as a national player—or have the additional value of documenting work consistent with the firm's nonprofit status.
C. What did Firms Hope to Achieve?
Interviewees from firms said that it is inappropriate to look at a firm's involvement in the Collaborative in isolation from its other ongoing work in disparities and elsewhere. While our analysis suggests that participation may have enhanced firms' commitment to addressing disparity issues, firms noted that the Collaborative's leaders should not assume that the Collaborative generated initial concern for the issue or was the only source of motivation. The participating firms were large companies that were involved in many collective activities, including work on disparities through their trade associations, quality alliances, and other coalitions.
Organizational context influenced firms' perceptions of what they hoped to gain from participation in the Collaborative. For example, firms that perceived themselves as already heavily invested in quality improvement might see fewer gains through learning from others or undertaking pilot interventions; for them, the Collaborative often made it easier to capture racial and ethnic data on members. A firm whose business was heavily based around racial/ethnic minorities perceived that it had more to share than learn, and was comfortable with that. There were several firms with existing internal initiatives to address disparities, and they perceived that following up on these priorities took precedence over new projects that might be spurred by the Collaborative.
The context of the Collaborative also influenced the resources firms could or wanted to make available to Collaborative activities. All of the firms involved in the Collaborative invested heavily in quality improvement and disease management, though their strategies varied, and some placed more emphasis on these areas of concern than others. In addressing disparities, they sought to build on these ongoing structures and strategies (as reflected in their approach to data collection and pilot interventions) rather than initiate new activities. In many instances, firms faced major organizational constraints on the resources available for participation in the Collaborative, particularly when dealing with challenges such as mergers, emerging from bankruptcy, or multiyear efforts to reconfigure their entire information systems platform.
In sum, our interviews suggest that each firm participating in the Collaborative wanted to be involved in the meetings and communications with one another and perceived that doing so would have important benefits for it and its work on disparities. Beyond that, firms had their own agendas and priorities, all of which influenced their capacity to support the Collaborative's work and their interest in doing so with specific projects. These differences were apparent from the start of the Collaborative and were important in understanding firms' evolving responses to the requests of the Collaborative. The core principles stated by AHRQ in its Memorandum of Participation appeared more central to AHRQ staff than to the firms participating in the Collaborative. (None of the firms interviewed mentioned the principles explicitly when discussing their involvement in the Collaborative.) By agreeing to participate in the Collaborative, firms may have agreed to a limited statement of goals, but were more likely to feel that they were agreeing to work together to share information on disparities and use it in ways that would be valuable within their organizations.
D. How was Firm Leadership in the Collaborative Positioned Within Each Organization?
Senior staff members led each firm's work within the Collaborative, reporting to senior managers in different locations at the top of each organization. Below, we review how firms positioned their linkages to the Collaborative and the implications for communications and reporting. We then discuss the implications of the leadership and communication structure for work on disparities throughout the firm. Some firms were more forthcoming about their internal operations than others. We avoid presenting details that would reveal aspects of internal operations that firms likely regard as sensitive and not publicly shared.
1. Organizational Location and Communication
In all cases, a firm's lead contact for the Collaborative was a high-level senior executive with direct access to senior firm leaders. Leaders varied across organizations; linkages to clinical leaders were more common than linkages to other leaders or the CEO. In addition, some lead contacts delegated day-to-day responsibility for work with the Collaborative to other staff in the organization. Such delegation appeared to increase in the second year of the Collaborative as firms took on more activity under pilot interventions.
Table III.2 describes some of the ways each firm structured its participation in the Collaborative. In four organizations, lead contacts reported to the medical leadership; in two other firms, lead contacts had dual reporting lines, involving both clinical leadership and health plan administration. In organizations where the lead reported to the CEO, the lead or CEO was a physician. In the one instance where the lead reported to an administrative executive in charge of marketing, the lead contact was selected because of extensive work with vulnerable populations; the lead receives support from a clinical staff member from within the organization. The differences in placement of liaisons to the Collaborative reflected internal characteristics of how different firms worked and did not appear to have hindered external efforts at collaboration, especially when all firms' liaisons had stature, seniority, and access to top leadership.
The work of the Collaborative appears to have been well communicated within the top leadership circle. All firms in the Collaborative kept at least some of this circle informed about the Collaborative, and some did so for a wider group. Leads regularly briefed the person(s) they report to about the Collaborative, and the latter seemed to sign off on key decisions. The leads reported to staff who often reported directly to the CEO and sat on major executive committees of the organization. In some firms, the Collaborative lead periodically briefed the executive leadership on the initiative, sometimes at length. Three firms had established ongoing organization-wide taskforces or groups to support their disparities work, at least two of which formed before the Collaborative; lead staff from the Collaborative were actively involved in such taskforces. In each of the other firms (and perhaps these three as well), the degree of reporting on the Collaborative varied with the relevance of the Collaborative to other activities underway in the organization. Communication was broader in firms where the Collaborative was directly helping to drive the agenda than in firms where it was not being used that way (perhaps because the organization was already moving in a given direction to address disparities at the time the Collaborative was formed). A few firms seemed to have more limited communication on the Collaborative with senior leadership because the work of the Collaborative did not closely match perceived leadership needs. In these cases, disparities might still be important, but not in a way that the Collaborative could or would address.
2. Organizational Complexity and the Implications for Communication
It appears that a relatively small circle of individuals from all or at least most firms knew about the Collaborative, although a broader set of people may be included in a firm's disparities work. Those involved in the Collaborative are high-level managers who helped drive organizational priorities. Thus, their participation in and support of the Collaborative were likely to influence firm behavior. However, broader communication and support for strategies that addressed disparities were necessary if firms were to eliminate racial/ethnic disparities. Several reasons probably explained why knowledge of the Collaborative might not be more diffused throughout the firms.
First, the firms are large, and it takes time to share information and develop buy-in across the organization. It was notable that the Collaborative—or at least the issue of disparities—was on the radar screen of at least some of the top leaders of participating firms.
Second (and as discussed later in this chapter), clinical interests defined the focus of early work of the Collaborative and thus these leaders were more aware of the Collaborative. The business sides of the organization—finance, marketing—have interests in the issue of disparities but frame the issue differently or do not place the same priority on this work without a push from senior leaders. Firms that had been involved most extensively in addressing disparities created cross-organizational structures to engage diverse components of the organization in supporting work to resolve disparities.
Third, the least centralized firms had a harder time implementing change. At least two of the national firms, for example, were heavily decentralized in assigning responsibility for care delivery and decisionmaking. Despite national firm leadership's encouragement of consistent national strategies, tensions between national and regional interests and priorities remained. Thus, even if both central and regional leaders agreed that disparities were an issue, each level may have had its own perspective on the primary actions to take; moreover, communications between central and regional efforts (or across regions) may have been incomplete. Thus, one firm moved much more slowly and cautiously in developing interventions than its national leadership might have wished, while another concentrated most of its early work in a state within one of its three core regions where support for such intervention was strongest.
The challenge of broad-based communication and buy-in was an issue for most firms, not just the largest or the least centralized. Most firms reported many steps between policy and execution. When firms took concrete steps toward implementation as part of the Collaborative—whether data collection, geocoding/surname analysis, or piloting interventions—additional staff were likely to become aware of the Collaborative. Nonetheless, given the scale of the firms in the Collaborative, such diffusion takes substantial time, and small-scale pilots were likely to touch only a small number of staff in the organization. The challenge, therefore, was to maintain the interest of senior leaders who set the tone and focus for an organization and to support a broader agenda that aimed not just to test change but also to introduce it across the organization.
E. What were Firms' Perspectives on Disparities?
A focus on disparities took many forms within the participating firms. Indeed, the challenge for top leaders was to harness for mutual benefit the interest in disparities as conceived across the operational units of each firm. This section examines three ways in which disparities were relevant to firms; these emerged in our round two interviews.
1. Firms as Employers and Large Organizations
The nine firms participating in the Collaborative were large organizations employing many people. Both legal requirements and internal interests meant that the firms were becoming increasingly attuned to the diversity of their workforce. Each firm wanted to understand its workforce and make certain that firm policies were culturally appropriate. Several of the organizations employed diversity officers whose main interest was in workforce diversity. We interviewed some of these officers and found that they think about disparities largely from the perspective of human resources, with little or no involvement in the organization's care delivery or quality improvement functions.
A few firms built on their role as an employer to support their interests in disparities and work with the Collaborative. Given that firms purchased health care for their employees, they were positioned (albeit not without challenges) to capture self-reported employee race and ethnicity data. As employers, the firms also stood to benefit from improved health outcomes resulting from interventions intended to reduce disparities. Firms also stood to generate good will by providing culturally appropriate care. Thus, the firms' role as purchaser with a large workforce provided an opportunity for some to target initial work on disparities within a subset of the commercial population—firm workers and dependents covered by the health plan.
Firms also viewed reducing disparities as an important part of their role in working within the community or broader environment. For example, one large firm was proud of its work in supporting nursing scholarships and a leadership academy to further diversity in the workforce. A regional firm emphasized its CEO's involvement with other influential business and political leaders in a coalition pushing for coordinated regional economic development that could reduce the area's socioeconomic disparities. Another proudly cited its effort with community colleges in 17 states to raise certification rates for bilingual students seeking medical careers. Several participants in the Collaborative noted that their internally funded foundations—while typically not involved in the Collaborative—supported broad-based community-focused efforts relevant to the issue of disparities. In at least one case, the firm aimed to link its member-focused strategy for diabetes to community-based interventions targeting these broader goals through work in local pharmacies.
2. Disparities and Firms' Quality Improvement Agendas
The round two interviews showed that interest in disparities was linked more closely to quality improvement than to any other firm function and disparity initiatives tended to fall under the purview of the organization's clinical leadership.
Each of the firms in the Collaborative saw quality improvement and reducing disparities as related, but differed in how they conceptualized the relationship. In their comments on this issue, some firms seemed to describe tension between the two concepts, noting that disparities, especially in health care outcomes (but also in health care processes), were influenced by a far broader variety of factors than firms could influence—for example, socioeconomic status and environmental health behaviors. In fact, some firms were concerned that efforts to address disparities would leave them overly accountable for outcomes beyond their control. When we asked senior leaders to comment on the relationship between reducing disparities and improving quality, their responses suggested that there were at least two views of how disparities relate to the quality agenda (Table III.3).
One view held that reducing disparities translated into high-quality care through concern with providing culturally appropriate care. Such a definition led to an interest in training providers, making interpreters available, and implementing other initiatives that enhance care systems' ability to meet user needs. A related view was that disparities are an example of a more general need for market segmentation to identify variables that differentiate people so that each group's needs can be met.
These views can be distinguished from another view that focused less on variables that differentiate people's characteristics and more on means to address the distribution of outcomes in improving quality. From this perspective, raising average quality was critical; the disparities in outcomes were less relevant than the fact that some outcomes are unacceptably low, regardless of the amount of disparity. Those with this view were probably more comfortable with quality improvement initiatives targeting areas of low performance than with race- or ethnicity-focused initiatives. Firms that appear to put more emphasis on quality improvement in positioning their products and plans were more likely than their counterparts to hold such a view.
We think that there is a link between a firm's view of disparities and the strategies they pursued to address them—including, for example, a focus on clinical versus social factors, the importance firms attached to capturing race/ethnicity data on all their members, and how they allocated their investments in quality improvement.
3. Disparities as an Opportunity or Threat to Marketing
Most firms explicitly stated that they wanted their membership to grow over time. Stagnant membership is almost always a problem because those who are continuously enrolled inevitably age and use more care. Unless a firm is able to attract new members, it may experience adverse selection and/or find its products priced out of the market. In addition, many firms viewed growth as an important business goal that could satisfy investors or reinforce other organizational goals.
Firms were particularly sensitive about reporting racial and ethnic information, particularly for African Americans, among whom a history of discrimination has led to high levels of distrust. Health plans often perceive that collecting racial or ethnic data before enrollment is illegal or will be viewed negatively by policymakers concerned that such data would lead to discrimination; our interviews uncovered evidence of this perception. In almost all cases, firms that did collect racial/ethnic information emphasized that it was voluntary. In approaching members for information, the firms sought to use sources that enrollees would regard as trustworthy and likely to use the information for the member's benefit. For example, firms tended to regard provider requests more favorably than plan administrative requests because patients might regard the former as more in their self-interest.
Yet, despite barriers to collecting racial and ethnic information, we found that marketing departments were very interested in using such data to enhance their success. Marketing staff used a different language from that of staff involved in quality improvement. Our interviews indicated that marketing staff saw their mission as member service. They viewed racial and ethnic subgroups as market segments to contact. They also indicated that membership was more likely to grow if they could show that interested members would know or be shown how to use health plans' systems. In the words of one marketing director, "'Ethnic marketing' is to marketing what disparities is to quality improvement." Firms that invested in addressing disparities said they did not do so for marketing purposes, but recognize that their investments allowed them to convey to purchasers their interest in serving all the diverse members of their workforce.7They said employers were more interested in a firm's capacity to respond to employees in different languages, for example, than in the finer nuances of quality improvement. They felt these interests would grow in importance as the United States population became more diverse. At the same time, they also said that "rates, product, and network" were dominant in driving the employer market and that only the most progressive employers were directly concerned with the issue of disparities.
F. What Effect Did the Collaborative Have on Firm Commitments to Addressing Disparities?
Because our evaluation began midway into the Collaborative, it is not possible to judge in full how firm perceptions changed over the course of the entire Collaborative. However, in our round three interviews, we asked firms' lead contacts and senior executives for their thoughts on this issue, and whether the Collaborative had any particular adverse effects on the commitment to reducing disparities. Eight of the nine firms participating in the Collaborative were part of this final round of interviews.
As lead contacts and other senior executives noted, their firms were aware before the Collaborative of disparities and the importance of addressing them. Yet the issue was more important to firms at the end of the Collaborative.
The shift was particularly striking in firms with the least emphasis on disparities before the Collaborative. One large national firm said that while its perspectives on disparities did not change, such perspectives were "more diffusely known throughout the organization," with staff aware that further quality improvement meant addressing disparities. Another firm, which integrated disparities into their disease management program after the start of the Collaborative, noted, "This is not 'side of the desk' stuff anymore.... It's incorporated into the way we do business and not a project or a pilot anymore." One firm that was already working on disparities said that its work would have gone a bit slower without the Collaborative. As another regional firm put it, "No one wants to be left behind." Even those that did not acknowledge any direct influence of the Collaborative described changes that seemed to derive from the work of the Collaborative—for example, starting to look within their minority populations at subgroups, taking steps to begin collecting primary data on members' race/ethnicity.)
As discussed further in Chapter VIII, firms typically expressed a desire for the Collaborative to continue beyond Phase I.Even though most felt that they would progress on their own, external collaboration reinforced these efforts and helped firms' efforts continue, despite the many competing priorities.