Chapter VIII. Accomplishments, Sustainability and Insights for Phase II
Evaluation of a Learning Collaborative's Process and Effectiveness to Reduce Health Care Disparities Among Minority Populations
A. Main Accomplishments and Their Sustainability
At the start of our evaluation, a participant suggested that the Collaborative would be a success if the firms all were still participating at its conclusion "They all stayed," another participant observed at the end of the Collaborative. Sponsors and support organizations can take pride in the fact that the Collaborative remained intact despite several events that could have shattered it. Yet, to a certain extent, it is not surprising that firms remained in the Collaborative—firms tended to perceive the costs of participation as relatively low in relation to the risks associated with dropping out. As one firm participant remarked, "No one wants to be left behind. That's a strategic disadvantage." While firms' continued interest in the Collaborative is a positive sign, it is important to look more substantively at the effort, what it accomplished, and how sustainable these activities will be.
The previous chapters have provided considerable detail on what was and was not accomplished through the Collaborative. We have drawn four major conclusions about what the Collaborative has accomplished with respect to reducing racial and ethnic disparities. These are:
- Increased organizational attention and commitment to disparities as part of the quality agenda for health plans.
- Growing recognition among firms that collecting primary data on member race/ethnicity is critical to making progress.
- Limited progress in learning more about how to alter care for patients in ways that will reduce disparities and especially in applying knowledge to alter care delivery.
- Increased awareness among diverse staff from sponsors and support organizations about how firms work in ways that are relevant to understanding their contribution to reducing disparities.
We discuss each of these below.
1. Organizational Commitment to Addressing Disparities
Members of the Collaborative participated as official representatives of large organizations, which contributed to their ability to influence organizational commitments to disparities. All of the firms participated with the support of their senior leadership, designated well-placed senior staff to serve as liaisons, and involved their traditional reporting structures to keep executives aware of their efforts.
Most firms used their existing organizational channels to address concerns relating to disparities, but the Collaborative also encouraged some of them to enhance their organizational structures to more effectively deal with disparities. Before the start of the Collaborative, two of the five national firms had modified their structures to help foster attention to disparities—one had established a firm-wide disparities taskforce reporting to the CEO, the other a Cross-Cultural Care and Services taskforce under medical leadership. The Collaborative reinforced these structures. Using the Collaborative as an impetus, a third created an informal mid-level staff workgroup that sought to develop support for and initiatives addressing disparities. Of the four regional firms, two formed interdepartmental committees/taskforces to address disparities and culturally and linguistically appropriate care, and at least two had briefed or planned to brief their Board of Directors on progress in meeting disparities objectives. Another institutionalized its disparities work by moving it from its "incubator" research and development department to its Office of Medical Affairs.
These structures—together with firms' increased recognition of disparities issues, via their participation in the Collaborative and other factors—should sustain interest. While the Collaborative focused only on diabetes, firm responses suggest that insights about disparities in diabetes care are influencing their care delivery in general.
However, there are challenges to sustainability, particularly stemming from the environment and the instability within the industry. All firms viewed the tight fiscal constraints imposed by the health care market as influencing their decisionmaking, although some are better positioned fiscally than others. Leadership turnover and change is also common in the industry. For example, one national firm's participation in Phase I was limited because of a merger and staff turnover, two others are now dealing with CEO turnover. Such turnover has the potential to reduce organizational knowledge of the Collaborative's work, slow decisionmaking, and modify priorities. Firms whose commitments have been translated into permanent change—for example, in data collection procedures or standard programming—are likely to be better positioned to maintain their progress, although further progress may be more challenging. Because not much as been publicized about the Collaborative to date, the cost of slower progress may not be as high as it would be if external expectations were higher. This could change as plans to increase awareness of the Collaborative become implemented.
2. Primary Data to Better Identify Disparities
As a result of the Collaborative, firms more strongly believe that primary race/ethnicity data are important in supporting quality improvement efforts that take into account the diversity in their enrollment. All but one of the firms now say their goal is to capture race/ethnicity for all members, and the latter firm is capturing it for selected patients in disease management programs. The geocoding/surname analysis experience in Phase I played an important role in helping firms develop a broader-based acceptance of the existence of disparities. It also highlighted to firms what geocoding could do (general patterns) and what it could not (member-specific identification to support interventions, or identify patterns of disparities when residential patterns are not highly concentrated by subgroups).
Despite what has been accomplished, there remains a large gap between what firms have done and what they ultimately seek to do. For example, one leading firm still has member race/ethnicity data for only a relatively small proportion of members, despite several years of concerted data collection. Two of the firms committed to collecting race and ethnicity data have not yet determined how to do so, and a third will not start until at least 2008, when its new IT system is in place. Firms seem to have an easier time collecting data on small subgroups of enrollees—those who visit portals or are in disease management—than obtaining more universal data for their entire enrollment, or sufficiently complete data in geographical areas to calculate rates and proportions (which is essential to geographic analysis). Most firms appear to feel it necessary to capture such data via their employer groups or from members, because working with providers will be difficult. Even those with affiliated providers face data collection challenges absent a strong push from management. Furthermore, because organizations are large, those that have data may not store it in such a way that it is accessible to other divisions and people within the firm. Phase II will prioritize supporting firms in primary data collection but the challenges—technical, organizational, and political—should not be underestimated.
Because of the time it takes to generate useable primary data on race/ethnicity, some firms plan to use geocoding/surname analysis to benchmark change by geographic area or further identify locations for disparity-oriented interventions. Firms used RAND support and methods in Phase I. While RAND will continue to make some tools available in Phase II, firms seeking individual assistance will have to enter into individual contracts with RAND, as external resources to support this are not available. The transition poses a structural barrier to sustainability. At least one firm has purchased its own software and plans to continue internal efforts, although it remains to be seen whether issues of consistency arise. Three others have or are considering contracting with RAND for some ongoing support or training to complement their internal efforts. In retrospect, it could have been valuable to consider earlier how to institutionalize firm capacity to address these issues, although firms seem to be making their own arrangements.
3. Limited Progress in Identifying and Implementing Interventions
During Phase I, firms made at best limited progress in modifying their care processes with the goal of reducing racial and ethnic disparities. Pursuit of interventions to reduce disparities took a back seat to data collection efforts for most of the Collaborative. As firms gained insight on disparities, they began to think more concretely about what they, as firms sponsoring health plans in diverse ways, could do to reduce disparities.
By the end of the Collaborative, seven of the nine firms had either completed or were in the process of completing pilot interventions, and two were in the process of developing them. Consistent with the Collaborative's focus, all of these interventions targeted primarily race/ethnic minority members with diabetes; four firms focused on Hispanic members and the others other subgroups. Most pilots were small, although size varied, and the approaches differed markedly across the firms, as described in the report. At the time of this evaluation, it was too early for most firms to assess the outcomes of their interventions. Still, most perceived that these pilot programs created a framework for future expansion and learning, and planned to pursue related interventions after the end of Phase I.
Firm progress in pursuing interventions was challenging for a variety of reasons. First, firms were uncertain where to begin, citing uncertainty about how they best could intervene to fill the gap. Second, firms were constrained by lack of data, as many interventions require knowing the race/ethnicity of particular members and most require at least an ability to geographically target. Third, the scale and complexity of firms created challenges to implementing effective interventions that could leverage the diverse functional systems in the firm and the split between corporate and regional responsibilities. Fourth, logistical issues, such as recruiting physicians to participate in provider-based interventions, were a challenge.
Perhaps the Collaborative's most significant contribution to care delivery was that it increased firms' awareness of the role disparities play in the quality improvement agenda. By the end of the Collaborative, firms typically saw this connection, rather than viewing addressing disparities as an additional or separate activity. Still, firms were constrained by the tight fiscal environment in which they operated and the competition for resources. Firms viewed building a business case for working on disparities as important to securing resources to address the issue, as well as for quality improvement.
4. Enhanced Industry Knowledge in Staff with Sponsor/Support Organizations
Although some key staff in sponsor and support organizations felt that their experiences in the Collaborative were consistent with their understanding of firm behavior, others openly acknowledged that they learned a great deal about the industry through the Collaborative. In most cases, the latter group of participants had more experience with provider-based organizations (or government research) than with complex health financing organizations like those in the Collaborative. These organizations were surprised by the severe limitations in available race/ethnicity data and the challenges in collecting it, as well as the organizational and other barriers within each firm and between it and the provider community. Conversely, participants were positively impressed with the interest and commitment to quality improvement among firms participating in the Collaborative. They also came to understand why many firms preferred member interventions to those focused on providers, as well as the reasons that progress was slow and efforts typically long-term. (Although they were not necessarily convinced that the trade-offs between this kind of focus and others made sense.) As a result, sponsors and support organizations developed a greater understanding of why firm goals typically relate more to policy changes than to changes that actually benefit patients immediately and directly. However, many still viewed provider-based organizations as more immediately relevant to reducing disparities.
Contribution of Communications. The communications and dissemination infrastructure was an important development in Phase I of the Collaborative. While many participating organizations agreed that there was relatively little to communicate in the first phase, GMMB's communications work was important in presenting a standardized and consistent external message about the Collaborative. Moreover, much of the Phase I communications activity—the development of a logo and other NHPC materials and the establishment of a core message, for example—has provided a foundation for Phase II work, when the Collaborative may have substantively more activities and result to report.
B. Future Plans for Phase II
To encourage continued attention to concerns over disparities, sponsors have decided to proceed to a second phase for an additional two years. The support infrastructure will be streamlined with a single contract (from AHRQ) to CHCS, with RAND serving as subcontractor. (RWJF will continue to be a co-sponsor and responsible for communications.) While many details are yet to be determined, the intent is that the Phase II objectives will be clearer than those of Phase I, with a focus on particular activities that firms agree are important. Not all of the firms participating in the Collaborative will necessarily be involved in each Phase II activity, but the foci for attention in Phase II are to be:
- Development of approaches to primary data collection on race/ethnicity.
- Collective work on ways to enhance language access in the national and local markets.
- Creation of the business case for work in this area, both nationally and within firms.
- Information exchange, both among participating firms and with other stakeholders.
- Communications related to the accomplishments of Phase I.
Details defining these objectives are still being developed, as are agreements with plans on how success will be measured.
C. Insights Relevant to Phase II
The Phase I experience suggests that continuing the Collaborative will be valuable to firms in sustaining and expanding the accomplishments to date. As one participating firm observed, the Collaborative serves as "the external cattle prod that keeps us moving." Given the external pressures on firms and the competition for resources, the Collaborative will encourage firms to continue to focus on disparities and provide a platform for sharing experiences, successes, and, if they choose, failures. This alone will be valuable to firms seeking insight and support.
However, there remain significant challenges to a successful Phase II, particularly if success is to be measured in terms of concrete accomplishments. While the activities firms have agreed to pursue in Phase II may appear more concrete and defined than those of Phase I, that clarity is to some extent misleading. While topic areas for Phase II have been defined, many details remain unclear and significant effort will still be required to drill down into the details of each topic. Moreover, from our observations of the process through which the specific areas of focus (primary data collection, language access, and the business case) were defined, we believe it will take strong leadership to move participating firms forward in a direction that they take ownership of and find useful, and that also makes progress on work that is both substantively and operationally clear and doable. The fact that firms themselves decided on Phase II activities—even though they require additional definition and specificity—likely increases the extent to which firms feel invested, at least at this stage. However, commitment will carry the work only so far, unless it can be leveraged to develop, implement, and succeed in specific substantive accomplishments.
In seeking clarity, sponsors and support organizations need to be realistic about what they can accomplish with the resources they have made available and those that firms can generate internally. On one hand, keeping all stakeholders engaged requires a broad focus, because each firm has its own priorities. On the other, to the extent that the focus is on broad, collective accomplishments rather than a process focused mainly on supporting communications among firms, only so much can be done. Although a conscious effort was made to limit the number of explicit activities in Phase II, there may be a natural tendency to handle differences of opinion among Collaborative members by expanding the scope of efforts to include all ideas instead of making strategic choices among competing priorities. As we read the scope for Phase II, such "scope creep" is reflected in defining goals to have national and market components (primary data, language access). Similarly the work to define business case for reducing disparities has been defined broadly at both the macro and firm business levels—referred to in Collaborative discussions as "Big B/little b" needs (each of which has its own set of complicated measurement and design issues). Beyond the specific objectives of concern to the task force, the Collaborative will have to invest in enhancing general information sharing and perhaps strengthening the substantive content of support in a number of areas. If these tasks all tap the same resources from firms and support organizations, there is a risk that none may be done well.
We also are concerned that too high a share of the resources available to the Collaborative have, in the past, been devoted to coordination rather than substantive analysis linked to other external efforts and scientific knowledge of the available evidence/state of work in each area. For example, in focusing on primary data collection, the Collaborative will need to identify how its efforts interface (if at all) with providers and/or purchasers and how they relate to existing efforts at standardization, such as Office of Management and Budget (OMB) or state requirements regarding collection of racial/ethnic data.
Because sponsor and support organizations have urged us to provide as much insight as possible on what we suggest with respect to Phase II, Table VIII.1 describes the areas we see as most critical in shaping Phase II, recognizing that there are a variety of relevant perspectives that can be brought to this task. These recommendations focus on developing targeted goals under each topic area in Phase II (including an outcomes-oriented approach to Collaborative meetings and conference calls) and not allowing the focus in each area to become too diffuse over time, which could result in less interest on the part of individual firms and/or in the Collaborative as a whole trying to move in too many different directions.
In conclusion, the Collaborative has enhanced firm interest in effective interventions to measure and address disparities. However, there remain many challenges in designing and supporting such measures and interventions, and many political, organizational, and market factors to consider. We encourage participants in the Collaborative to assess their priorities and lessons learned from Phase I as they continue to work on this important issue.