The Structure of Regional Health Improvement Collaboratives
To be successful, the roles that Regional Health Improvement Collaboratives play need to be performed with the full support and trust of all of the key stakeholders in health care:
- healthcare providers, i.e., physicians, medical practices, hospitals, and health systems;
- healthcare payers, i.e., health insurance plans and public programs such as Medicaid;
- healthcare purchasers, i.e., employers who purchase health insurance for employees; and
- healthcare consumers and organizations representing consumer interests.
The best way to ensure the support and trust of these stakeholders is to have them actively engaged in the governance of the organizations delivering the functions, as Regional Health Improvement Collaboratives do.
Because Regional Health Improvement Collaboratives go by many different names, it can sometimes be hard to distinguish them from other organizations at the national, state, and local levels that develop or implement programs designed to improve the quality and control the costs of healthcare, such as Medicare quality improvement organizations (QIOs), business health coalitions, regional health information exchanges, consumer health coalitions, medical societies, hospital associations, etc. The key differences between Regional Health Improvement Collaboratives and most of these organizations is that the Collaboratives are governed by individuals and organizations from all four of the key stakeholder groups, and the Collaboratives address quality and cost issues across a broad range of patients and providers. This is why Collaboratives are referred to as "multi-stakeholder" rather than merely "multi-member" organizations. Other differences are that most Regional Health Improvement Collaboratives establish their direction through consensus among their members and implement their efforts through voluntary cooperation of the members, rather than through government mandates, financial rewards or penalties, etc.
Beyond this, however, no two Regional Health Improvement Collaboratives are structured exactly alike. Collaboratives are very diverse in terms of their goals, structure, and programs because of the differences in the number, structure, and capabilities of the purchasers, payers, providers, and other community organizations in their local regions.
- Some Regional Health Improvement Collaboratives had their origins in efforts among healthcare providers to work collaboratively to improve the quality of care they were delivering, and then they evolved over time to involve a broader array of stakeholders. For example, one of the first Regional Health Improvement Collaboratives, the Institute for Clinical Systems Improvement (ICSI) in Minnesota, was established in 1993 by three healthcare systems (HealthPartners, the Mayo Clinic, and Park Nicollet Health Services); today, the majority of the members of the Board of Directors are physicians or staff of medical groups, but there are also representatives of health plans and consumers on the Board.
- Other Regional Health Improvement Collaboratives were initially formed through the efforts of health plans or businesses in the community seeking ways to control increasing healthcare costs or to address concerns about healthcare quality in the community. For example, both the California Cooperative Healthcare Reporting Initiative and the California Quality Collaborative are multi-stakeholder Regional Health Improvement Collaboratives, but they were formed through the leadership of the Pacific Business Group of Health (PBGH), a major business health coalition based in California, and they continue to be housed at PBGH. In some cases, the Regional Health Improvement Collaborative also serves as the community's health purchasing coalition. For example, both the Maine Health Management Coalition and the Puget Sound Health Alliance are multi-stakeholder collaboratives, but their policy requires that a majority of the members of their Boards of Directors be healthcare purchasers.
- Still other Regional Collaboratives were formed from the beginning as multi-stakeholder efforts. For example, the Pittsburgh Regional Health Initiative (PRHI) was formed in 1997 as a community organization with representation from a wide range of groups that were interested in advancing health care quality - hospitals and physicians, health insurance plans, major employers, consumers, academics, foundations, local government, and civic leaders.
Some regions have two or more Regional Health Improvement Collaboratives. In these communities, one of the organizations typically takes responsibility for collecting and reporting on various measures of healthcare quality and/or cost, while another carries out initiatives designed to help healthcare providers improve performance on those measures.
As a result of this diversity, communities which do not have a Regional Health Improvement Collaborative but want to form one have a variety of models to choose from. Since a common element of all Collaboratives is their multi-stakeholder structure, the most important first step in establishing a Collaborative is for leaders from each stakeholder group to seek out leaders from other stakeholder groups and reach agreement that the interests of their communities would be served best by having all stakeholders working collaboratively toward improving healthcare quality and reducing costs.
Although state governments will be playing an increasingly more central role in healthcare reform in the future, partly as a result of the programs in the 2010 federal Affordable Care Act, this does not mean that Regional Health Improvement Collaboratives will no longer be needed. While the regulatory powers and financial resources of state governments give them some unique strengths, such as the ability to mandate the submission of quality and cost data by providers and payers and the ability to provide anti-trust safe harbors to help establish multi-payer payment reforms and help independent providers coordinate their services, there are also important limitations on the ability of state government to carry out key functions successfully, such as:
- the difficulty of supporting multi-year healthcare transformation efforts through changes in state administrations and changes in fiscal priorities;
- the difficulty of balancing regulatory enforcement powers with programs to facilitate provider improvement; and
- the difficulty of customizing state programs to reflect the diversity of regional healthcare markets within large states.
In contrast, the independence and stakeholder governance of Regional Health Improvement Collaboratives provides greater ability to support providers through multi-year transformation efforts and to do so in a way that can be adapted to the unique needs of individual geographic regions. Consequently, the greatest success in healthcare transformation will likely come from strong partnerships between state governments and Regional Health Improvement Collaboratives.