The Structure of Regional Health Improvement Collaboratives

To be successful, regional health improvement collaboratives (RHICs) work with the support and trust of all of the key stakeholders in healthcare:

  • 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 RHICs do.

Because RHICs 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. The key differences between RHICs and other healthcare organizations is that the RHICs are governed by individuals and organizations from the four key healthcare stakeholder groups, and address quality and cost issues across a broad range of patients and providers. This is why RHICs are referred to as “multi-stakeholder” rather than merely “multi-member” organizations. Other differences are that most RHICs 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 RHICs  are structured exactly alike. RHICs are diverse in terms of their structure and programs because of the differences in the number, structure, and capabilities of the purchasers, payers, providers, and other organizations in their local regions.

  • Some RHICs had their origins in efforts among healthcare providers to work collaboratively to improve the quality of care they were delivering, and then evolved over time to involve a broader array of stakeholders. For example, one of the first RHICs, 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, purchasers and consumers on the Board.
  • Other RHICs 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 RHICs, 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 RHIC also serves as the community’s health purchasing coalition. For example,  the Washington Health Alliance  is a multi-stakeholder collaborative, but its policy requires that a majority of the members of its board of directors be healthcare purchasers.
  • Still other RHICs 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 RHICs. In these communities, one of the organizations may take 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 that do not have a RHIC but want to form one have a variety of models to choose from. Since a common element of all RHICs is their multi-stakeholder structure, the most important first step in establishing a RHIC 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 play an increasingly central role in healthcare reform, partly as a result of the programs in the 2010 federal Affordable Care Act, RHICs remain critically important to transforming healthcare. The regulatory powers and financial resources of state governments give them 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 election cycles, changes in state administrations and changes in fiscal priorities;
  • the difficulty of balancing regulatory enforcement powers with programs to engage stakeholders and facilitate  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 RHICs 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 RHICs.

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