Regional Health Improvement Collaboratives Needed Now More Than Ever: Program Directors' Perspectives

Published Online: September 21, 2012
Randall D. Cebul, MD; Susanne E. Dade, MPA; Lisa M. Letourneau, MD, MPH; and Alan Glaseroff, MD, ABFM
We are present or past program directors of 4 regional health improvement collaboratives (RHICs) in the northwest, north central, and northeast United States, among 16 programs supported by the Robert Wood Johnson Foundation’s (RWJF’s) Aligning Forces for Quality (AF4Q) initiative. In this article, we summarize our common

vision and describe how commitments are being shaped and implemented according to healthcare market forces among regions. The sustainability of these initiatives is influenced by regional and national forces that could challenge Americans’ ability to experience improved health outcomes and reduced costs of healthcare. Multi-stakeholder collaboratives that promote transparency and collaboration are needed nowmore than ever to improve the value of healthcare for patients and other purchasers.

Regional Context: Think Nationally, Act Regionally

The Network for Regional Healthcare Improvement describes RHICs as nonprofit organizations based in a specific geographic region that are governed by multi-stakeholder

boards to help their community identify opportunities for improving healthcare quality and value, and to lead strategies to address those opportunities.1 It is estimated that over 50 RHICs are currently engaged in cooperative health improvement activities at the regional level, working with providers who collectively care for as many as 120 million people, or over 40% of Americans. As a result of the 2009 federal stimulus bill, analogous regional initiatives were undertaken in the federally supported Beacon Community Program. More recently, initiatives were supported by the Innovation Center of the Centers for Medicare & Medicaid Services. 

The AF4Q initiative presented a unique opportunity for regional health improvement, with a common national vision articulated by the RWJF and adopted by the leaders of

these 16 regional collaboratives. The vision, largely supporting the Institute for Healthcare Improvement’s Triple Aim Initiative of better care, better health of populations, and lower per capita costs,2 anticipated a future state with several complementary components. It includes: (1) multi-stakeholder collaboration across purchasers (public and private employers and union trusts), payers, providers, and patients; (2) regionwide public reporting of performance of all providers, including reporting of patients’ experience with their care along with metrics related to care quality and outcomes; (3) active regional provider partnerships in patient-centered quality improvement with a particular focus on reducing disparities in care; (4) consumers who are actively engaged in their health and healthcare; and (5) reformed delivery systems and payment mechanisms that reinforce each of these components.

In addition to the common elements of this vision, RHICs across the country are working to find local solutions to the following more or less universal challenges: (1) a primary care system that is under-resourced and undervalued to address the growing prevalence of chronic disease and an aging population; (2) rampant misuse of emergency care for nonemergent problems; (3) overuse of potentially avoidable care from hospitals, specialists, and procedures at the same time that needed care is too frequently lacking; (4) poor coordination of care for patients across providers and systems of care; (5) poverty and its socioeconomic effects on health and access to healthcare; (6) poor lifestyle choices; (7) increasing lack of health insurance; and (8) payment that encourages delivery of healthcare services (“volume”) without incentives for providing or choosing high-quality, cost-effective care (“value”). In this challenging landscape, the AF4Q RHICs serve as neutral conveners and brokers (ie, the Switzerland) in their increasingly competitive markets, embracing transparency and accountability for healthcare and outcomes throughout their regions.

In addition to these common national themes, the regions are influenced by their market histories and local forces, and by the shared influences of national markets and federal initiatives. Contexts vary across regions in several important ways. Some regions include significant rural areas with widely dispersed providers and stretched capacity, such as Western New York, Humboldt County (California), and statewide programs in Minnesota, Wisconsin, Oregon, and Maine,whereas other regions include urban and suburban areas with a higher density of large healthcare systems like Puget Sound (Washington), Cleveland, Detroit, Memphis, Kansas City, and Cincinnati. Market forces and RHICs in Puget Sound, Cincinnati, and Maine are influenced heavily by large employers and other purchasers, while RHICs in Cleveland, Wisconsin, and Humboldt County are driven largely by primary care providers.

Sources for provider performance measurement range from exclusive reliance on health insurance claims to virtually exclusive reliance on medical records. National health

plans with large local penetration dominate the insurance market in several areas. Minnesota is supported largely by regional plans, while other regions are influenced by a varied mix of highly competitive regional and national plans. In its funding, the RWJF has supported RHICs with pre-existing initiatives in Humboldt County, Minnesota, Puget Sound, and other regions, while new programs were supported in Albuquerque, Kansas City, south central Pennsylvania, and western Michigan. In Cleveland, a new program was supported in a region with a history of an employer-driven quality initiative that collapsed in the 1990s, leaving a long shadow.3

Each RHIC’s trajectory into healthcare reform is heavily influenced by these and other forces that have affected both the opportunities and challenges of their regions. We

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