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Lessons from Aligning Forces for Quality: Five Emerging Trends

January 7, 2015 at 10:34 AM Leave a comment

I recently attended one of the last meetings of the Aligning Forces for Quality (AF4Q) communities, sixteen communities around the country that have been doing payment and delivery system reform for almost a decade, sponsored by the Robert Wood Johnson Foundation. I’m sure when the whole program wraps up next April, there will be a formal report on the findings and learnings. For now, here‘s a sampling of what I’ve learned.
• Payment reform is hard, and is greatly propelled by a dominant entity demanding change. When I worked in Albuquerque, reform efforts really took off when New Mexico Medicaid included participation in a payment reform pilot as a requirement for health plans doing business with them. In Michigan, Blue Cross Blue Shield of Michigan reorganized their delivery system into a series of Physician Organizations that are tasked with improving quality and controlling cost. In Cincinnati the ongoing scrutiny of large employers drives their provider community to compete on cost and quality. The theme is that both health plans and providers pay attention when a large source of their revenue demands that they do business differently.
• Providers do best when the incentives are harmonized between payers. Over and over again we heard from providers that paying attention to multiple bonus schemes and/or quality metrics from different payment sources is very difficult. If we can harmonize these incentives, there is a greater chance we can drive change at the practice level. The current Comprehensive Primary Care Initiative (CPCI) is a product of this thinking, testing whether having the same metrics and incentives across public and private payers results in greater practice level change. The whole idea is to increase the signal to noise ratio.
• Meaningful consumer engagement remains elusive. We continue to struggle with what reporting and metrics will be meaningful enough for consumers to use to choose providers and plans. Are we simply producing measures that are relevant to policy wonks but not average people? Or are the things that average people care about so diverse that we can’t create standards across the board? Is it just that most of us use the product very occasionally, and therefore don’t have an opinion until we are embroiled in a major illness or injury? These questions remain unanswered.
• Data can be very powerful, but it takes substantial work to make it relevant and useful. A number of AF4Q communities now have access to All Payer Claims Databases (APCDs), and even with that advantage, it takes a long time to get meaningful reports out of them. Fundamentally claims were intended for one purpose: to notify a payer that services have been rendered and payment was due. But pragmatically it is often still the most accessible evidence of a clinical encounter, and so we are using these data for lots of purposes for which they were never intended. This creates problems with attribution, episode definition, analysis and interpretation of the data.
• Despite the above, almost all of the hardest challenges in payment and delivery system reform are cultural and social, not technical. As much as data analysis is still in the working-out-the-bugs phase, all of it is technically possible now. The remaining barriers are very frequently political and cultural. Some entities feel these data are key to their business advantage, and are loathe to share with others, even those who consume and pay for the services in question. There is a growing awareness that such a stance is indefensible; after all, who has a greater right to the data than those who pay for the services and those who receive them? It further takes a concerted effort by those who pay and those who use to get access to what they should have anyway. Much of the push for this access is from organizations like the AF4Q communities, entities called Regional Healthcare Improvement Collaboratives (RHICs).
Has a decade of effort to reform payment and delivery been worth it? Undoubtedly there are those who wish for more progress than has been made. I am surely one of those. But nevertheless I think it has been a success—not because all the problems have been solved, but because of the kinds of problems we are working on now vs. ten years ago. Ten years ago, almost no one had an APCD. Ten years ago, no one could conceive of how bundled payments would actually work. And ten years ago, we couldn’t even hear the voices crying for true patient partnerships, not token engagement. There is plenty left to do; for a moment, though, we should pause to celebrate what we’ve done, and how much closer we are to the system we want.

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