In an effort to support local efforts to improve health care quality and control costs, U.S. Health and Human Services (HHS) Secretary Leavitt in February designated 14 regional or community-based collaboratives as "Chartered Value Exchanges" (CVEs).
These multi-stakeholder entities, comprised of health care purchasers, providers, health plans, and consumer advocacy organizations, are engaged in advancing what the Bush Administration has defined as the "four cornerstones of Value-Driven Health Care": transparency of quality information; transparency of prices; interoperable health information standards; and positive incentives that reward value.
Designation as CVEs enables the coalitions to participate in a nationwide learning network sponsored by the Agency for Healthcare Research and Quality (AHRQ). The network offers peer-to-peer education, identification of promising practices, technical assistance from experts, a Web-based knowledge management system, and other tools.
The network held its first meeting in late February, during which representatives from the CVEs shared their experiences and best practices in enhancing consumer access to information on quality and cost. AHRQ is currently developing software to help the CVEs customize and use a large set of longitudinal hospital care data from the Healthcare Cost and Utilization Project family of databases.
Additionally, HHS expects that, late this summer, each CVE will receive performance scores, derived from Medicare claims data, on 12 performance measures for physician group practices in the state. CVEs are expected to soon be able to combine this information with comparable data from commercial payers (through private sector data analyses), enabling additional quality improvement initiatives.
"Because health care is delivered locally, it makes sense to establish performance standards and measures at the national level, but to implement them at the community level," says Andrew Croshaw, senior executive advisor for Value-Driven Health Care at HHS.
The CVEs represent a range of models in terms of specific strategies, priorities, membership, and maturation. Some have been active for years; others have formed recently in response to this opportunity. The initial 14 groups were selected among 38 applicants (Figure 5). A second group of CVEs will be announced in July, and an additional selection round is expected in October 2008.
One of the challenges in building the CVE model is "overcoming sociologic barriers," says Croshaw, "It takes time for health care providers and payers to develop sufficient trust to work together on performance measurement and quality improvement initiatives."
Potential Impact on States
Despite the community emphasis, the Chartered Value Exchanges can and do involve states in a number of ways. Medicaid and/or state employee benefit agencies are active members in some CVEs, such as the Puget Sound Health Alliance and the Detroit Area Health Council, described below. The state agencies can contribute Medicaid or state employee data to broaden the private data collection and reporting efforts. States may support or promote the CVE initiatives by providing their constituents with information about them through state Web sites. In addition, states can look to the CVE efforts for models that could be expanded or adapted. Further, states could build on relationships among stakeholders already formed and developed through the CVE collaborations.
Below we describe three CVEs—in Michigan, Oregon, and Louisiana—that illustrate a range of value-driven initiatives being pursued by regional coalitions.
Greater Detroit Area Health Council
The Greater Detroit Area Health Council (GDAHC), based in Detroit, Michigan, is a broad coalition of more than 70 organizations representing health care purchasers, providers, insurers, and consumers working to try to improve health care quality, enhance access to care, and reduce health costs in southeastern Michigan. In addition to major corporations, unions, and advocacy organizations, members include state and local public entities, including the Michigan Department of Community Health, which administers Medicaid.
"The majority of the state's population is in our area, so any improvement realized will directly benefit Medicaid and the state as a whole," says Jan Whitehouse, senior vice president of GDAHC.
GDAHC's current focus is its Save Lives, Save Dollars Initiative (SLSD). First implemented in 2005, its goal is to achieve 100 percent adherence to selected evidence-based clinical practice guidelines, and to save $500 million over three years or reduce health care cost growth by 1 to 3 percent. Its main strategy is to encourage all regional stakeholders to adopt standard performance measures and pay providers based on those metrics. So far in 2008, the largest commercial payers in southeast Michigan agreed to pay incentives for several SLSD recommended measures, including meeting generic prescription drugs rates and cancer screening rates. However, payers are not limited to providing incentives only for these measures. Payers are testing a measure for management of lower-back pain, which is likely to be implemented for differential payment in 2009. Payers also agreed to establish incentive programs around a set of principles concerning quality improvement.
A key component of the SLSD initiative is a Health Care Performance Report Web site that provides comparative information on hospital quality and health plans. Performance reports on physician organizations are expected to be available this summer. GDAHC is also working through its Web site to build consumer engagement in using comparative performance measures.
GDAHC officials say that the public reporting and other coalition efforts appear to be having a positive impact: hospital and health plan performance on recommended measures has improved in recent years. Several SLSD stakeholders report overall health care spending has been trending downward over the past year or two, but it is not known how much of this can be attributed to GDAHC's efforts given the difficulty attributing changes in service utilization or spending growth trends to any particular factor. "We think financial savings will be longer-term in nature," says Whitehouse.
Oregon Health Care Quality Corporation
The Oregon Health Care Quality Corporation, based in Portland, Oregon, is a nonprofit partnership that brings together physician groups, nurses, hospitals, health plans, purchasers, consumers, and policymakers in an effort to improve the quality of health care in Oregon through community-wide collaboration. The group focuses on projects that measure and report care quality, assist providers to improve quality, engage consumers in decisions about their care, and foster electronic exchange of health information. Project priorities are set by a 32-member Board of Directors, which includes representation from Oregon state agencies.
The Quality Corporation is currently focused on Aligning Forces for Quality in Oregon, an initiative led by the Robert Wood Johnson Foundation to assist communities in aligning market forces to improve the quality of health care for patients with chronic conditions. The goal is to enable providers to measure their performance and improve their ability to deliver quality care, and to help patients and consumers understand their role in recognizing and demanding high-quality care. To measure performance, the Quality Corporation is helping providers organize and collect electric medical record data. Legal and policy issues have posed a barrier to measurement and reporting, and the Quality Corporation is working with its partners to resolve these issues.
The Quality Corporation is on track to report quality measurement data in early 2009, with public reporting to occur in the fall of that year. In preparation for the release of publicly reported data, the Corporation is working with providers to help them use the data for quality improvement, and collaborating with health care access advocacy organizations to give consumers information that helps them partner with their doctors in managing their own care.
The Quality Corporation had also been coordinating with stakeholders to create a sustainable health information exchange. While this project is currently on hold due to funding constraints, the Quality Corporation remains committed to building Oregon's health information system. In addition, the Quality Corporation acts in an advisory capacity to the Health Information Security and Privacy Collaboration, which is working to ensure the security and privacy of health information exchanges.
Louisiana Health Care Quality Forum
The Louisiana Health Care Quality Forum, based in Baton Rouge, Louisiana, is a private, nonprofit organization formed as part of the post-Katrina effort to rebuild the health care system in hurricane-affected areas of the state. The forum focuses on short-term recovery and long-term system redesign. A 13-person volunteer board sets priorities for evidence-based, collaborative initiatives to improve the health of the people of Louisiana. The recognition that things need to be done differently than in the past has provided additional impetus for stakeholders to come together, and the Forum has enjoyed broad provider participation and support. Current Forum priorities include measuring quality, adopting patient-centered medical homes, leveraging health information technology, and improving consumer access to health information.
The Quality Forum acts on its priorities through four committees. The Louisiana Department of Health is involved in all of the committees, working in partnership to align stakeholders in the effort to redesign the health care system as they rebuild. Recent accomplishments include:
- submitting an application to the Centers for Medicare and Medicaid Services for a demonstration project to enhance Medicare reimbursement rates for physicians who adopt electronic health records;
- adopting the Joint Principles of the Patient-Centered Medical Home (PCMH) policy statement and hosting a summit to provide hands-on training and resources for providers to build medical homes;
- utilizing a pre-Katrina, multi-payer database that houses data on 60 percent of the population to examine health system performance for various subpopulations, and updating and expanding this database; and
- developing health literacy campaigns to begin in the spring of 2009.
In addition, the Forum is one of two Chartered Value Exchanges selected by HHS to pilot sustainability tools. Through this pilot, HHS will provide technical support to the Forum as it to helps define practical strategies for building stability and financing for the multi-stakeholder collaboratives. The results of Louisiana's experience will be shared with the entire Learning Network.
 See http://www.hhs.gov/valuedriven/fourcornerstones/index.html.
 See http://www.ahrq.gov/qual/value/localnetworks.htm.
 According to Croshaw, HHS does not currently have authority to share Medicare claims data with the CVEs; there are attempts to change this through legislation. Also, to avoid HIPAA and data security concerns, the Centers for Medicare and Medicaid Services contracted with a Quality Improvement Organization to analyze the measures at the physician group level by state.
 Members include General Motors, the Henry Ford Health System, AARP, Aetna, and others. For the full list see: http://www.gdahc.org/membership.asp?ContentID=35.
 The creation of the Forum was recommended by the Louisiana Health Care Redesign Collaborative, see http://www.dhh.louisiana.gov/offices/?ID=288.
 The Commonwealth Fund is supporting efforts to improve Louisiana's health care system. One grant provides technical assistance in planning the implementation of a medical home system of care and another is funding a survey of neighborhood clinic users and non–clinic users about their health care experiences.
 Definition and principles, developed by NCQA. See http://www.ncqa.org/tabid/631/Default.aspx.