There is growing interest in community-wide, evidence-based quality improvement for chronic conditions. America's Health Insurance Plans (AHIP), a national trade association of health plans that is the result of the merger between the American Association of Health Plans and the Health Insurance Association of America, is sponsoring several initiatives to form community partnerships of health plans, physicians, and local quality improvement organizations. This novel, collaborative approach targets such chronic diseases as diabetes, asthma, and cardiovascular disease by coordinating and combining the efforts of individual health plans within a single market. This field report presents findings of a formative program evaluation funded by The Commonwealth Fund in 2002. The evaluation identified key attributes that led to the successful formation of Taking on Diabetes (TOD), AHIP's community partnerships in Albuquerque, New Mexico; Kansas City, Missouri; and Westchester County, New York. It sought to answer the following questions:
- What elements and forces are necessary to bring together competing organizations?
- What is necessary to sustain these community partnerships?
- What recommendations can be made to replicate this approach for other chronic conditions and in other communities?
- To what extent do local market characteristics and structures set the direction of community partnerships and influence success?
Interviews, Market Analysis, and Site Visits
The authors conducted two dozen semi-structured interviews, gathered comprehensiveinformation on the medical and insurance market at the three sites, and observed meetingsof the community partnerships at two sites. In preparation for the interview guides and thesubsequent data analysis, the authors conducted a thorough review of the literature ongroup dynamics and health care partnerships. They identified 50 attributes thoughtnecessary for successful establishment and sustainability of groups and community healthpartnerships. The authors grouped these attributes into the following eight domains:governance/accountability, nature of the problem being addressed, composition,differentiation, coordination and integration, centrality, alignment, and market structure.The semi-structured interviews covered each domain. The authors measured the strengthof agreement for each attribute as reported by the participants, and paired the attributeswith the community partnership outcome at each site.
This report's primary finding is that competing health plans and local organizations can establish and sustain viable partnerships around a shared goal. This successful outcome may be reached by following different paths, starting from different origins, and operating in different environments. A nascent community partnership does not need to meet a set of hard criteria, be located in a particular type of market, or follow a particular protocol. Rather, sponsors of community partnerships must pay careful attention to principles of group dynamic theory, such as fostering a sense of belonging to the group, sharing information and plans, and aligning individual goals with group goals.
The authors also found that each partnership site has unique characteristics, some of which directly affect the prevalence of diabetes and the operational logistics of the interventions. Albuquerque, New Mexico, is a consolidated health plan market, composed of four health plans ranging in size from about 9,000 members to over 181,000 members. An integrated delivery network owns the dominant health plan; no new plans have started in over 10 years. It has the highest health plan penetration of the three communities. The Albuquerque area has a comparatively low population density. Over 40 percent of the population is uninsured or on Medicaid. Of the three sites, Albuquerque is the community with the lowest per capita income and the highest poverty rate. Around 20 percent of its population is Latino and 4 percent is Native American.
The Kansas City, Missouri, market is the most active of the three sites. HMOs and PPOs combined have about 90 percent of the private-sector market. However, enrollment is fragmented across 18 plans, with no dominant player. There is a great deal of churning, with several new start-ups in the past two years, as well as some dramatic departures. Kansas City is not as wealthy as Westchester nor as well educated as either Albuquerque or Westchester but has a greater percentage of people with jobs and public or private insurance than does Albuquerque. About 20 percent of its population is African American.
The stability of the health plan market in Westchester County, part of the New York metropolitan area, is between that of Albuquerque and Kansas City. Three-quarters of its HMO market is divided nearly evenly across three long-established health plans, with the remainder of the market composed of 15 much smaller health plans. Despite their long-standing availability in the area, health plans have only a 32 percent penetration of the insured market, and 40 percent of the private market. Westchester is an affluent community. Over one-third of the population has a college degree, and the median household income is 1.5 times that of Albuquerque. Around 15 percent of the population is African American, 10 percent is Latino.
The HMO and PPO personnel at each site were very interested in forming community-wide partnerships to address diabetes. But this shared interest did not mean that AHIP could develop a simple recipe for success. The table shows how AHIP played different roles according to the organizational dynamics and background of each community.
|Table ES-1. Selected Features of the Three Sites|
|Albuquerque, N.M.||Westchester County, N.Y.||Kansas City, Mo.|
|Group origin||TOD formed it||Already formed||Weakly formed|
|Initial project||Common guidelines||Common guidelines||BTS for selected doctors|
|Financing (staff and in-kind contributions)||Combination of state, PRO, TOD||N.Y. State HMO Association; some state; TOD||Local foundation funding; TOD support of BTS|
|Notes. BTS, Breakthrough Series; TOD, Taking on Diabetes, PRO, Peer Review Organizations|
Group Dynamics More Important Than Market Characteristics in Forming Partnerships
The authors took a different approach from most prior studies of community health partnership formation. Instead of focusing primarily on market structure, they interviewed the participants to delve into the organizational characteristics that led to successful group formation. The authors found that market characteristics play relatively minor roles in dictating whether partnerships will be established and sustained. Market characteristics do influence the success of partnership initiatives.
This field report suggests that competing health plans, physicians, and other health care organizations can successfully establish and sustain community partnerships. The authors believe that careful attention to organizational and group dynamics can result in successful partnerships, regardless of the market structure. Although more research needs to be done using different programs and among different communities, the partnership participants and the authors have several recommendations that should increase the likelihood of fostering successful initiatives. These recommendations are as follows:
Establishing the Partnership
- Identify an unbiased facilitator.
- Identify an active coordinator.
- Recruit at least one strong local champion.
- Build consensus from the ground up.
- Obtain agreement among participants that there is a clear need for communitywide intervention.
- Be sure participants are willing to work on mutual objectives.
- Include unrestricted funding (even small amounts) and allow the partnership to decide how to spend it.
- Require in-kind or financial contributions from each participant, so they become vested in the project.
Sustaining the Partnership
- For the first project, design a visible, clearly beneficial, low-cost intervention that may be accomplished within 12 months (e.g., community-wide practice guidelines).
- Appoint or hire a local site coordinator.
- Ask for expert assistance when needed.
- Build an evaluation plan into projects.
- Design a long-range plan with intermediate goals that provide early success.
- Gain visibility for the successful implementation of various projects.
Creating a Successful Intervention
- Be consistent with the work of other health care quality players (e.g., quality improvement organizations, state department of health, purchasing coalition, or medical society initiatives);
- Build inter-organizational links and foster group cohesiveness;
- Impose minimal, extra administrative and financial burden on participants;
- Leverage existing interventions.
Finally, the authors conclude that community partnerships will have an easier time involving the entire community and getting started in health care markets that are:
- Relatively stable; and
- Relatively consolidated, with key participants included.