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Value and Payment Policy
May 27, 2020

Expanding the Quality Collaborative Model as a Blueprint for Higher-Value Care

Author Affiliations
  • 1Department of Surgery, University of Michigan, Ann Arbor
  • 2Center for Healthcare Outcomes and Policy, Ann Arbor, Michigan
JAMA Health Forum. 2020;1(5):e200413. doi:10.1001/jamahealthforum.2020.0413

The state of Michigan is home to the largest group of continuous quality improvement (CQI) collaboratives in the United States. In response to a charge from health care consumers and several large employers to improve the value of care, the state’s dominant private payer made the strategic decision to invest in a portfolio of collaboratives to create a statewide learning health system. These programs acknowledge that patients, clinicians, hospitals, and payers all want the same thing—high-value care.

In Michigan, the physician community sets a quality improvement agenda, which ultimately informs value-based reimbursement and pay-for-performance programs. These initiatives are pragmatic and evidence-based. Performance benchmarks and criteria for hospital and provider participation are set by the collaboratives and clinical community. This model acknowledges that effective quality improvement respects the tribal nature of medicine. Said another way, orthopedic surgeons will listen most to other orthopedic surgeons about how to improve orthopedic surgery.

There are 17 CQI collaboratives in Michigan today. Costs are among the lowest in the country, quality is high, and patients are satisfied with their care.1-4 While some have proposed that more states adopt the CQI model, others have rightfully questioned whether Michigan’s experience is generalizable and can be replicated elsewhere. Acknowledging these concerns, there are several considerations for expanding the use of CQI collaboratives to improve the value of health care.

Principles for Physician Leaders Seeking Partnerships With Private Payers

  1. The quality improvement agenda is set by providers. Providers meet regularly, identify high performance for the services in which they specialize, and disseminate best practices. Payers and health systems yield the quality agenda to the clinical community. Providers must steward this responsibility with care, balance, and devotion to all patients.

  2. Incentive programs build on the quality improvement agenda. Value-based reimbursement and pay-for-performance programs are specialty specific. These initiatives are pragmatic, evidence based, and designed by the clinical community with the help of health system leaders and payers. The incentives are simple to promote engagement from physician and administrative leadership within hospitals.

  3. Incentive programs are nonpunitive. Penalty-based quality programs are deleterious to the ethos of collaboration. Performance metrics often prioritize participation and effort. Clinical quality metrics are based on hospitals’ previous performance rather than hospital-hospital competition.

  4. The data are accurate and timely. Providers must believe that the data are accurate. Collecting patient-reported outcomes and complex process measures takes expertise and resources. But this also allows quality metrics to be thoughtfully risk-adjusted. This addresses concerns from all stakeholders about the influence of case mix or sociodemographics on financial incentives. Accurate data and risk adjustment are also key to ensure equity and limit the potential for programs to exacerbate existing disparities. Although there is enthusiasm for new technologies (eg, artificial intelligence) to improve efficiency, collaboratives acknowledge that quality data sometimes necessitate careful chart review. Support from payers is critical.

  5. Good ideas come from everyone. Health care providers are continuously innovating to make care more patient centered. These innovations originate as pilot programs that extend up to state-wide efforts. The providers that come up with these innovations are committed to sharing them across the entire state. For example, a recent effort focused on opioid prescribing led to a reduction in average postoperative prescriptions from 35 to less than 15 pills in 18 months.5

  6. Payers are committed to population health. Whereas the largest private payer in Michigan holds a 58% market share among privately insured beneficiaries, the CQI collaboratives benefit every patient.6

Challenges in Expanding This Model of Quality Improvement

  1. Support from academic medical centers. There are advantages to housing data coordinating centers and program leadership within academic medical centers. However, it may be difficult to rally clinician leaders to put the collaborative first and academic promotion second. It is also time intensive to assemble a diverse council of advisors to reflect the breadth of practice environments within each state. These are major barriers toward the implementation of best practices.

  2. Separating the quality improvement agenda from hospital and private payer strategic leadership decisions. There is a “blood oath” that the data and work of the CQI collaboratives will never be used for market advantage. Payers may be unwilling to fund these initiatives if they are also unable to see hospital-specific data. This minimizes the chances that payers leverage quality improvement work in contracting negotiations.

  3. Maintaining focus on service to the state. It is hard for collaboratives to maintain a population health focus. This is the single most important aspect of a successful collaborative program. In Michigan, this focus has been built over decades and does not come easily. The collaboratives focus on patient outcomes and stories of service to patients, an effective countermeasure to insidious forces within health care that lead to provider burnout and the perception that margin supersedes mission.

There is opportunity for large private payers and Medicare to promote the CQI model, but the imperative is much less clear. The Centers for Medicare and Medicaid Services (CMS), for example, has the scale to convene all hospitals in the country. However, CMS has historically not embraced a model in which multiple local quality-improvement agendas supersede singular national quality-improvement programs. Although the efficiency of large programs is clear, it also blunts local engagement that comes from grassroots quality-improvement efforts. Despite being more agile and regionally organized, private payers have other problems—namely, limited agency over uncovered lives and an unwillingness to take on financial risks for an unproven strategy to improve value.

Collaborative investment by CMS and private payers may be the best way to expand the CQI model. This collaboration would distribute risk and capitalize on the strengths of each entity. Specifically, it leverages the scale and ability for CMS to signal new priorities in quality improvement. It also empowers private payers who know the local markets to engage in new ways with health systems and providers. Even though the novelty of such a partnership is logistically daunting, Michigan’s experience suggests that the clinical community is ready to act.

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Article Information

Open Access: This is an open access article distributed under the terms of the CC-BY License.

Corresponding Author: Kyle H. Sheetz, MD, MSc, Center for Healthcare Outcomes & Policy, University of Michigan, School of Medicine, 2800 Plymouth Rd, NCRC B016, Room 100N-11, Ann Arbor, MI 48109 (ksheetz@med.umich.edu).

Conflict of Interest Disclosures: None reported.

References
1.
White  C, Whaley  C. Prices Paid to Hospitals by Private Health Plans Are High Relative to Medicare and Vary Widely: Findings From an Employer-Led Transparency Initiative. RAND Corporation; 2019.
2.
Vu  JV, Collins  SD, Seese  E,  et al.  Evidence that a regional surgical collaborative can transform care: surgical site infection prevention practices for colectomy in Michigan.   J Am Coll Surg. 2018;226(1):91-99. doi:10.1016/j.jamcollsurg.2017.10.013PubMedGoogle ScholarCrossref
3.
Hurley  P, Dhir  A, Gao  Y,  et al; Michigan Urological Surgery Improvement Collaborative.  A statewide intervention improves appropriate imaging in localized prostate cancer.   J Urol. 2017;197(5):1222-1228. doi:10.1016/j.juro.2016.11.098PubMedGoogle ScholarCrossref
4.
Share  DA, Campbell  DA, Birkmeyer  N,  et al.  How a regional collaborative of hospitals and physicians in Michigan cut costs and improved the quality of care.   Health Aff (Millwood). 2011;30(4):636-645. doi:10.1377/hlthaff.2010.0526PubMedGoogle ScholarCrossref
5.
Vu  JV, Howard  RA, Gunaseelan  V, Brummett  CM, Waljee  JF, Englesbe  MJ.  Statewide implementation of postoperative opioid prescribing guidelines.   N Engl J Med. 2019;381(7):680-682. doi:10.1056/NEJMc1905045PubMedGoogle ScholarCrossref
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