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Partners in Improvement

Jay Moore, for HealthLeaders Media, March 26, 2009

BCBSMA approached the Massachusetts Hospital Association to partner on the project after deciding that "individual boardrooms might not be as receptive," Shonkoff says. Nevertheless, BCBSMA did encounter resistance; some hospital leaders "took the posture that they were far along in this work and that the course would be too elementary," she says.

But that initial skepticism has "pretty much dissipated," Shonkoff says. The curriculum involves a six-hour course in a retreat setting and focuses on six areas—mission, strategy, culture, performance, leadership, and resource allocation. The program aims to spark the creation of hospital quality improvement plans to eliminate performance gaps. Boards also have a financial incentive to create such plans; hospitals can earn additional money if they adopt quality improvement plans that address a certain number of quality gaps, she says.

Twenty-five hospitals have completed the course, Shonkoff says. Additionally, BCBSMA in February launched the Trustee Advantage program, which awards five $50,000 grants to hospital boards (matched by $25,000 from each hospital) to engage a quality and governance "coach" to assist with improvement efforts.

Obstacles to overcome

Creating a provider-payer collaboration to improve quality is not without hurdles, however. Payers must align initiatives with what providers believe is genuinely important. BCBSMA enlisted input from multiple provider organizations to help craft the trustee curriculum, Shonkoff says. "We had an advisory session with hospital leaders, and they said they wanted to learn more about best practices and have individual coaching." For providers, the ubiquitous theme of physician support certainly applies to quality collaborations, Abookire says. But another important consideration for hospital leaders considering an initiative like the Alternative Quality Contract is their willingness to put their financial welfare in their own hands.

"Organizations without the existing infrastructure to achieve the quality goals would be at risk," Abookire says. "An organization needs to work collaboratively with its physician group, because we're at risk together. Sharing the risk in the Alternative Quality Contract can develop that relationship, because everyone has the same goal. That may be a novel concept for some hospitals."

Financial risk and alignment aside, some measure of momentum on both sides of the reimbursement equation appears to be building for providers and payers to work together more closely. "E-prescribing, computerized physician order entry, and patient safety studies are all initiatives that put into practice a system that will deliver the right care at the right time. In order for these programs to be successful, all partners need to work together," Fallon says.

Creating significant quality partnerships may come down to changing a longstanding provider-payer dynamic, Abookire says. "The dynamic traditionally does pit one against the other, because if the dynamic is only about money, the dynamic almost by definition is a win-lose," she says. "I think there are many folks endeavoring to align incentives around quality, but [the AQC] takes it to another level. Is it a harbinger of things to come? I'm an optimist—if we do it well, it could change the dynamic so that everybody wins."

Jay Moore