How States Can Be Successful In Leading Health Care Delivery System Reform Shelly Ten Napel, M.S.W., M.P.P., Enrique Martinez-Vidal, M.P.P., Alison Rein, M.S., and Hilary Kennedy, M.P.A., M.Sc. November 2011 www.academyhealth.org 1 Introduction State Principal Quality Improvement Initiatives Supported by Technical Assistance from the SQII* Over the past year, health reform has moved largely into the purview of states. A recent The early implementation of the Center for Improving Value in Health Colorado Care (CIVHC) multi-state technical assistance project designed to help states improve quality Development of a Colorado-based All-Payer Claims Database and value in their health care system can provide several valuable lessons for state Kansas Medical home pilot policymakers and those working to help states be successful. The project offers Medicaid cost containment valuable insights into: what factors are predictors of state success, what barriers Massachusetts Patient-Centered Medical Home Initiative states are likely to encounter, and what Massachusetts Strategic Plan to Reduce Readmissions and Improve technical assistance strategies can help a Transitions of Care state achieve its health reform goals. Minnesota Provider Peer Grouping From 2008-2010, AcademyHealth, with support from The Commonwealth Baskets of Care Fund, coordinated the State Quality Early discussions around the implementation of Accountable Care Improvement Institute (SQII), a project Organizations designed to advise and accelerate Ohio Establishment of the Health Care Coverage and Quality Council state quality improvement efforts. An examination of the experience of eight Support for the Medical Homes and Payment Reform Task Forces states (Colorado, Kansas, Massachusetts, Minnesota, Ohio, Oregon, Vermont, and Providing expertise to the Health Systems Performance Committee of Oregon Washington1) that completed the more the Oregon Health Policy Board than two-year project provides insights Technical resources for the development of an Oregon-based All- into elements that can make reform efforts Payer Claims Database successful at the state level, as well as the Patient-Centered Primary Care Advisory Group types of barriers that can prevent progress. All of the states participating in the SQII Washington Washington Patient-Centered Medical Home Collaborative were pursuing the same overall objective: achieving better value in their health care Multipayer Reimbursement Model Pilot systems (i.e., higher quality health care at a lower cost). Nevertheless, they varied in Ongoing technical support for the refinement and expansion of the Vermont Blueprint for Health their approaches and accomplishments. *Note: In some cases, states had already passed legislation enacting the initiatives described above before the This brief draws some conclusions about SQII began (i.e., Minnesota, Vermont, and Oregon). In those cases, SQII supported the challenging work of policy those differences, and provides some refinement and implementation. “lessons learned” for technical assistance providers and others who seek to help make state reform efforts successful. Methods States Identify Similar Data for this brief were collected through exit interviews with the team leaders of Delivery System Understanding the potential of technical the eight participating states. Additional Reform Goals assistance to states is even more critical After a selection and site visit process, the information was collected through given the enactment of the Patient SQII convened all participating states for observation, written reports and action Protection and Affordable Care Act (ACA). an intensive two-and-a-half day training plans from the states, and presentations Capitalizing on the opportunities available and goal-setting meeting. States brought by state officials and expert faculty. The under the ACA for delivery and payment teams of both public and private sector authors continuously communicated with systems redesign will be critical to sustain leaders. Some states, like Vermont and representatives of all eight states throughout the coverage expansions included in the Minnesota, came to the meeting with the course of the SQII initiative. new federal law. fairly established goals that were already enumerated in legislation. Other states 3 revised and adapted their goals during the course of the meeting, as they learned States Build on • Medical homes: The state and the private from both expert faculty and each other. Existing Strengths sector were charged with establishing a set of agreed-upon metrics for a As all eight states identified their goals, By the close of the SQII (December 2010), Minnesota health care home. The state they began to coalesce around several Vermont had the most well-funded and and the private sector would then be strategies, including: fully executed delivery system reform required to pay an increased amount strategy in place. The Blueprint for Health to providers who met the standard. • Patient-centered medical homes; model—which enables providers to offer a The statewide standards are based on • Improved transitions of care and reduced full complement of medical home services outcome rather than process measures.5 preventable hospital admissions and with the help of community-based care readmissions; teams—was piloted in three communities Although Ohio and Colorado had many • Cost and quality measurement efforts; during 2008 and 2009 with legislation successful private sector initiatives, there passing in 2010 to expand the model was less of a history of state action. In • Multi-payer approaches to payment statewide. Vermont’s success was built on 2006, voters in both states elected new reform; governors who were committed to years of experimentation with chronic • Improving population health and condition management using the Chronic improving health care quality. Each state achievement of the Triple Aim;2 and Care Model.3 By the end of the SQII, the decided to establish a public-private • Cross-cutting consumer engagement Vermont legislature was considering how to quality council—the Ohio Health Care strategies. incorporate the ACO concept, which would Coverage and Quality Council and the build on the Blueprint model and expand it Colorado Center for Increasing Value in In addition to those strategies, a few of the beyond primary care. Health Care (CIVHC)6 — to vet ideas states grew increasingly interested in the and identify priorities for the state. concept of accountable care organizations Craig Jones, the Vermont SQII team leader Although each of these initiatives will (ACOs), reflecting the burgeoning interest and director of the Blueprint, notes, “We likely provide valuable infrastructure in the topic nationally. have gone from a stage of ‘this doesn’t for the state moving forward, the two work,’ to ‘this will work; we can make it states spent much of the SQII program Although there were important variations work.’” His point is that—with persistent establishing relationships and building in the reform strategies and methods leadership and consistent progress— the infrastructure to support and spur employed by participating state teams, success breeds success. eventual reforms. That groundwork was they all wanted to improve prevention and not necessary in states like Minnesota chronic condition management efforts, When Minnesota joined the SQII, it already and Vermont, which both had a history with particular emphasis on improving had a longstanding culture of collaboration, of collaboration between the public and care coordination. in which the state worked closely with private sector and an understanding that purchasers and plans to begin developing the state would assume a leadership role. In spite of having selected very similar standard cost and quality measures.4 In goals, the eight SQII states varied in their States with Supportive 2008, that significant groundwork enabled approaches and accomplishments for several the state to pass legislation that includes, reasons. First, each state was building on a different foundation of strengths and among other components: Stakeholders are limitations. Second, the role and engagement • Provider peer grouping: The legislation More Likely to Have of stakeholders varied significantly between states. Third, political leadership required the development of a Successful Quality was stronger and/or more continuous in provider tiering system based on their performance on cost and quality metrics. Improvement Initiatives some states than others; and fourth, states Representatives of both Massachusetts • Baskets of care: The legislation charged and Minnesota noted that it was critical invested differentially in key information the Department of Health with choosing infrastructure components (e.g., data to have insurers be supportive of their several conditions that would allow collection tools and analysis). Finally, states delivery system reform efforts.7 Vermont bundled payments across providers for a exhibited varying levels of commitment has a Blue Cross/Blue Shield plan that has certain medical procedure or condition; (and enjoyed differing levels of cooperation) been proactive and willing to work with for example, knee surgery. The state, in in leading multi-payer payment reform the state toward reform. In general, states coordination with the private sector, would that would provide the kind of long-term in the SQII that have mostly local and set quality metrics and providers would bid transformation necessary to achieve the nonprofit health plans have had an the expected cost for a basket of care. stated objective of high-value health care. 4 easier time promoting their participation in state-based reforms. That pattern is also Leadership Investment in Data likely to emerge as states begin working Craig Jones believes that a key ingredient to Vermont’s success has been “consistently Collection and with health plans to develop health strong leadership at the state level; (having) Analysis insurance exchanges. The rigorous generation of appropriate a governor and legislature willing to stay committed to this, to not back down during data can provide a unique, nonpartisan Several of the states organized formal impetus for reform and can provide a tough fiscal and political times has been quality councils to promote positive critical feedback mechanism once a reform key.” He acknowledges that many attribute stakeholder engagement. They recognized effort is underway. The data can then be Vermont’s success to its small size and that delivery system reform cannot used to illustrate which efforts are effective progressive culture, but insists that those happen with the state working in isolation. in achieving the goals of the initiative, and conditions are not sufficient without the It requires at least the commitment of which need to be modified or adapted presence of strong leadership. purchasers, plans, and providers, and mid-stream. often the engagement of consumers. Phil In states without term limits, a strong leader Kalin and Jay Want, executive director and Because avoidable readmissions were a in the legislature can bring needed longevity board chair of CIVHC, respectively, and high cost driver in the state, the Health and subject area expertise. Massachusetts, Colorado’s SQII co-team leaders note, Data Consortium of Massachusetts Vermont, Minnesota, and Oregon all had “We think about building public will. We identified transitions of care as an long-standing committee chairs in the area of try to have discussions around the state area where the state should focus its health care who were important champions about making choices. We have a view that efforts. They did this through strong in promoting reform. if you get enough of the right people in state regulatory actions and through the room, you can really move forward.” participation in the STate Action to Avoid By contrast, Kansas saw significant Colorado also had access to financial Rehospitalizations (STAAR) program.8 turnover in leadership that curtailed many support from the active foundations Similarly, Minnesota has a strong data of its efforts. The state started the SQII in the state. In times of budget deficits, consortium called Minnesota Community with the support of Governor Kathleen innovative engagement with foundations Measurement. They define themselves as Sebelius, who was knowledgeable about can be one way for states to maintain a “collaborative effort” in a community and committed to improving the health support and momentum for their of “those who believe that you cannot care system. The reform work of the reforms. improve what you don’t measure.”9 Kansas Health Policy Authority (KHPA) was also supported by a moderate The group brings together providers, The role of stakeholders is particularly purchasers, plans, consumer groups, and Republican leader in the legislature. In a important when one considers the long- quality improvement organizations to short period of time, KHPA lost both their term nature of delivery system reform promote greater transparency in the belief legislative champion as well as Sebelius as compared with shorter-term election that this focus on data and transparency who was called to serve as U.S. Secretary cycles. The importance of strong political will lead to better health outcomes. of Health and Human services. As a result, leadership for setting a reform agenda Common quality measures are the when the state faced a prolonged period of and providing consistent support for that cornerstone of Minnesota’s medical home budget shortfalls, both staff and program agenda cannot be overstated. Nevertheless, and provider tiering efforts. funds for health reform were reduced. it is important to recognize that political leaders change and priorities can shift, Vermont has an all-payer claims database Throughout the SQII program, state as can the resources at their disposal. (APCD), which it uses to measure the cost representatives and faculty talked about The tenure of private-sector leaders and impact of the Blueprint, and to produce two types of leadership as being necessary groups can span many gubernatorial valuable reports on the performance of for successful reform: 1) political administrations, and those leaders can participating providers.10 Recognizing the leadership; and 2) project management have a powerful influence on the success importance of a strong data infrastructure leadership that keeps both state officials of both legislative initiatives and the to support decisions, Colorado and and stakeholders on task, accountable, implementation of reforms that have Oregon both passed legislation during the and moving toward a shared goal. Though been enacted. States pursuing such efforts course of the SQII to initiate an APCD. political leadership is important, states would be well served to seek stakeholder Both state team leaders counted this as an also need to invest in staff with the input and support early and often. important success. Barbara Langner, the dedicated time and skills needed to lead a complex but collaborative decision- Medicaid director in Kansas (which also making and implementation process. has an APCD and has invested significant 5 resources into its ability to use and analyze payers, plans, and providers to develop a Fiscal environment: All states were hit by data) and SQII team member, stated that new payment model. As has been an issue the tidal wave of the economic downturn, better access to data has enabled them for many, the state faced the challenge of some harder than others. The poor economy to identify key cost drivers so they can plans not wanting to increase payments meant that states were unable to invest target efforts more effectively to achieve without holding providers accountable for resources in new initiatives; they had to meaningful savings. By the end of the SQII, results. Providers, on the other hand, were figure out ways to start new projects with seven of the eight participating states had concerned about the start-up costs that existing funds. They were also stymied in some form of an APCD.11 would be needed to make the necessary their effort to garner private funds, since changes that could achieve results. health care stakeholders also had new worries about the bottom line. Ohio was Commitment to Ultimately, the state developed a payment one of the states hardest hit by the recession. Multi-Payer Payment model that offers primary care physicians Amy Rohling McGee, former health policy Reform the opportunity to share in the savings if their patients have fewer preventable advisor to Governor Ted Strickland and Ohio’s SQII team leader, pointed out that Nothing gets the attention of health emergency room visits and avoidable the inclination of insurers (for example) to care stakeholders like payment reform. hospital admissions. In addition to take on the modest financial risk posed by Although it is not sufficient for achieving the components described above, the payment reform related to medical homes successful reforms (providers also need Washington program also includes patient was likely limited by each insurer’s financial data and training on how to transform and provider surveys to assess satisfaction, situation. Kansas felt that its reform effort their practices), it does demonstrate the tracking of clinical process and outcome suffered a substantial setback by state a commitment to pay for quality measures, and the provision of ongoing budget problems. Conversely, Richard (not volume) and to support more access to performance data for providers.12 Onizuka, director of health care policy for transformational change. Reform also marks the Washington State Health Care Authority a turning point in the way a state does Before undertaking a multi-payer initiative, and that state’s SQII team leader, noted business, and effectively requires that key states should consider the payer dynamic that the state’s severe budget deficit may stakeholders come to the table. in their state. In states without a dominant actually have spurred more aggressive action payer, health plans are accustomed on cost-saving and quality improvement Payment reform that extends beyond to operating in a highly competitive initiatives than would have occurred in a less Medicaid or other government payers is also environment, and it can be difficult to get dramatic fiscal environment. critical. If the goal is to change the behavior them to start working together. In other of providers (who likely see fee-for-service states, such as Vermont, the dominant Health information technology: Hunt Blair, patients as well), payment signals must be health plan can be an important partner Vermont’s lead on health information consistent over a sufficient number of payers. in advancing reform. Joel Weissman, technology and SQII team member, This type of comprehensive payment reform former senior health policy advisor to indicated that, until recently, a major can be seen in the Vermont Blueprint, and Massachusetts’ secretary of health and barrier to achieving delivery system reform also in the Minnesota provider tiering and human services and SQII co-team leader, was the limited capability of its health health care homes initiatives. underscores the importance of getting information technology systems. While the all payers on board: “We can’t change the state is seen as a leader in this area—they Washington State also has pursued an health care delivery system one payer at a have a state-wide fund that supports HIT innovative patient-centered medical time. We have seen decades of payers doing development, a state-supported registry home pilot, which is an example of how different things, and it doesn’t have any for Blueprint providers called DocSite, advanced payment reform principles lasting impact until all payers act in unison.” and significant statewide effort on health can be brought together with strong information exchange—they are still being slowed down by the need to create patches Barriers to Success training, data collection, and evaluation to create a promising medical home for systems that are being marketed as more model. Washington began by selecting Changing the status quo is never easy, sophisticated and interoperable than they more than 30 practices to participate in a especially in an environment as complex actually are. State officials have been forced transformation project. Though it did not as the U.S. health care system. It is much to take on the role of helping to facilitate involve a change in payments, it did provide easier to block change than to be an agent of conversations between health care providers practices with training and technical positive reform. Not surprisingly, the SQII and data/technology experts to ensure that assistance. At the same time, Washington states also faced barriers to success over the essential fixes are made. state officials also began working with course of the initiative. 6 Unclear lines of responsibility and doing, it’s clear, there is good empirical offers some valuable “lessons learned” for accountability: States are one player in a evidence, so we should line up behind this.’ those working in states. dynamic and complex health care economy. It is more amorphous now.” The state teams in the SQII were facilitators, Real-time peer-to-peer learning: In a context conveners, and role models, but it was rare On the other hand, the limitations in in which policymakers are learning as they that they directly required action or could the evidence should not be overstated or go (some evidence is available, but there hold various stakeholders accountable given as a reason for complete inaction. are no definitive answers), learning from for participation and outcomes. Even There was general agreement among the on-the-ground experience of others when a state is directly purchasing health states on the need to experiment and then in nearly real time is critical. Phil Kalin of care services (a scenario in which they evaluate new programs and ideas. When Colorado says, “SQII really allowed us to be presumably have more direct control), they Vermont was considering taking their able to talk to group leaders and see where are often working through intermediaries Blueprint model statewide during the 2010 our efforts overlapped with others, see how such as managed care plans and other legislative session, some counseled caution others are approaching things, and building private contractors. This makes it harder to given that there has not yet been time to relationships across the country with directly influence the nature of the contracts collect sufficient data to prove that the people and organizations that are doing being developed with providers and thus (chronic care) model saves money. Don similar work and really build a learning influence the way care is being provided. George, president and CEO of BlueCross/ community.” Jay Want of Colorado laments, BlueShield of Vermont, came out in “After going to the first SQII, I came back Loss of momentum: System reform is support of expanding the program saying, with APCD envy.” (As a result, Colorado extremely complex and it is easy for a “We know what doesn’t work, and that is passed legislation the following year to state to lose momentum in the face of our current system.” authorize development of an APCD in the opposition, competing health reform state). “I always look to states ahead of us priorities, and/or the difficulty of the Consumer engagement: In general, states or dealing with the issues we are dealing tasks involved. Managing the pace of struggled with the best way to educate with,” says Richard Onizuka of Washington. change becomes a significant leadership and engage consumers. Clearly, consumer The technical assistance providers were challenge. At times, some stakeholders attitudes and expectations are critical also able to bring to light examples from may purposely slow down the deliberative to the success of reform, but states had leading states not involved in the SQII. process as a tactic for preventing reform. difficulty deciding when and how best Technical assistance providers also facilitated In other cases, stakeholders may be eager to effectively communicate and work contacts between state officials from SQII for change but become frustrated with the with representatives from the patient and states and non-participating states, such as pace of progress. In many cases, states are consumer communities. Pennsylvania and Rhode Island, resulting managing a range of expectations, goals, in additional sources of on-the-ground and levels of eagerness for reform; keeping experience for the SQII states. stakeholders on task and working together Helping States Achieve is not easy. Successful Delivery Mutual support: Dr. Want also talks about Need for additional measures and best System Reform the difficulty of going against the flow of ‘business-as-usual.’ “Most of the people The fate of many provisions within the practice standards: When asked about going to SQII meetings are looking to the federal Patient Protection and Affordable barriers to reform in her state, former future, so they look mildly to moderately Care Act (ACA) have fallen largely Minnesota Health Commissioner and insane to stakeholders back in their own into the varied and complex context of that state’s SQII co-team leader Sanne states. If a bunch of crazy people are state policymaking. National nonprofit Magnan responded, “Patient experience moving in the same direction, you can organizations and state and local measures are not at the level they need to all be crazy together.” The status quo is foundations are looking for ways to help be. We don’t have a primary medical home often everyone’s fallback option, and so equip states for the task ahead. Federal measure for patient experience yet. This is champions of change need mutual support policymakers, too, want to empower states a national issue, but moving slower than if they are to remain bold and persistent. to successfully implement all aspects of the we would have liked.” ACA, including insurance market reform, Small group meetings: The SQII offered implementation of health insurance Colorado co-team leader Phil Kalin feels small topic-based meetings that included exchanges, and the type of cost containment that states are still limited by the lack of four to six people from three states and and quality improvement efforts undertaken evidence. “There is nothing you can point a handful of faculty experts. The total by states in the SQII. To this end, the SQII to and say, ‘This is what we should be number of participants was around 7 30. These meetings allowed in-depth around delivery system reform in the state. creating and revisiting these documents. interaction and conversation, not just the Two years after their first meeting, through It is also easy for state staff to get stuck in question-and-answer that occurs in larger the work of the committee that grew the infrastructure of their own agency or meetings. They also allowed participants from their initial Summit, the state now hierarchy. By consistently asking for cross- to dig into the detailed, operational aspects supports a medical home pilot and has agency team participation, the SQII sought of the selected topics. The states learned recently joined the Institute for Healthcare to combat this tendency. from the experts, but also from each other. Improvement’s STate Action to Avoid Formal opportunities were provided for Readmissions (STAAR) initiative. states to present their own challenges A Note about the State and to allow the other participants to In-state meetings with outside experts: Staff Who Effectively ask questions and offer suggestions. The evaluation responses for these meetings Several states pointed out that having external experts visit their state was Led SQII Teams These lessons learned are not meant consistently cited them as being one of extremely helpful for a variety of reasons. to give all the credit for state success to the most valuable avenues for providing First, in-state meetings allow state officials the SQII program. The SQII staff was technical assistance. to invite multiple stakeholders who can consistently humbled and amazed by the all benefit from the outside expertise. dedication, talent, and technical skill that Expert faculty: The reality is that every Second, the cachet of having a national their state partners brought to the task of reform effort will encounter roadblocks expert associated with a national program system change. The SQII team observed along the way. Support and advice from is always helpful for raising the profile of a that there is no substitute for effective and outside experts can be critical for moving meeting or initiative. Third, they can help knowledgeable staff at the state level. past obstacles. When Washington was to contextualize and legitimize the policy setting up the payment reform component direction in which the state is moving. The need to train and retain effective staff of their patient-centered medical home, “You are never a prophet in your own will be particularly important as states they came to an impasse between the land!” observes Ohio’s Rohling McGee. seek to implement the ACA in the wake payers and providers. Both public- and of recent (and ongoing) budget cuts and private-sector leaders in Washington Well-tailored and targeted technical hiring freezes. The SQII team holds the met with national payment reform assistance: Successful technical assistance view that effective TA must equip state experts, which helped them work out a providers must listen to those they are leaders for the challenging task ahead compromise between payers and providers trying assist. The SQII became relevant by rather than simply doing the work for and the project regained momentum. answering the questions states were asking them. As states obtain more federal and responding to the dilemmas they funding to hire consultants, it will be Safe environment for team learning: The were facing. Gretchen Morley, director of important for state staff to consider ways SQII always allowed states to bring teams health policy development at the Oregon that consultants can expand their capacity of people to meetings, providing them Office for Health Policy and Research and without simply taking the expertise with the designated space and time to that state’s SQII team leader, noted that, outside of state government. talk and brainstorm among themselves. It especially as states faced tight budgets and offered a protected opportunity for state limited staff resources, “What helped was leaders to talk about ideas and strategy our relationship with (the SQII team); Conclusion without the demands of schedules, knowing that we have you all as a resource, Delivery system reform is a complex, meetings, and deadlines associated with and having you tailor the assistance.” multi-stakeholder, long-term process. their “day jobs.” When teams attend Keeping reform on track in spite of the meetings together, they all have access to Accountability: The SQII team learned many barriers that can arise will be an the same information, time to synthesize about the need to balance an approach enormous challenge for states in the years and contextualize together, and can more that responds to the expressed needs ahead. Nevertheless, technical assistance easily develop shared objectives. When the of states and that holds state teams providers can help make states more Ohio team attended its first SQII meeting, accountable for their active participation successful by listening to them, convening the team did not have consistent goals. in the program. Strategic plans and them to learn from each other, providing They left the meeting with a shared plan timelines are effective tools for achieving them with needed expertise, and helping for a Summit, which ultimately set the system change. In some cases, state officials them overcome inevitable hurdles. stage for conversations and work groups benefit from being held accountable for Though it signals a time of great 8 opportunity, the ACA also brings new challenges for states: they will not only Endnotes 5. Minnesota Department of Health, 2008 Health Care Reform Summary; June 2008. 1. New Mexico did not continue through the entirety http://www.academyhealth.org/files/SQII/ need to coordinate with others in the state of the project. MNHealthReform2008Summary.pdf but —to an even larger extent than before 2. The Triple Aim concept was developed by the 6. The Ohio Health Care Coverage and Quality Institute for Healthcare Improvement (IHI); it is Council was created during the course of SQII —they will need to coordinate with federal the simultaneous pursuit of three aims: improving while the Center for Improving Value in Health officials. As we look ahead to this challenge, the experience of care; improving the health of Care (CIVHC) began just before Colorado joined a quote from Craig Jones, Vermont team populations; and reducing per capita costs of SQII. Colorado used the resources of SQII to health care. See http://www.ihi.org/IHI/Programs/ educate and support the work of CIVHC. leader, is instructive: “If you view state- StrategicInitiatives/TripleAim.htm. led reform as hand-in-hand with federal 7. Note that insurers in Massachusetts and Minnesota 3. The Chronic Care Model was developed by Ed are nonprofits. reforms, then technical assistance would Wagner, MD, MPH, Director of the MacColl Institute for Healthcare Innovation, Group Health 8. Funded through a grant from The Commonwealth foster maturity of relationships between Fund, the Institute for Healthcare Improvement’s Cooperative of Puget Sound, and colleagues of federal and state governments. States the Improving Chronic Illness Care program STAAR initiative aims to reduce rehospitalizations are a transformation engine and federal with support from The Robert Wood Johnson by working across organizational boundaries by Foundation. It is defined by the following engaging payers, state and national stakeholders, guidance is behind it. If you were to foster patients and families, and caregivers at multiple characteristics: self-management, decision interaction, it would help states move to the support, delivery system esign (which includes a care sites and clinical interfaces. http://www. next level. We are moving to a stage where team-based approach to care and a commitment ihi.org/IHI/Programs/StrategicInitiatives/ to outreach), clinical information systems (or StateActiononAvoidableRehospitalizationsSTAAR.htm it is not states swimming upstream, but registries), organization of health care (to insure 9. MN Community Measurement. http://www.mncm. they are swimming with the platform of the that care is coordinated and not haphazard), and org/site/?page=about ACA, ONC, and AHRQ. The focus of the community (health organizations work with 10.Department of Vermont Health Access, Blueprint other community groups to promote population for Health 2010 Annual Report; January 2011. assistance needs to foster that.” health). For further information, see http://www. http://hcr.vermont.gov/sites/hcr/files/final_annual_ improvingchroniccare.org/ report_01_26_11.pdf About AcademyHealth 4. In 2004, the state joined with private health care purchasers to develop the Smart Buy Alliance which 11.The one exception is Ohio. Washington has the Puget Sound Health Alliance, which is a voluntary AcademyHealth is the professional agreed to uniform performance standards, cost and organization of payers, plans, and providers in quality reporting requirements, and technology which the state participates. Because participation home for health services researchers, demands on health plans and providers. Those in the claims database is voluntary, there are policy analysts, and practitioners, and participating in the Smart Buy Alliance rewarded limitations on the uses of the data and not all a leading nonpartisan resource for the providers and plans that could show they were claims in the state are included. Oregon and providing high quality care. Minnesota’s Smart-Buy Colorado are still developing their all-payer claims best in health research and policy. With a Alliance: A Coalition of Public and Private Purchasers databases. Minnesota limits the use of claims data growing membership of more than 3,500 Demands Quality and Efficiency in Health Care; to their provider tiering project; all other uses are researchers and other experts in health care, May 26, 2005. http://www.commonwealthfund. not permitted. org/Content/Innovations/State-Profiles/2005/May/ 12.State of Washington, Final Update on SQII Project. AcademyHealth promotes and facilitates Minnesotas-Smart-Buy-Alliance--A-Coalition-of- Presentation at the SQII Final Meeting, June 14-15, interaction across the health research and Public-and-Private-Purchasers-Demands-Quality- 2010. http://www.academyhealth.org/files/SQII/ policy arenas. www.academyhealth.org and-Effi.aspx WAFinalMeeting.pdf 9