The Evolution of Aligning Forces
Over the span of Aligning Forces for Quality (AF4Q), the Alliances undertook multiple goals in the cost arena. The Alliances addressed cost and efficiency of care in a defined and measureable way by focusing their cost reduction efforts on conditions their communities specifically selected. Alliances also recognized the importance of transparency, and therefore included a set ofhealth care cost or efficiency measures in their public reports. As the program has progressed, the Alliances have increased their focus on reducing health care costs and spending to promote not just high-quality health care, but more importantly, high-value health care. In addition, each Alliance has developed a set of community-specific cost goals to measure its continued cost work.
The Alliances’ efforts around health care costs entailed a shift from solely addressing clinical quality to addressing cost, which injected tension into tenuous relationships. Cost is a particularly difficult issue because of differing stakeholder perspectives on what is cost versus revenue, emergent cost measures, the real and perceived barriers to accessing data, and concerns about unintended consequences. This complexity resulted in many Alliances initiating their efforts by addressing waste, utilization rates, high-tech imaging, and other less politically charged issues, instead of addressing cost or prices directly.
The nature of the AF4Q program allowed Alliances to forge their own paths regarding health care costs. Depending on their market and community, they wrestled with choosing the right strategy for addressing costs (stemming cost increases or reducing costs), with some Alliances targeting certain conditions or procedures (e.g., C-sections) and others approaching it from a broader perspective (e.g., narrowing variation).
Sometimes, Alliances paired consumer education campaigns with efforts to reduce costs (e.g., appropriate use of antibiotics, emergency department utilization, or generic drug utilization). Both the Detroit and Washington Alliances successfully tackled increasing generic drug utilization in their markets, with huge cost savings. In September 2012, Detroit reported an improvement of almost 18 percentage points between 2006 and 2010 in the use of generic (non-brand) medications. The New Mexico Alliance launched a campaign to educate patients about whether medical situations call for a visit to an emergency department or an urgent care facility.After the campaign, four local hospitals shared data and reported that non-emergency visits had dropped between 6 and 16 percent depending on the hospital, compared with the previous year—an average of 1,573 fewer non-emergency ED visits per hospital.
Alliances have used cost and quality data to successfully track and reach a number of different goals within their markets. They have also used cost and quality data to help practices adopt patient-centered models of care, improve care coordination, use electronic health records more effectively, and regularly measure care to identify opportunities for continuous improvement.