First 14 communities designated Chartered Value Exchanges by HHS

Organizations will have special access to Medicare data

After a year of reviewing applications from multi-stakeholder organizations across the country, the U.S. Department of Health and Human Services (HHS) has selected the first 14 communities to be designated Chartered Value Exchanges (CVEs). (See the list of CVEs, below.)

Chartered Value Exchanges

The CVEs represent one of four "cornerstones" on which HHS seeks to build its health care reform initiative, which involves:

  • advancing interoperable health information technology;
  • measuring and publishing quality information to enable consumers to make better decisions about their care;
  • measuring and publishing price information to give consumers information they need to make decisions on purchasing health care;
  • promoting incentives for quality and efficiency of care.

As CVEs, these organizations will reap a number of benefits, including:

  • The ability to join a nationwide Learning Network sponsored by HHS' Agency for Healthcare Research and Quality (AHRQ). This network will provide peer-to-peer learning experiences through facilitated meetings, both face to face and on the web;
  • Access to HHS experts and new tools, including an ongoing private web-based knowledge management system;
  • Information from the Centers for Medicare & Medicaid Services (CMS) on physician-group level performance, which will be available this summer.

Bringing communities together

As multi-stakeholder organizations, the CVEs comprise representatives from numerous community groups, including providers (health systems, hospitals, and physician groups), health plans, employers, consumers, and insurance carriers. They work on the theory that the only way to optimize quality is to engage all of these groups.

While they have similar missions, each CVE has its own unique approach. "We were formed with a pure focus on value in health care," says Karen Feinstein, PhD, president and CEO of the Pittsburgh Regional Health Initiative, which was founded in 1998 as one of the first regional multi-stakeholder coalitions. "Our goal is to increase the quality of services provided and hopefully by increasing that quality taking waste, errors, complications, and inefficiencies out of the system so every dollar spent finds value," she says.

On the other hand, she says, the Alliance for Health in Grand Rapids, MI, is a regional health systems planning agency that has served a 13-county region in western Michigan for 60 years.

"Originally one of the federal health systems planning agencies, we are a strategic planning organization," explains Bridget White, vice president. "We convene the business group on health, the physician group on health, the nursing coalition, insurance companies and agencies, and so on."

The Puget Sound Health Alliance, based in the Seattle area, "was formed in 2005 at the instigation of the King County executive, who got frustrated with the rate of increase of health care costs," recalls Margaret Stanley, MHA, executive director. As a multi-stakeholder organization, she explains, "we can see both the supply side and the demand side; we work together, and get all the stakeholders at the table."

The alliance includes employers (both public and private), health plans, provider organizations (medical groups, hospital associations), and consumers.

Initiatives are impressive

Each of these organizations already has racked up an impressive list of quality successes — each with their own unique target areas.

"We have several targets," says Feinstein. "We started to look at what we buy with health care dollars that does not add value — such as error, waste, unnecessary procedures. We wanted to determine how a clinical service unit could deliver only high-value care, and we looked to processes that work in other sectors — such as the Toyota method. We then developed our own methods, which we call 'Perfecting Patient Care.'"

To spread this knowledge, the initiative created its own university. "Thousands of people — including QI professionals, trustees, nurses, and doctors — have gone through our university," says Feinstein. "We teach our method and have a whole series of champion programs. People sign on, do major projects, and demonstrate how they might use Toyota methods to eliminate poor care."

While doing this, she says, "We also feel in many ways we need to engage the employer and consumer — the people who purchase and select health care more directly. We can train people and have sites with excellent care, but the biggest reward will be when people select care from quality providers."

The Michigan quality story, says White, includes having several of its business executives, particularly from General Motors, playing a major role in the formation of The Leapfrog Group.

"We were one of the early Leapfrog rollout communities," she notes. "Then, the Michigan Health and Hospital Association wanted to 'play' this game. We began to realize the Leapfrog measures had some limits, and using volume as a quality proxy really missed the boat on some smaller and more rural hospitals, so we formed the Michigan Health and Safety Coalition in 2003. We took the Leapfrog standards, added additional criteria beyond volume for a little more definitive and inclusive set of hospital quality measures, and today we use them both."

Actually, the alliance's pursuit of quality began about 13 years ago when the business coalition on health became involved in value-based purchasing and HEDIS data. "The coalition said they were paying all this money and didn't even know what they were buying," White recalls. "So they started asking health plans to publicly report HEDIS measures. Then, this evolved into an expanded request for information and value-based purchasing." This approach, she notes, ultimately was adopted by the National Business Coalition on Health, which uses a standardized method for evaluating health plans and publicly reports results.

"From this, we began to understand what value and quality were, and the next place we looked was the hospital," White continues, noting it coincided with the Institute of Medicine's Landmark report "To err is human."

"Many of our hospitals also have their own dashboard of their own quality indicators," White notes, adding that the alliance is now focusing on physicians.

"I am really proud of our hospitals; they have really embraced the process and are genuinely engaged and committed to publicly reporting quality," says White. "The business coalition approached them a couple of years ago about using Lean tools and they have actively embraced implementing Lean systems. I'm also very impressed by their openness; Spectrum Health became the first hospital organization in the state to report charges for the most 100 frequent treatments."

In Seattle, the alliance has established clinical improvement teams in various chronic diseases and other areas — heart disease, diabetes, low back pain, depression, asthma, prevention, and prescription drugs. "We also have a hospital quality measures group and an affordability work group," adds Stanley. The clinical improvement teams are charged with determining what the quality measures and clinical guidelines should be, drawing from national standards, and recommending change strategies — what each party needs to do to make care of a given disease better. "These are most detailed for providers," says Stanley. "Ambulatory care measures might include using a disease registry, calling patients in for regular visits for diabetes care, or encouraging heart disease patients to take a cardiac risk assessment."

While it is too soon to track improvement, Stanley says the alliance will be surveying employees and others to see if they have followed its recommendations. "We published a report on Jan. 31 we called a 'community checkup,'" says Stanley. "We found room for improvement, and a lot of variation across and within measures. But this gave us a baseline."

What CVE designation means

The CVE leaders all agree their new designation will help them achieve their long-term goals. For Feinstein, engaging the employer and consumer is "the missing piece" in her organization's equation, and "that's where the CVE designation adds value to us. While we are creating high value and training these champions, we need at the same time to be demonstrating their value with hard data. We can't say someone went through our training and therefore a certain demonstration project has merit; we have to eventually say we develop providers who are better than the pack — and they have to be rewarded."

The best way to do that, she says, is to have insurers willing to pay favorable rates and pay for quality improvements made by these providers, "and also make that information known to the employers selecting plans and the consumers who make decisions within those plans."

"Data, data, and data" are paramount, Feinstein continues. "So much of this is predicated on giving consumers credible, reliable data," she explains. "We want to be fair — the more data we have and the more we can show a realistic picture of excellence, the more we can go forward to encourage the use of those data. We hope not only to get data we never had — including drilling down to the physician level — we hope the collaborative will enable us to sort out the pros and cons. Having this national network and being connected to people like [Brookings'] Mark McClellan and the leadership at AHRQ will give us a better understanding of value and [enable us] to create better transparency for the consumer."

AHRQ, she explains, is "the home of the CVE — they are command central. AHRQ has designated facilitation to Pat Power and her group, called CHI, in Sacramento. There will also be a string from Mark McClellan and his team at Brookings."

"We are all struggling with rising health care costs," adds David Fleming, MD, chairman of the Puget Sound Health Alliance and director of the Seattle/King County Health Department. "Our approach is to convene key stakeholders in delivery and jointly define measures for improving quality — which is one way to control costs. Actions at the local level need to be driven by local innovation, and being a CVE in that network enables us to learn what is and what is not working across the country. There needs to be a way of sharing information across these local organizations and this will enable us to do our work better."

People around the country are trying different QI approaches, he continues. "The CVE designation enables information to be collected, analyzed, and displayed at AHRQ, so AHRQ will now be able to serve as a clearing house for information."

One of the big benefits, Stanley adds, will be the Medicare data. "When we report to clinics on these performance measures, we will really have information that represents almost all their practice," she notes. "One of the advantages of public reporting is when we merge this information with our own information you get a much larger database and sample size is not as much of an issue."

"We think CVE designation will inspire and motivate us to continue the on path we are on," says White, noting that her organization is also participating in the Robert Wood Johnson Foundation initiative "Aligning Forces for Quality."

"In fact," she says, "out of the 14 CVEs, eight are 'aligning forces' communities." (For more on this initiative, go to:

Access to information is critical, White continues. "We are down the path on beginning to measure quality performance of physician groups and organizations, and in order to do that we need to aggregate data from commercial payers, and also work with our state to get Medicaid data," White explains.

"By being a CVE, the very large and important piece — data from Medicare — is available to us. Now we will have a very complete data set to measuring quality, publicly reporting quality, and most important, the doctors and organizations will have complete and meaningful data for quality improvement."

Hospitals will benefit from the CVE designation at "a couple of levels," says White. "First, many hospitals either own or partner with a physician organization, and they will really be seeing movement toward a higher level of system integration. As we see that across hospitals and physician groups — both primary care physicians and specialists — it gives us a more comprehensive and accurate look [at performance] for all our actionable set of quality measures on inpatients and outpatients, on which we can take more meaningful action on getting better health results."

Bridging the gap between inpatient and outpatient care is critical, she continues. "We really need to bridge that gap; take, for instance, chronic conditions," she offers, "they may account for as much as 80% or more of our total health care costs, according to research. We see a lot of repeat admissions, often because when patients leave the hospital they are stabilized, but they do not continue [proper care] at home. If we can bridge the hospital's successful results with the primary care providers, we will have more of a continuum of care and, ultimately, get better results."

[For more information, contact:

Karen Feinstein, PhD, President and CEO, Pittsburgh Regional Health Initiative, Centre City Tower, Suite 2400, 650 Smithfield Street, Pittsburgh, PA 15222. Phone: (412) 412-594-2555. E-mail: Web:

David Fleming, MD, Chairman, Margaret Stanley, MHA, Executive Director, Puget Sound Health Alliance, Seattle, WA. Phone: (206) 448-2570. Web:

Bridget White, Vice President, Alliance for Health, 1345 Monroe Avenue NW, Suite 256, Grand Rapids MI 49505. Phone: (616) 248-3820. E-mail:]