'Value exchanges' next step in HHS QI initiative

Goal is person- and population-centered health

The Department of Health and Human Services (HHS) has unveiled a new phase of its Value-Driven Health Care Initiative, an undertaking with several components all designed to support QI through public reporting of cost and quality data.

The voluntary plan calls for the development of "value exchanges," which HHS describes as "nationally chartered, local collaboratives that would become part of a nationwide system using nationally recognized standards to measure and improve quality of care at the community level."

These value exchanges are considered "advanced" versions of the community leader collaboratives selected and chartered by HHS. While the final form (and who it will comprise) has not yet been determined, HHS anticipates that pre-existing collaboratives will be at the core. In order to receive a value exchange charter, says HHS, candidates must be independent, nonprofit, local organizations that are:

  • recognized as a community leader;
  • actively engaged with critical local stakeholders;
  • financially sustainable;
  • facilitating the collection of provider-level measurements across the Institute of Medicine's six aims;
  • using or promoting performance measures for public reporting of cost and quality, rewarding better care, quality improvement, and interoperable health IT;
  • fostering collaboration and information sharing;
  • supporting knowledge transfer;
  • conducting ongoing evaluation and improvement efforts;
  • using national performance measures effectively.

"We haven't designated [any value exchanges] yet," says Nancy Wilson, MD, MPH, senior advisor to the director of the Agency for Healthcare Research and Quality (AHRQ). AHRQ will administer and maintain the national learning network, which will provide expert faculty, tools, resources, and web-based communications to members of the exchanges to facilitate expansion and sharing of QI techniques.

Wilson notes that the Federal Register has just published a notification of a 60-day period for public comment. "Then we will post RFPs [Requests for Proposals] to apply — hopefully, by Sept. 1," she says.

Explaining the vision

As for the vision behind the value exchanges, "I would say the goal is really enhancing person- and population-centered health by improving quality health care services and reducing costs," says Wilson, adding that "thinking about the person and the population is a bit different than has been done historically; we have not always tried to operationalize QI work around that notion."

The other piece of the goal, she continues, is for employers, health plans, providers, consumer groups, and all stakeholders to work together to improve health care value for patients. "Historically, providers and hospitals have been leaders in QI," she says. "What we are suggesting is that we can make some breakthrough improvements by engaging all stakeholders in the community."

This effort, she explains, operates on some underlying assumptions. "We really think that greater transparency of this information will improve consumer selection of providers and management of health, and will also accelerate QI by providers — if they think in terms of comparative performance information," Wilson asserts. "And, having more information in the marketplace is really going to allow insurance plans to design benefits and payments [around more efficient use of health care services]. Personally, for example, it would be great if plans provided some sort of discount or benefit that incentivized folks to do prevention."

Many stakeholders involved

Following this model, the value exchange is, in essence, a multi-stakeholder coalition, Wilson explains. "These are the folks at the table; their authority is by consensus — and it is voluntary. We are encouraging local stakeholders to sit down together, agree on a common goal, commit energy and resources to that goal or goals and measure how well they perform."

Hospital quality managers, she continues, "have a critically important role to play. They are the folks who have the tools for QI, and in general it is the providers who need to come up with the recommendations for what makes sense for the redesign of health care. After all, they understand how to improve the system of care."

What's important for hospitals to recognize, she says, is that there is a great need and value for the hospital community to look beyond its borders and work for patient value across care settings. "Yesterday I attended a breakout session where a hospitalist was giving a presentation about palliative care and the importance of working across settings so that patients at the end of life who truly wanted to be in the hospital were in the hospital but those who preferred other support systems would have those as well," Wilson shares. "There are multiple examples of how we can improve value for patients."

One of the problems in the past, she notes, had been focusing only on improving quality and lowering costs for a particular stakeholder. "That does not always pan out," says Wilson. "We have to think more as a county, for example, and find the win-win for the hospital, the patient, and so forth."

The common goal that unites employers and plans with providers and consumer groups, Wilson says, is value for the patient. "That's really critically important," she observes. "Historically, employers and plans have been perceived by providers as simply emphasizing cost, and provider groups have been perceived as working to improve quality without considering cost. We do not have the luxury of having stakeholder groups going off in parallel — we need everyone at the table. We are very clearly stating that quality is local, QI is local, and success requires local stakeholders committed and working together."

[For more information, visit the HHS transparency web site: www.hhs.gov/transparency, or contact Nancy Wilson at (301) 427-1310.]