RAND Center of Excellence

Overview

The Agency for Healthcare Research and Quality (AHRQ) funded the RAND Corporation, in collaboration with researchers from Pennsylvania State University, UCLA, and Harvard University, to create a Center of Excellence on Health System Performance. The Center's charter is to identify, classify, track, and compare health systems in today's health care markets and to characterize the attributes of high-performing health systems—those systems that can more nimbly translate new research evidence into routine clinical practice, thereby improving quality, reducing costs, and achieving better patient outcomes.

Our Strategy

The Center's researchers use a mix of qualitative and quantitative methods to examine the rapidly evolving health system landscape. We are investigating changes in health systems (for example, increased consolidation, greater integration among hospitals and physician organizations, and growth of health information technology [IT] systems), seeking to understand how changes like these may affect the ability of hospitals and physician organizations to achieve high-quality care at lower costs. The Center is developing a taxonomy to characterize the types of existing health systems, to catalog their important attributes, and to examine the relationship, if any, between health system attributes and system performance on quality and cost measures.

Taking a Deep Dive

Center researchers are taking a "dive deep" within health systems and their participating physician organizations in four regions of the United States, conducting indepth interviews to gain a richer understanding of health systems than is possible to glean from analyzing administrative and claims data or examining the responses to fixed choice surveys. Our deep dive is intended to yield a more complete understanding of the complex structures of health systems, as well as the many contextual and environmental factors that contribute to health system performance.

Our Partners

In addition to the Center’s multidisciplinary, multi-institutional research team, we are fortunate to be partnering with four of the Nation's preeminent regional quality collaboratives. By sharing their insights, experience, contacts, and data with us, these organizations are providing an invaluable laboratory for the Center's work and collaborating with us to disseminate our findings to those who can most benefit from them.

The Center’s partners are:

• Integrated Healthcare Association of California.
• Minnesota Community Measurement.
• Washington State Health Alliance.
• Wisconsin Collaborative for Healthcare Quality.

Leadership

The RAND Center of Excellence on Health System Performance is led by Cheryl Damberg, senior principal researcher and RAND Distinguished Chair in Healthcare Payment Policy.  The Center is directed by M. Susan Ridgely, senior health policy researcher.

To advance the Center’s charter, our researchers are addressing questions such as the following:

• What is a health system? What are its fundamental characteristics?
• What types of health systems currently exist and how are they changing over time?
• What important attributes characterize different types of health systems?
• What defines a health system as "high performing"?
• What mechanisms available to health systems (such as deploying clinical decision support within health IT, adopting risk-based payment models, or using care redesign strategies) facilitate more rapid uptake of evidence-based care practices?
• Is there a relationship between health system attributes and health system performance on cost and quality measures?
• How do market factors (e.g., the competitiveness of the local health care market) influence health system performance?

Research Projects and Data Core

Center researchers are examining some of the mechanisms that health systems and their affiliated physician organizations use to promote the uptake of evidence-based practices in primary care. In particular, our investigators are keenly interested in how these three sets of mechanisms affect health system performance:

• Adoption and routine use of health IT.
• Provision of financial and nonfinancial incentives to physicians.
• Strategies for addressing fragmentation of care.

The Center is organized around a Data Core, led by José Escarce, which has assembled and maintains a data library for Centerwide use.

Data Core

The Data Core provides Center research teams with an integrated data library, as well as methods, measurement, and analytic support. Center data come from multiple sources (Federal, State, regional quality collaboratives, private sector, primary data collection); data are housed at RAND with appropriate safeguards. Research activities of the Data Core team include:

• Defining a health system.
• Defining high performance.
• Characterizing the attributes of health systems and the health care markets in which they operate.
• Looking at relationships between the attributes of health systems and high performance.
• Creating a taxonomy of health systems.
• Examining how health systems are evolving over time.

The Data Core also provides support to four independent study teams. Each team is collecting primary data to examine a specific aspect of health systems that may influence how uptake of evidence-based practices and performance affect quality, cost, and patient outcomes.

Health Information Technology, led by Paul Shekelle

Health IT can promote adherence to clinical guidelines, improve care quality and patient safety, and help reduce costs.  However, the effects of implementing health IT vary across health systems, suggesting that context and implementation are important to consider when incorporating health IT into routine clinical practice.

The Health IT study team is using secondary data (e.g., HIMSS survey) to characterize all health systems in the Center’s four study regions in terms of their adoption and use of a range of health IT functionalities. In addition, the team is pursuing a richer understanding of how health systems and their provider organizations “make health IT work” (e.g., how it is actually used, how management supports it, how it meshes with system goals and priorities, etc.).

Using existing survey data collected by one of our partners (Minnesota Community Measurement), the Health IT team is developing a profile of health IT use and Patient-Centered Outcomes Research (PCOR) adoption in Minnesota.  The team will conduct site visits to learn whether the picture of health IT use emerging from the survey (which is completed by administrators) is consistent with what frontline clinicians tell us about daily practice; what the chief barriers and facilitators to PCOR uptake are; and what contextual factors clinicians and administrators consider influential in terms of delivering evidence-based care.

Incentives, led by Cheryl Damberg

The current health care environment is characterized by widespread experimentation with incentives, operating at multiple levels (for example, payer to health system, health system to physician organization, and physician organization to individual physician). Incentives can be both financial (e.g., compensation) and non-financial (e.g., behavioral nudges, physician profiling). But despite the prominence of incentives, we lack a sound understanding of how to design and use them to improve health system performance.

The Incentives study team is cataloging the type, size, and focus of incentives being used by health systems and constructing a taxonomy of incentives. The team is seeking to understand how physician organizations translate external incentives into the internal incentives they use to motivate desired behaviors from frontline physicians. To do this, the team is collecting primary data, using surveys and interviews, in a representative sample of 25 health systems across our four study regions.

The data, together with data from the Data Core, will enable them to characterize the external incentive environment, the internal incentive schemes in 25 health systems and their physician organizations, and the factors that influence the design decisions made by these and other health care organizations.

Integration, led by Sara Singer

Fragmentation undermines the ability of health systems to deliver good patient care and to achieve good outcomes. A common strategy for addressing fragmentation is to adopt integrated organizational models such as accountable care organizations (ACOs). Other integration mechanisms focus on the clinical level, such as improving communication between primary and specialty physicians. However, studies have yet to demonstrate whether greater integration at the organizational level leads to greater integration at the clinical level and consequently better adoption of evidence-based practices and better outcomes.

The Integration study team is evaluating the relationship between a health system's degree and type of organizational integration, its achievement of clinical integration, and adoption of evidence-based practices by primary care providers. Using PO practice site manager and staff surveys, the team is measuring organizational and clinical integration and contextual factors for 90 to 100 practice sites in 50 physician organizations in 25 health systems in our four study regions to assess the relationships between contextual and organizational factors and levels of clinical integration.

Safety Net, led by Justin Timbie

Community health centers (CHCs) provide primary care to vulnerable and low-income residents. Unlike other types of physician organizations that have rapidly joined large health systems, most CHCs maintain only informal connections with other local health care providers and health systems. However, the expansion of new delivery models and value-based payment systems are providing new incentives for safety net providers to develop more integrated systems of care.

The Safety Net study team is examining strategies that CHCs use to achieve greater care integration with three types of service providers: specialists, hospitals (and emergency departments), and social service organizations. Strategies include establishing formal agreements; aligning infrastructure, planning, and service improvement activities; and implementing care coordination strategies designed to promote continuity of care and information sharing.

The team is fielding a survey of more than 400 CHC medical directors in 12 States and DC and conducting indepth interviews with medical directors and staff of 40 CHCs in our four study regions to better understand how these strategies are used, whether they achieve higher levels of integrated care, and how integrated care affects use of PCOR practices. The team is also examining the role of context (including participation in Medicaid ACOs) in explaining both the use and effectiveness of strategies to promote integrated care.

 For more information, visit the RAND Center of Excellence to Study High-Performing Health Care Systems.