Elsevier

Social Science & Medicine

Volume 67, Issue 6, September 2008, Pages 1018-1027
Social Science & Medicine

Understanding a collaborative effort to reduce racial and ethnic disparities in health care: Contributions from social network analysis

https://doi.org/10.1016/j.socscimed.2008.05.020Get rights and content

Abstract

Quality improvement collaboratives have become a common strategy for improving health care. This paper uses social network analysis to study the relationships among organizations participating in a large scale public–private collaboration among major health plans to reduce racial and ethnic disparities in health care in the United States. Pre-existing ties, the collaborative process, participants' perceived contributions, and the overall organizational standing of participants were examined. Findings suggest that sponsors and support organizations, along with a few of the health plans, form the core of this network and act as the “glue” that holds the collaboration together. Most health plans (and one or two support organizations) are in the periphery. While health plans do not interact much with one another, their interactions with the core organizations provided a way of helping achieve health plans' disparities goals. The findings illustrate the role sponsors can play in encouraging organizations to voluntarily work together to achieve social ends while also highlighting the challenges.

Introduction

Many health care initiatives—including publicly sponsored efforts and public–private partnerships—incorporate a strong collaborative component to achieve their goals. In recent years, quality improvement collaboration has become a common strategy for improving health care. One example involves the growing interest in rapid cycle quality improvement efforts like those sponsored by the Institute for Healthcare Improvement's Breakthrough Series (Berwick, 1989, Berwick, 1998). Through collaboration, participants learn about the variations in practice and identify potential changes in care delivery processes that can promote change (Kilo, 1998). Though most collaborations focus on general quality improvement, some have gone beyond this to address disparities in quality for diverse racial and ethnic populations (Institute of Medicine, 2002, Landon, 2007).

While techniques for evaluating collaborative outcomes are developing (Cretin et al., 2004, Landon, 2007), less is known about evaluating collaborative processes. Researchers generally rely on qualitative information obtained through interviews with participants, supplemented by numerical counts of events (e.g., meetings, attempted changes). We complement this traditional qualitative approach with formal analyses of a collaborative structure and use social network analysis (SNA) to provide additional insight on collaborative processes. Several existing studies have examined the organizational structure (often through SNA) of coordinated service networks such as mental health networks, trauma centers, and services for the aged (Bazzoli et al., 1998, Bolland and Wilson, 1994; Goldman, Morrisey, Ridgely, Frank, Newman, & et al., 1992). Directly examining the structure and functioning of health care collaborative processes is the focus of this paper.

The National Health Care Collaborative (NHPC), formed in late 2004, comprises large health plans from across the United States and is sponsored by the Agency for Healthcare Research and Quality (AHRQ) of the U.S. Department of Health and Human Services and by the Robert Wood Johnson Foundation (RWJF). Sponsors hoped supporting collaboration would encourage collective action and engagement on reducing health care disparities and encourage participating health plans to think creatively about reducing disparities.

Together, the NHPC plans covered more than 76 million people in the United States at its formation. Five—Aetna, CIGNA, Kaiser Permanente, United Health Group and WellPoint—provide health care coverage nationwide in many locations. Four—Harvard Pilgrim Healthcare of Massachusetts, HealthPartners of Minnesota, Highmark, Inc. in Pennsylvania, and Molina Healthcare, Inc. headquartered in California—are regional firms. Participating plans became involved in NHPC by attending meetings or being invited to participate by NHPC sponsors or support organizations. The NHPC decided to focus on diabetes because quality measures are readily available and the condition affects a large proportion of the population (and disproportionately racial and ethnic minorities). Substantial disparities are known to exist in diabetes care nationally (AHRQ, 2006), and the NHPC allowed health plans to explore and confirm disparities within their own membership (NHPC, 2006) (For additional detail, see Gold et al., 2007.).

Nine participating health plans and six other organizations, as sponsors or supporters of the NHPC, were involved in the first phase. The NHPC's cosponsors—AHRQ and RWJF—each actively participated in the effort's activities. Under contract to the sponsors, two primary “support organizations”—the RAND Corporation (a large, nonpartisan research organization) and the Center for Health Care Strategies (a nonprofit organization focused on improving quality and cost effectiveness of publicly financed health care)—helped coordinate efforts and provide technical assistance. The Institute for Healthcare Improvement (a nonprofit organization focused on improving quality of health care) and a communications firms, GMMB, also provided support.

The NHPC's first phase was consistent with many health care collaborations (Kilo, 1998). Over 2 years, the NHPC held four in-person meetings of all participants. In addition, support organizations held periodic conference calls with individual health plans, helping each plan to measure possible racial/ethnic disparities and to put interventions in place to reduce disparities. Conference calls of all NHPC participants took place periodically, and calls between the sponsor and support organizations were held every few months to discuss the future plans for the NHPC.

Fig. 1 shows a framework illustrating the pathways through which the NHPC could influence work to reduce racial/ethnic disparities. Participation was meant to help enhance health plans' commitment to reducing disparities. These commitments translated into concrete actions that could, over time, strengthen efforts to reduce disparities. NHPC aimed to help plans develop and improve data on disparities, and identify and implement pilot interventions to reduce disparities. When ideas on data and interventions developed, the NHPC encouraged sharing this information between participants. The ultimate goal was communicating the collaborative results to organizations and others external to the NHPC. The NHPC is of interest because while we know a great deal about the centralized control of change (Goldman et al., 1992), we know much less about how to leverage the voluntary energy of independent organizations to manage that change.

Section snippets

Methods

SNA was used to help understand collaborative processes because it focuses attention explicitly on relationships and ties among the organizations. This is a critical systemic feature beyond the attributes of network members (Wasserman & Faust, 1994). SNA allowed us to examine communication and collaboration across organizations. The network data were collected between December 2005 and January 2006 (about 18 months after the NHPC started) and were used to supplement ongoing, independent and

Overall perceptions of the NHPC

Participants were positive about the NHPC (Table 2). All but one participating organization felt that the NHPC was at least somewhat important to attaining organizational goals (Question 1). In fact, 10 of the 15 organizations reported that the NHPC was very important or crucial for achieving organizational goals with regard to reducing health care disparities. Overall, organizations felt that the NHPC has carried out its responsibilities and commitments “to a considerable extent” (Question 2).

Summary of findings

Organizations are necessarily interdependent and these interdependencies generate complex networks with cooperative and competitive ties. The network analyses highlight the central role of the NHPC's sponsor organizations and primary support organizations as part of the core of the network for all of the studied relationships (with s5 as an exception). During the first few years of the NHPC, sponsors and primary support organizations had the most contact with participating plans and formed the

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David Introcaso, then in charge of this evaluation for the Agency for Healthcare Research and Quality (AHRQ), envisioned and supported network analysis as a vital component of the evaluation. We are grateful for the support of all participants in the National Health Care Collaborative (NHPC) for their willingness to provide data essential to this work. This study was funded as part of a contract between AHRQ and Mathematica to evaluate the NHPC. At Mathematica, Judith Wooldridge provided valuable input throughout the evaluation. All views expressed in this paper are those solely of the authors and not necessarily of any of the involved organizations or NHPC participants.

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