Comparative Health System Performance Initiative: RAND Center of Excellence

Principal Investigators 

Cheryl L. Damberg, Ph. D., and M. Susan Ridgely, J.D.

Partners

• Pennsylvania State University.
• University of California, Los Angeles (UCLA).
• Stanford University.
• Harvard University.
• Integrated Healthcare Association of California.
• Minnesota Community Measurement.
• Washington State Health Alliance.
• Wisconsin Collaborative for Healthcare Quality.

Overview

The RAND Center of Excellence is working to identify, classify, track, and compare health systems in today's healthcare 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.

Aims

The Center's researchers are using a mix of qualitative and quantitative methods to examine the rapidly evolving healthcare landscape. The team’s aims include:

• 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.
• Cataloging the attributes of health systems and their component entities (i.e., hospitals, physician organizations) and examining the relationship between health system attributes and performance on quality and cost measures.

Research Projects

RAND researchers are taking a "deep dive" within 24 health systems and their participating physician organizations in four States (California, Minnesota, Wisconsin, and Washington), conducting indepth interviews with a broad set of health system and physician organization leaders to gain a richer understanding of health systems than is possible to glean from administrative and claims data or fixed-choice surveys. By going inside health systems, Center investigators seek to gain 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.

To advance the Center’s work, the team is addressing research 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 health systems changing over time?
• What important attributes characterize different types of health systems?
• What attributes define  a health system as "high performing"?
• Is there a relationship between health system attributes and health system performance on cost and quality measures?
• What mechanisms—such as deploying clinical decision support within health IT and other structural supports, using incentives, and engaging in care redesign—are health systems using to facilitate rapid uptake of evidence-based care practices?
• How do market factors (e.g., the competitiveness of the local healthcare market) influence health system performance?

Researchers are examining some of the mechanisms that health systems and their affiliated physician organizations use to promote the uptake of evidence-based practices and to drive performance improvement. In particular, Center investigators are examining three sets of mechanisms to understand variations in the application of these mechanisms and how these variations affect health system performance:

• Adoption and routine use of health IT.
• Use of financial and nonfinancial incentives with physicians, including behavioral nudges.
• Role of clinical integration and whether organizational integration is associated with clinical integration.

Additional information about RAND’s research projects is included below in the Data Core section.

Data Core

The Center's Data Core is constructing an integrated library of secondary data from multiple sources (Federal, State, regional collaboratives), coordinating empirical analysis across the Center, and undertaking analyses of secondary data to describe variation in performance across health systems and physician organizations and to compare performance of providers in and out of health systems. The Data Core is also leading the “deep dive” site visits to gather primary data to describe the organization and governance of health systems and to assess what these organizations are doing to get to high performance.

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

1. Health Information Technology: The Health IT Project is examining how health systems facilitate the adoption of health IT by physicians and is using primary data (interviews with chief information officers in 24 health systems) to explore the relationship of health IT adoption and use to health system performance. The team is using secondary data (e.g., HIMSS survey) to characterize all health systems nationally in terms of their adoption and use of a range of health IT functionalities, how this use has changed over time, and how the adoption of different electronic health record functionalities relates to performance.
2. Incentives: The Incentives study team is cataloging the financial and nonfinancial incentives physician organizations within the focused sample of 24 health systems are using to drive health system and provider behavior. For the financial incentives, the team is describing targeted behaviors (i.e., measures), strength of incentives, and alignment between internal and external incentives. The team is also assessing whether physician organizations are using behavioral nudges to influence physician behavior. The project is examining variation across health systems in the use of different types and mixes of incentives and the association with performance.
3. Integration: 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 its adoption of evidence-based practices by primary care providers. Using physician practice site manager and staff surveys, the team is measuring organizational and clinical integration and contextual factors in practice sites within the physician organizations in the 24 health systems and will explore the relationships between contextual and organizational factors and levels of clinical integration.
4. Safety Net: The Safety Net study team is examining strategies community health centers (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 study team fielded a survey of more than 400 CHC medical directors in 12 States and the District of Columbia and is conducting indepth interviews with medical directors and staff of 40 CHCs in the 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 patient-centered outcomes research practices.

For more information, visit the RAND Center of Excellence on Health System Performance.