Health Reform and the Role of Community Partnerships in Promoting Quality and Value

Now that the Patient Protection and Affordable Care Act has been signed into law, the key question is whether it will lead to improved quality and better value in health care. While many people feel that this is an issue best left to the federal and state governments, many analysts feel that the reforms needed to improve quality and value cannot be done by governments alone but that real, lasting reform needs to occur at the community level.

It is unknown, however, whether communities have the capacity for such complex reform. An initiative currently being funded by the Robert Wood Johnson Foundation, called Aligning Forces for Quality (AF4Q), may give us a better idea whether communities have the capacity to facilitate such complex change. AF4Q is RWJF’s core strategy to help improve the quality of health care. As part of AF4Q, RWJF is currently investing in efforts to improve health systems in 17 communities across the nation. The initiative brings a commitment of resources, expertise, and training to turn promising practices into real results at the community level.


This week’s post is the fourth in our five-part series “Viewpoints: Health Economics.” This series of posts from invited authors will examine issues in health economics and health policy following the passage of health reform. Watch for the final piece in the series in the coming weeks.


AF4Q asks the people who get care, give care, and pay for care to work together toward common fundamental objectives to lead to better care. The initiative aims to lift the overall quality of health care, reduce racial and ethnic disparities, and provide models for national reform. RWJF is focusing their initiative on three interrelated strategies that experts believe are essential to improving health care quality: performance measurement and public reporting, consumer engagement, and quality improvement.

Researchers at Penn State (where I am a faculty member) and other universities are leading the evaluation of AF4Q. The overall objectives of the evaluation are to (1) chronicle and document the activities of the AF4Q communities; (2) understand the impact of these activities; (3) identify key barriers and facilitators of AF4Q community success; (4) document and communicate lessons learned for purposes of dissemination to other communities; (5) make suggestions to the AF4Q national program office regarding program activities, including technical assistance or other needs; and (6) provide valuable feedback and data to the communities for formative purposes.
As part of our evaluation, a key focus has been on the multi-stakeholder entities that oversee and coordinate activities within each of the communities—the alliances, as we call them. Vital to their ability to meet and maintain the objectives of the AF4Q initiative is the ability of alliances to develop the capacity to sustain efforts in the long term. This concept of capacity building is defined as the activities and structures that leverage existing resources in pursuit of common objectives and are sustainable in the long term.

Using qualitative data collected from early interviews with key stakeholders from four AF4Q communities, we conducted early assessments of capacity building. From our data, we identified two domains that are vital to capacity building. The first domain, infrastructure and governance, is composed of the following components:

  • Establishment of the right organizational and governance structure,
  • An appropriate balance of power and participation,
  • A decision-making strategy,
  • The ability to make collateral leadership work,
  • Clearly defined staff and member roles, and
  • The development of resource capacity.

The second domain, stakeholder relations and participation, encompasses the following:

  • Building on cultural and historical relationships,
  • The alignment of stakeholder goals,
  • Active recruitment of stakeholders, and
  • Successfully sustained participation.

One central finding from our work is that while alliances face similar challenges, there is no one-size-fits-all approach to capacity building. Environmental and market factors, as well as alliance goals, greatly influence what strategies for capacity building are appropriate for each alliance. We also note that there are many tradeoffs and challenges to capacity building, which are highly interdependent; strengths and problems in one area of the alliance can lead to strengths and problems in another. Finally, while developing a successful business model and securing monetary resources are vital for success, alliances must focus on all the domain components described above.

It is important to note two things. First, these results are from very early stages of alliance development. Capacity building is an ongoing process that involves a pattern of learning, reevaluation, and readjustment over time. Second, capacity building is just one of many issues related to quality improvement that we are examining as part of our evaluation of AF4Q. We also have preliminary findings regarding communities’ experiences with data aggregation for the creation and dissemination of public reports; the challenges faced by alliances in developing strategies to engage hospitals and doctors in quality improvement; and the use of benefit design changes, such as tiered hospital networks, to involve patients and consumers as drivers for improved quality of care. Research summaries describing these findings can be found at our evaluation website.

We are still unsure of the degree to which successful capacity-building positions communities to accomplish a charge as lofty as improving the quality and value of health care. However, the work of the AF4Q alliances will give us a better understanding of this and whether lasting reform truly begins via government intervention or at the community level.

It is important to remember that there are issues aside from community partnerships that are paramount to reform of the health care system including payment reform, information and outcomes transparency, patient and provider behavior change, the use of health information technology, and insurance coverage. Each of these is receiving attention as reform implementation commences. We will be interested to see if those communities that have developed a local capacity for quality improvement are able to make progress more rapidly.


As a leading nonprofit health care research and consulting institute dedicated to improving human health, Altarum encourages open discussion and debate about the many challenges in health care today. All postings to the Health Policy Forum (whether from employees or those outside the Institute) represent the views of the individual authors and/or organizations and do not necessarily represent the position, interests, strategy, or opinions of Altarum Institute. Altarum is a nonprofit, nonpartisan organization. No posting should be considered an endorsement by Altarum of individual candidates, political parties, opinions, or policy positions.


Dr. Scanlon has rightly put a spot light on implementation of the promises in the Patient Protection and Affordable Care Act. Who pays, how, and when are critical issues. The relative roles of Federal and local governnment agencies and the degree to which nonprofit providers and other civil society organizations are empowered or constrained have not been articulated.

The Nationa Association for Business Economics (NABE) Health Economics Roundtable is holding an open teleconference at 11:00 a.m. (EDT) on June 17 entitled “Assessing the New Healthcare Landscape: What issues did the Patient Protection and Affordable Care Act address and what still remains?”

The speakers, John Holahan, Ph.D, Director, Urban Institute’s Health Policy Research Center, Urban Institute and Bowen Garrett, Ph.D, the Center’s Senior Research Associate, the principal
authors of “The Cost of Failure to Enact Healthcare Reform: 2010 – 2020, will discuss the factors that went into the Urban Institute’s Health Insurance Policy Simulation Model (HIPSM), a microsimulation model of health insurance coveragereforms that served as the foundation for their recent publication; to what degree they believe the final legislation either addressed the costs of failure or left them unresolved; and how implementation strategies might influence the
effectiveness of the reforms.

Registration is free for members of the Health Economics Roundtable. Nonmembers can participate for a fee. For more information and to register for the event, go to

If you missed this event, an MP3 recording of the session will be available about a week after the event.

Richard C. O’Sullivan
Principal, Change Management Solutions
1290 Bay Dale Drive, #318
Arnold, MD 21012
Office: +1 410-793-5685
Mobile: +1 410-349-7008
Skype: Rosullivan

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