DRIS Initiative Evaluation Report: Cross Cutting Themes from Phase I and II of the DRIS Initiative

by Dr. Ira Moscovice, Ph.D.
Institute of Rural Health Services Research

The purpose of this report is to summarize the initial accomplishments of DRIS and to identify and synthesize the major cross-cutting themes that have emerged during the first two years (1997 and 1998) of the DRIS Initiative which includes the completion of Phase I activities and the partial completion of Phase II activities.

The ideas presented here are based on information collected from two rounds of visits to each site (completed during July and October 1997, and August, September and October 1998). Structured interviews were conducted with eight to ten individuals from each site with diverse viewpoints, including administrators, health professionals, board members and community representatives; telephone and/or in-person interviews were conducted with CIRHM staff, the community systems consultants for each site, and the James Irvine Foundation staff; secondary data and reports were reviewed by CIRHM, from the DRIS sites, and the data consultants; and information was gathered from the DRIS Advisory Committee meetings, the DRIS annual meetings, and conference calls with CIRHM and Foundation staff.

DRIS Accomplishments

There are several ways to measure the accomplishments of the DRIS process during the past two years. The major objectives of Phase I and the initial objectives of Phase II have been achieved at four of the five sites. These objectives included:

Formation of a Community Health Council with broad representation;

Training and education of community representatives on current trends affecting rural health care;

Collection, analysis and dissemination of relevant information on the health care system at the DRIS sites;

Completion of a scope of service analysis for the DRIS sites;

Discussion and analysis of the potential functions at the DRIS sites with agreement by key stakeholders on an initial set of proposed functions; and

Establishment of a Cooperative Vehicle responsible for the oversight of the proposed functions.

The sites currently are awaiting the results of feasibility analysis (to be completed in the next three to six months) examining the fiscal and political realities of the proposed functions. Proposed functions that have the support of key stakeholders and pass the fiscal viability test will then move into the pre-operational planning and implementation phase. The sites have focused their efforts on two main areas. First, the formation of an entity such as a Community Health Organization (CHO) or Administrative Services Organization (ASO) to develop administrative and medical management functions that involve limited provider risk. Second, the development of clinical pathways for community health problems (e.g., behavioral health, substance abuse and respiratory illness) identified during the data collection and analysis phase of DRIS.

In addition to the direct effects that have led to the selection of proposed functions, positive spillover effects of DRIS include the receipt of additional health related grants and the use of the Community Health Council structure to address other important community issues (e.g., environmental concerns, rapid expansion of a health system that is reducing consumer choices and the adoption of a regional budgeting approach by a county health department). These spillover effects occurred in part due to the extensive data set collected and analyzed during Phase I of DRIS as well as the potential for community collaborative efforts unleashed by the formation of a Community Health Council at each DRIS site. DRIS has enabled communities to have a formal process for community collaboration and planning around health care issues that extends beyond the grant activities and, hopefully, can be maintained and nurtured in the future.

Cross-Cutting Themes

Karem Pacheco, Administrator, Valley Medical Group and Tanya Schultz, M.F.C.C. Center for Individual/Family Counseling both of Lompoc Valley.

The themes described below are not unique to a particular DRIS site or individual involved with the DRIS Initiative. They represent issues that cut across the sites and are central to the overall progress of the DRIS process. These themes address issues related to the assessment of the underlying assumptions of the DRIS model as well as the implementation of the model.

1. The DRIS process provides a structured framework for broad segments of rural communities to address health care delivery and financing issues in an evolving managed care marketplace.

The primary achievement of the DRIS process is that it provides rural communities an opportunity to examine how rural areas and rural health fit into the overall health care system in a structured framework that is data-driven, community-based, and focused on survival in a managed care marketplace. More often than necessary, rural communities have not addressed these issues because of limited financial and technical resources; lack of strong, stable leadership; opposition of local providers; minimal availability of relevant data; and misperceptions of environmental forces.

The DRIS process has made a wide array of technical consultants (e.g., financial, legal, data and systems) available to the sites and has disseminated a large amount of data to the key participants at each site. DRIS has encouraged broad community involvement in the process and has worked with each site to develop a representative Community Health Council that extends well beyond local providers and employers.

The initial implementation of the DRIS process faced several challenges. The majority of sites were used to receiving and controlling financial resources under a grant process. It took time for the key stakeholders to understand and recognize the value of receiving technical assistance, rather than dollars. The amount of time, the degree of complexity, and the number of individuals involved with the collection, analysis, and dissemination of relevant data surpassed the expectations of all those involved. In future efforts, the data process should start as soon as participant sites are identified and firm agreements on data formats and dissemination strategies and links of data to educational and training activities should be developed as early as possible.

CIRHM has addressed the above issues by developing products (e.g., legal analysis of antitrust concerns and financial analysis of managed care feasibility for locally-run health plans) that provide practical help to the sites and a consistent data template for use across sites. While the delayed data collection led to time delays in accomplishing the Phase I objectives, it also provided time for the key participants at the sites to understand the value of the DRIS process.

At the inception of the Initiative, each of the DRIS sites had different needs, time lines, and driving forces and were at different stages of maturation, development, and threat of managed care penetration. Some sites were relatively isolated, had minimal managed care presence in their area, and dysfunctional relationships among local providers. Other sites had already developed organizations they believed were capable of entering into managed care contracts and wanted to jump-start the Phase I educational, community assessment, and community council development activities.

2. DRIS sites progress at their own speed. The DRIS process had to be flexible to accommodate differences in site needs, time lines, driving forces, and threat of managed care penetration.

CIRHM had to develop a strategy for how DRIS would be combined, or overlaid, on the existing activities at each site. Underpinning this strategy was a recognition that DRIS had to accommodate and build on the existing activities at each site while adhering to the principles central to the DRIS effort. The decision to move to three outcome-based phases with clearly delineated milestones had the effect of improving relationships between CIRHM and the sites and sent a strong message that the DRIS process was sensitive to site needs and was not a cookie-cutter approach. As a result, consultants and sites have been given additional time to organize their Community Health Councils and negotiate relationships with existing provider groups; to examine the large amount of data collected and complete the community assessments; to establish a single entity responsible for implementing the activities or functions proposed at each site; and to provide matching resources for the latter stages of the project.

In many ways, DRIS is a hybrid of a community development model and a client/consultant model where the client is the community. Over time, this is reflected in the changing roles and responsibilities of external and community-based entities.

A necessary condition for the DRIS Initiative’s long-run success is local ownership of the process. This means that those individuals most affected by DRIS activities have the greatest influence on decisions affecting those activities. The appropriate role for external entities (e.g., private foundations, consultants, government and non-local health care organizations) in developing integrated rural delivery systems is not always obvious. Potential roles include educator, data collector and analyst, neutral convener, mutual arbitrator, provider of technical assistance and funding source for capital expenses, etc. These roles may change over time with initial emphasis on community capacity building and later emphasis on technical consulting on specific projects. The benefits of the above roles may be large as long as local stakeholders are open to receiving support from non-local entities.

3. The roles of local and external entities in DRIS vary and evolve over time. The degree of local ownership of the change process is inversely related to the amount of control and support exerted by external entities. As the level of external support is reduced, communities need to identify an entity that will be responsible for decision making about the local health care system.

The key question is whether the DRIS process will eventually evolve from the perception and/or reality of being CIRHM-driven to being community-driven. The James Irvine Foundation and CIRHM encouraged local ownership through the milestone grants of $10,000 for establishing the Community Health Council and $20,000 for selecting a Cooperative Vehicle to implement specific functions. A much larger step will involve local control of implementation grants of up to $200,000 for selected functions through a legally established Cooperative Vehicle.

Another indicator of the transition of power and control to local entities is the relationship between the Community Health Council and the local coordinator. In several sites, CIRHM now contracts with the Community Health Council or the Cooperative Vehicle for local coordination. The local coordinator is directly supervised by and reports to the local entity. At one site, the transition to increased site control was facilitated by a local entity with a history of responsibility for collaborative projects. At another site, the transition was stimulated by the departure of a local coordinator who moved out-of-state.

Participating rural communities need to take increased ownership of the DRIS process and define and accept meaningful roles for non-local entities that support their vision of an integrated delivery system. This latter step is more likely to occur during Phase III of the DRIS process, which involves the implementation of relevant functions (i.e., when the process moves from education, assessment, and data to action steps).

The DRIS process needs to identify a legitimate voice to represent the community and make decisions about the local health care system’s future. This voice should be an organized formal entity that can serve as a stable host for activities and balance the competing interests of stakeholders such as providers, employers, and local residents. Each site needs to determine the relationship of its Community Health Council to the Cooperative Vehicle. Are they essentially the same entity? Will the Council serve as an advisory body to the Cooperative Vehicle, become an independent entity that facilitates local health care improvements, or cease to exist once DRIS has ended? The answers to these questions will vary by site. Each, however, needs to understand the role of its Council and Cooperative Vehicle in selecting and implementing functions/activities supported by DRIS and decide whether either of these entities is the community’s legitimate voice.

From the outset, DRIS has been defined as a data-driven process. Despite resistance from some of the sites concerning the value of data and the need to update data sets that were several years old, CIRHM stood firm on the importance of having the best data available to inform the decisions on the functions/activities that would be implemented at each site.

Over time, the richness and potential value of the epidemiologic, supply/demand, and economic information collected by the data consultants began to be recognized at several sites. For example, priority health issues related to substance abuse in one site and respiratory illness in another site were highlighted in the data analysis. This eventually led to the selection of clinical/community pathways as functions to be addressed in these sites.

A key concern is how to keep the major stakeholders working together as a team once they own the data. Can data wash away the historical differences of hospitals that have vigorously competed with each other for many years or repair the dysfunctional relationships that may exist between a medical group practice and the local hospital? Can data alter the preconceived notions of local leaders already invested in the development and marketing of a local health plan? These are the difficult challenges that faced CIRHM and the consultants as they entered Phase II of the DRIS process.

Caje Segura, Vice President, International Chemical Workers Union and Raul Zermano of the Central Coast Pensions, both of the Lompoc Valley Healthcare Council.

4. Most sites valued the data-driven emphasis of the DRIS process. Timely data can be used to inform decisions but won’t necessarily de-politicize the decision-making process.

Each of the sites has gone through an extensive process to identify functions that address a community need and meet the DRIS criteria of being informed by data, having community buy-in, and preparing the local health system for managed care. Potential functions ranged from those that were solely delivery system oriented (e.g., implementing clinical and community pathway models and developing information system linkages) to those that also included a financing component (e.g., creating a community-controlled entity responsible for ASO functions such as claims administration, member services, and quality and utilization management; and developing a single signature authority for joint contracting for local providers).

Change is difficult to accomplish in many rural environments because of financial, technical, political, and leadership constraints; relative isolation and limited linkages to non-local entities; and the comfort associated with maintaining the status quo. The seminal question underlying the DRIS Initiative is to what extent a data-driven, community-based process supported by external expert facilitation and market-driven pressures can provide leverage for changing the delivery and financing of health care in rural environments in California.

At this point in time, most of the DRIS sites have interest in developing ASO-type functions (e.g., claims administration, QA/UM, credentialing, marketing and case management and information system linkages) that involve limited provider risk. Sites view this as a logical next step in their preparation for managed care. Leaders at several sites suggested that a successful ASO could be an important step toward the development of a locally-based community health plan in the future.

5. The selection and assessment of functions has been a large hurdle for the DRIS sites. There is primary interest in developing Administrative Services Organization type functions (e.g., claims administration, QA/UM, credentialing, marketing, case management, information system linkages) that involve limited provider risk.

The majority of health providers in the DRIS sites did not feel the urgency of increasing their financial risk. They prefer to be involved with limited-risk managed care functions. In a similar vein, the rural employers we spoke with at the DRIS sites were interested in capping the financial risks associated with their employee health costs. They also mentioned the constraints (e.g., union issues, multiple site employer issues and employee reluctance to changes) they face in changing their health benefits packages or administration. The Cooperative Vehicle at each DRIS site is either a fledgling entity or a body with limited experience in managing financial risk. All of the above suggests that the implementation of managed care functions with greater financial risk in rural sites in the future may require a non-local partner as well as a well-designed plan for how risk will be shared among the key actors mentioned above.

In the short run, financial feasibility analysis are being completed for the ASO functions selected by the sites. These analysis appropriately view the ASO as a new business and will examine issues such as the relevant scale of ASO activity, the potential volume of business based on service area population, and the required start-up and development costs. This information will help the key stakeholders at each site when they address the make or buy decision for ASO functions.

Conculsion

The DRIS Initiative has produced a structured framework for promoting the development of integrated rural health care systems through changes in decision-making processes and the development of new delivery and financing functions/activities. It is difficult to develop a replicable managed care product for rural environments. With strong leadership from the current executive director of CIRHM and the Community Health Councils and Cooperative Vehicles, DRIS has the potential to strengthen the long-term ability of rural communities to meet the challenges dictated by the managed care marketplace.

Next in the DRIS process will be steps related to the final selection and implementation of relevant functions/activities. The challenge facing DRIS is to develop strategies that can help translate its short-term accomplishments into fiscally and politically viable activities that meet community needs and can be implemented in the rapidly changing managed care environment in California.

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