How Collaboration Improves U.S. Health Care

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In the face of escalating healthcare costs and inconsistent quality, the call for increased competition in the United States healthcare system has been prominent. Proponents argue that competition could incentivize hospitals to deliver superior care at reduced costs. However, it's crucial to acknowledge that competition isn't a universal remedy; the quality of care remains highly variable both within and between health systems, and some research indicates that competition may even diminish quality and worsen disparities, particularly among less profitable patient groups. An alternative and potentially more effective approach involves fostering collaboration among hospitals, an idea that entails sharing internal data, financial transparency, and cooperative efforts with neighboring institutions. Although this notion may appear ambitious, it's already in practice, yielding positive outcomes. 

Why Collaborate? 

Collaboration holds immense significance, not only within a company but also between different organizations. It fosters enhanced problem-solving, peer-to-peer learning, a shared sense of purpose, and the emergence of innovative ideas. Rosabeth Moss Kanter emphasized the vital role of collaborative relationships between companies in achieving individual success. Successful collaborations among organizations are characterized by their capacity to unveil unanticipated opportunities, generate fresh value rather than engage in zero-sum transactions, and operate as collective endeavors with equal contributions from all stakeholders. This concept has been coined as the "collaborative advantage." 

Collaborative Success Stories 

In 1997, Blue Cross Blue Shield of Michigan initiated the BMC2 Cardiovascular Consortium, a program with a simple yet ambitious goal: bring hospitals together to enhance cardiovascular disease care, a leading cause of death in the United States. Starting with five hospitals, it expanded to encompass over 50 hospitals across Michigan. These hospitals shared in-depth clinical data, including their approaches to treating the disease, complication rates, and technology utilization. This transparency unveiled hidden performance gaps, led to innovative solutions, and spurred practice improvements. Instead of competing, hospitals began to learn from one another. Impressive outcomes in infection control or smoking cessation, for instance, were shared and adopted collectively. Consequently, this collaboration elevated care quality, reduced cardiovascular complications, hospital readmissions, care costs, and mortality rates statewide. 

• Bariatric surgery — 56% reduction in mortality 
• Blood clot prevention — 175,000 unnecessary lab tests prevented 
• Cardiovascular care — 51% reduction in bleeding complications 
• General surgery — 23% reduction in surgical-site infections 
• Hospital medicine — Reduction in unnecessary antibiotics, leading to a change in national guidelines 
• Knee and hip replacement — 53% fewer discharges to extended care facilities after surgery 
• Urology — 50% reduction in procedure-related hospitalizations 

Moreover, collaboration in healthcare proves invaluable in crisis response. The Michigan Hospital Medicine Safety Consortium, comprising over 40 hospitals, adeptly redirected its collaborative efforts to address the Covid-19 pandemic. Within a month of the first documented Covid-19 case in Michigan, this collaborative established a statewide database for tracking Covid-19 hospitalizations and identifying critical risk factors for severe illness. The outcome was a publicly accessible risk calculator that aided clinicians in assessing patient risk on an individual basis. This model of collaboration extended nationwide, with healthcare systems across the country uniting to share information and resources, effectively combating the pandemic. 

Furthermore, the financial benefits of collaboration cannot be understated. Preventing complications, reducing hospital admissions, and minimizing unnecessary care translate into substantial cost savings. Collectively, Collaborative Quality Initiatives (CQIs) have saved an estimated $1.4 billion in healthcare expenses. A study by the RAND Corporation reveals that Michigan boasts some of the nation's lowest healthcare costs. This success has prompted other states like Illinois and Wisconsin to adopt a similar collaborative approach to enhance care quality and reduce expenses, demonstrating that collaboration may rival, if not surpass, competition in achieving the elusive goal of better care at lower costs in healthcare. These insightful examples explain the true value of collaboration across teams, organizations and functions to the benefit of patients and customers. 

How Does Collaboration in Health Care Work? 

Collaborative quality improvement has been a fixture in healthcare since the 1980s, involving multiple stakeholders, including clinicians, non-clinicians, departments, and entire hospitals, pooling resources to share information, identify performance gaps, and develop solutions. This approach departs from the traditional proprietary model, emphasizing transparency by openly sharing outcomes, processes, and expenses across the group. 

The impact of this collaboration is twofold. Firstly, it provides hospitals and physicians with insights into their performance relative to peers, enabling them to identify high and low performers, fostering competition and improvement. Secondly, it facilitates the tracking of performance over time, allowing for the assessment of effective strategies. In essence, collaboration contextualizes performance, addressing the critical need for benchmarking and revealing that leaders in one aspect of care may lag in others 
The second major advantage of hospital collaboration is that it empowers those providing care to shape the improvement agenda, highlighting the crucial importance of physician and hospital engagement. Once hospitals grasp their standing within the group, they can take ownership of localized solutions. 

For instance, when a coalition of 26 hospitals in the Michigan Spine Surgery Improvement Collaborative identified patients' post-surgery urination difficulties as a major challenge, local experts—spine surgeons, anesthesiologists, and nurses—developed tailored solutions. Remarkably, these solutions saved an estimated $20 million. This approach sharply contrasts with traditional top-down regulatory reform, where uniform regulations mandate identical problem-solving approaches across all hospitals, often without sufficient data. Regrettably, such a top-down approach can result in inefficient resource utilization and unintended patient harm. Conversely, collaboration allows hospitals to enhance their performance by leveraging their unique processes, addressing specific challenges, and capitalizing on their individual strengths. 

Scarcity and Abundance 

The concepts of "scarcity" and "abundance" mindsets, popularized by Stephen Covey, provide a valuable lens through which to examine the dynamics of competition and collaboration. The prevalent call for competition in healthcare often stems from a scarcity mindset, where resources are perceived as fixed, and the healthcare industry is viewed as a zero-sum game reliant on securing a competitive edge. This perspective can often dominate boardrooms, where hospitals may regard each other as adversaries to be surpassed or absorbed. In this framework, only a subset of hospitals that outcompete their peers is expected to see improvement. 

Conversely, an abundance mindset, which regards opportunities as additive rather than mutually exclusive, offers the possibility of simultaneous improvement for all hospitals. Unlike the scarcity mindset, which necessitates a winner for every loser, an abundance mindset recognizes the potential for "win-win" scenarios. Collaboration emerges as a potent avenue to harness these opportunities. Over more than two decades, Michigan has showcased the benefits of this collaborative approach, delivering reduced costs, enhanced quality, and heightened patient satisfaction for payers, providers, and patients alike. Collaboration underscores the idea that healthcare thrives when its most exceptional talents collaborate rather than compete, suggesting that increased collaboration might be precisely what the healthcare industry requires. 

What should CMS do? Six Actions

1. Promote Collaborative Initiatives: CMS should actively encourage and support collaborative initiatives among healthcare providers, similar to the Collaborative Quality Initiatives (CQIs) in Michigan. This can be achieved by providing incentives and resources for hospitals and healthcare organizations to collaborate on improving care quality and reducing costs. 
2. Emphasize Transparency: CMS should advocate for greater transparency in healthcare by encouraging hospitals to share data and performance metrics. Transparency enables hospitals to benchmark their performance against peers, identify areas for improvement, and adopt best practices. 
3. Localized Solutions: CMS should recognize the importance of localized solutions. Encourage healthcare providers to take ownership of solutions at a local level based on their unique challenges and strengths. This approach can lead to more effective and efficient improvements in patient care. 
4. Measure Outcomes: Develop a robust system for measuring healthcare outcomes, not just costs. CMS should focus on tracking metrics related to care quality, patient satisfaction, and health outcomes. This data can help identify successful collaborative efforts and guide future initiatives. 
5. Abundance Mindset: Promote an "abundance mindset" within the healthcare industry. Encourage healthcare organizations to view collaboration as an opportunity for mutual benefit rather than a zero-sum competition. This mindset shift can lead to more widespread improvements in healthcare. 
6. Incentivize Collaboration: Consider offering financial incentives and reimbursement models that reward healthcare providers for participating in collaborative efforts and achieving specific quality and cost-saving outcomes. 

In summary, CMS should prioritize collaboration, transparency, and localized solutions as key strategies to address the challenges of rising healthcare costs and inconsistent quality while also emphasizing the importance of an abundance mindset within the healthcare industry. These actions can contribute to better care at lower costs, benefiting patients and healthcare providers alike. 

Resources: 

Michigan Hospital Medicine Safety Consortium; https://www.mi-hms.org/quality-initiatives/mi-covid19-initiative-retired 

COVID-19 In-Hospital Mortality Risk Score Model: https://micovidriskcalc.org/ 

Blue Shield - Collaborative Quality Initiatives: https://www.valuepartnerships.com/programs/collaborative-quality-initiatives/ 

Rand Research Study: https://www.rand.org/pubs/research_reports/RR3033.html 

Science Direct: https://www.sciencedirect.com/science/article/abs/pii/S1070324116304084 

Science Direct: https://www.sciencedirect.com/science/article/abs/pii/S0741521421019777 

Science Direct: https://www.sciencedirect.com/science/article/abs/pii/S1070324116304084 

Forbes: https://www.forbes.com/sites/carolinecastrillon/2020/07/12/5-ways-to-go-from-a-scarcity-to-abundance-mindset/?sh=6dfc8c2b1197 

CNS Journal: https://journals.lww.com/neurosurgery/abstract/2023/10000/minimally_invasive_transforaminal_lumbar_interbody.18.aspx?context=featuredarticles&collectionid=39