Why Can’t We Be Friends? The Challenge of Public-Private Collaborations that Improve Health Care

State health policymakers face more work than they can handle now. Delivery system reform. Medicaid sustainability and expansion. Affordable Care Act (ACA) implementation. The latest public health issue. Angry constituents. When can they collaborate with private sector leaders working on some of the same issues?

The Fund, with the help of the Network for Regional Health Improvement, recently convened teams of state staff and Regional Health Improvement Collaboratives (RHICs)—local coalitions of providers, health plans, and other stakeholders focused on improving health care—from eight states for a couple of days to share successes in collecting and reporting claims and clinical information and do some joint state-level planning.

Some great insights emerged, but the convening left me with a more fundamental conundrum: why can’t these guys be more aligned? State health policy staff are overworked and underfunded. In RHICs, state health policy leaders have powerful groups of stakeholders who are self-organized and committed to promoting largely congruent goals: improved population health, better value medical care, and a better patient experience of care. What a great opportunity for collaborations that improve health care.

Yet the underlying tenor from the teams at our convening was one of challenge: the work of aligning state and private sector health improvement efforts is hard. Participants indicated that while there are positive working relationships between state staff and RHICs, these relationships could be more productive. After all, they have so much in common—and the need for improvement is so great. What hinders productive collaboration? When I asked the participants, the answers were revealing.

State staff admitted to:

• A public sector workforce culture that often focuses more on preservation of tenure, turf, and authority than on developing newly required project management, contracting, and analytic skills.
• Government procurement processes that discourage “special partnerships” and close coordination with private entities.
• Outdated public sector information technology, particularly in Medicaid.
• Perhaps most important, a lack of alignment within state government on health policy and data use priorities, made worse by a paucity of money for planning, particularly among those not receiving federal State Innovation Model funding.

RHIC staff pointed to several things they could do to strengthen public sector partnerships:

• Be more inclusive. Engage and align other stakeholders in their improvement efforts—particularly employers and consumers—to make it easier for policy consensus to emerge.
• Define roles. A contractual relationship where services are bought by the state from the RHIC may be part of a viable business model but is fundamentally different from a collaboration to achieve a common goal.
• Produce results. Document practices that demonstrably lower the costs and improve the health of populations, and disseminate that information.
• Show an even greater commitment to system change. Acknowledge and address the skepticism expressed by some state officials about the ability of institutions like hospitals and health plans that are RHIC leaders to help change the systems from which they currently benefit.

Underlying these barriers to collaboration, however, are a few more fundamental challenges.

What’s going on? I’m not sure there is agreement in these partnerships about what their specific, common goals are. Having participated in a few of these public/private partnerships that were simultaneously trying to improve health care value, electronic health records adoption, health information exchange, health care transparency, and provider engagement, I’ve observed that staying focused is hard, especially when new revenue opportunities encourage “scope creep,” taking on new responsibilities that expand the organization’s focus and perhaps even its mission.

Goals chosen ought to be few, clear, modest (at least initially), and mutually important. If you can’t separate the partners and have them articulate common goals, chances are excellent the partnership is not going to do much.

Should I stay or should I go? Building and maintaining trust and respect among the partners is challenging in local environments with long histories, conflicting priorities, limited resources, bounded authority, and multiple roles.

State people at the convening acknowledged public processes could often be more transparent, and officials more straightforward with their private sector partners. RHIC leaders admitted to the reality of multiple agendas among their leadership and noted that private sector officials do not always appreciate the complexity of state government and the competing demands their partners face.

This convening was apparently a shot in the arm for participants. Groups from each state were grateful for the time together to reflect and plan. In the weeks after the meeting, several reported that the local dialogue had changed considerably as a result of the time away from home. The real lesson: good partnerships, like any other successful relationship, require constant attention, communication, and commitment. There is no easier way.