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ORIGIN AND MISSION Maine has created a partnership among three equal organizations and coalitions to focus on quality improvement – the Maine Quality Forum (MQF), the Maine Health Management Coalition (MHMC), and Quality Counts (QC). The Maine Quality Forum, which is the legislatively authorized component of the partnership, was established in 2003 by Gov. John Baldacci and the Maine Legislature as part of the Dirigo Health Reform. MQF has been charged with collecting research, promoting best practices, collecting and publishing comparative quality data, promoting electronic technology, promoting healthy lifestyles, and reporting to consumers and the legislature. Quality Counts, established in 2006, is committed to working together across organizations and communities to improve health care systems and outcomes with the people of Maine. Quality Counts coordinates existing but disparate efforts across the state that support local, patient-centered, and coordinated systems of care, as well as the resources that support them. Its goals are to improve health status, promote consistent delivery of high quality care, improve access to health care, and contain health care costs. In existence since 1993, the Maine Health Management Coalition is an employer-led partnership among multiple stakeholders (including MaineCare or Medicaid). The Coalition works collaboratively to maximize improvement in the value of health care services delivered to MHMC members’ employees and dependents. MHMC has three public reporting initiatives that report quality data on hospitals and primary care practices, using mostly publicly available data that is organized and reported in a manner usable for employers and consumers. Through its Employee Activation Initiative, MHMC helps member organizations develop and share tools to communicate information about quality health care to employees. MHMC also has a multi-stakeholder workgroup that is designing a payment reform model to pilot. The model will build on previous work commissioned by the Maine Quality Forum that analyzed unwarranted variation. GOVERNANCE This partnership of partnerships has come together to support a range of quality initiatives in the state, and together with the state’s emerging regional health information organization is an AHRQ-recognized Chartered Value Exchange for Maine, though it has no formal mission or governance structure. Each of the three organizations and coalitions has its own mission, board, and structure, representing diverse stakeholders. The three organizations have cross-populated advisory groups and developed collaborative leadership on initiatives (e.g. the Aligning Forces for Quality initiative’s executive leadership team). Although different funding and governance structures make it challenging to share projects, the partners have effectively supported a range of improvement activities, and they coordinate and communicate in a concerted effort to avoid duplicating efforts. ACTIVITIES AND ACCOMPLISHMENTS •    Maine’s partnership is focused on the areas of medical home, practice improvement, public reporting, and consumer engagement. MHMC reporting focuses on the physician, practice, and hospital performance levels, using a variety of data sources; MQF uses clinical and administrative (claims) data for hospital reporting and is using administrative data to analyze hospital and physician cost and quality. MQF is transitioning from Maine-designated measures to NCQA/Bridges to Excellence measures. Quality Counts focuses on promoting multi-stakeholder collaboration and the spread of quality improvement learning. •    The Voluntary Practice Assessment Initiative (VPAI) is a 24-month project offering free, confidential quality and patient satisfaction assessments to small, unaffiliated, and certain other primary care practices in Maine. It is funded by MQF, uses MHMC measures, and will provide access to the QC Learning Community (which offers information about tools and resources to help practices improve their systems of care). •    The three organizations together were awarded a grant from the Robert Wood Johnson Foundation’s Aligning Forces for Quality initiative. QC serves as the lead organization for the grant, and representatives from QC, MHMC, and MQF serve on the executive leadership team. •    Maine was awarded status as a Chartered Value Exchange by the Agency for Healthcare Research and Quality (AHRQ) in January 2008. MHMC convened the Maine CVE Alliance, which includes MQF and QC, as well as HealthInfoNet, Maine’s regional health information exchange. As part of the CVE, MQF led the successful application for the CMS demonstration initiative to promote the adoption of electronic health records. The project’s intent was to reward the delivery of high quality care supported by the adoption and use of electronic health records in physician practices. (The project has since cancelled by CMS.) •    The partners are leading a three-year, patient-centered, multi-payer medical home pilot. The first phase of the pilot (planning) was completed at the end of 2008. The second phase (implementation) began in January 2009, with solicitation of applications.  

ORIGIN AND MISSION In November 2008, five Minnesota organizations signed an accord to form an alliance called The Minnesota Health Care Value Exchange. The alliance was established to support HIT; quality improvement and measurement; price transparency and public reporting; incentives to promote high-quality, efficient care; and consumer engagement and education. The five partner organizations comprising the Minnesota Health Care Value Exchange are: •    Buyers Health Care Action Group (BHCAG), a non-profit coalition of large private and public employers working to redirect the focus of the health care system to optimal health and value; •    Institute for Clinical Systems Improvement (ICSI), a non-profit organization that brings together medical groups, hospitals, health plans, employers, and other groups to provide patient-centered and value-driven care to patients in Minnesota and surrounding states; •    MN Community Measurement (MNCM), a community-based, non-profit organization that works to accelerate the improvement of health through measurement and public reporting of health care performance; •    Smart Buy Alliance, an affiliation of private, public, group, union, and individual health care purchasers working to ensure that health care reforms focus on improving health and health care delivery for all Minnesotans. It includes Minnesota Management & Budget (state employees) and Human Services (Medicaid, SCHIP, and MinnesotaCare); and •    Stratis Health, a non-profit organization that leads collaboration and innovation in health care quality and safety, serves as a trusted expert in facilitating improvement for people and communities, and is the state’s Quality Improvement Organization (QIO). GOVERNANCE Although each of the five member organizations has its own separate governance structure, the Minnesota Health Care Value Exchange has a board with one representative from each organization. The Minnesota Health Care Value Exchange elects members to fulfill specific responsibilities, including convener of meetings and logistics (Buyers Health Care Action Group), AHRQ contactor (Smart Buy), finance representative (to be determined), and Medicare data steward (Stratis). ACTIVITIES AND ACCOMPLISHMENTS The Minnesota Health Care Value Exchange is working to coordinate health reform activities and build upon the quality improvement, performance measurement, and public reporting activities already occurring in the community. Priority areas include care model redesign, purchasing redesign, payment reform, consumer engagement initiatives, and electronic medical record and personal health record implementation. The Minnesota Health Care Value Exchange received Chartered Value Exchange designation from Department of Health and Human Services Secretary Mike Leavitt in March 2008. The alliance’s activities directly relate to state health care reform legislation signed into law in May 2008 (Senate File 3780, Senate File 2942, House File 3149, and House File 1812). The goal is to move toward achieving quality, affordable, accessible health care for all Minnesotans. The legislation includes “health care home” criteria; e-prescribing; the use of encounter data to establish peer groupings of providers based on quality and efficiency; as well as payment reform, quality measurement, and cost/quality transparency. Minnesota Health Care Value Exchange is the coordinating body for members’ work on state health reform legislation, including: •    The Minnesota Quality Reporting and Incentive Payment System, •    Health care home support and development, •    Bundles of care measurement and payment, and •    Provider peer grouping by cost and quality. The value exchange also is developing funding and other support for care re-design projects (e.g. Depression Care Improvement). Member organizations have partnered in the past for Quality Care and Rewarding Excellence (QCare), an initiative created by the governor’s executive order in 2006. QCare aims to gather, analyze, and distribute data on health and health care in Minnesota to guide health care reform in the state. QCare identified certain focus areas (diabetic care, public health, hospital “never events”) in which to improve care, in addition to consensus goals for the state to achieve by certain dates. The QCare group included physicians, hospital leaders, members of the legislature, and businesses, as well as state agencies.    

ORIGIN AND MISSION Pennsylvania’s partnership began with an HRSA state planning grant that established the HRSA State Plan Advisory Council. A consensus that emerged from that process led to the Prescription for Pennsylvania (Rx for PA), an initiative that is administered through the Governor’s Office of Health Care Reform. Rx for PA is Gov. Edward G. Rendell’s comprehensive health care reform initiative to address the access, affordability, and quality of health care in the commonwealth. Rx for PA is a set of integrated strategies to eliminate inefficiencies in the health care system, better manage chronic conditions, eliminate health facility acquired infections, enact common sense insurance reforms, and offer access to affordable health care insurance for the uninsured. Rx for PA aims to ensure that every Pennsylvanian has access to quality health care. State officials are working through Rx for PA to align quality initiatives of various state agencies, including the Pennsylvania Health Care Cost Containment Council (PHC4); the of Health, Public Welfare, and Insurance; and an independent state agency, the Patient Safety Authority (PSA). GOVERNANCE Although the Governor’s Office of Health Care Reform has no formal governance structure, it coordinates the efforts of several state agencies that have public-private governance structures, including PHC4, PSA, and the Chronic Care Management, Reimbursement and Cost Containment Commission (CCC). Regular cabinet meetings are held to coordinate internally. FUNDING Funding is provided through the state budget process. ACTIVITIES AND ACCOMPLISHMENTS The CCC was created under Rx for PA through executive order by Gov. Rendell in May 2007 to improve how Pennsylvanians with chronic disease receive health care. The commission is responsible for developing a strategic plan to effectively manage chronic disease across the state. The strategic plan includes recommendations for the informational, technological, and reimbursement infrastructure needed to support the implementation of a combination of the chronic care model and the patient-centered medical home (PCMH) model throughout Pennsylvania, which will improve quality outcomes and cost effective treatments for patients with chronic diseases. The Chronic Care Commission has established a multi-payer partnership, with support and funding by all large payers, convened and supervised by OHCR. Practices sign up for and make a three-year commitment to participate in regional learning collaboratives that are implementing patient-centered medical home and chronic care models. Practices are making infrastructure and care delivery changes, including: •    Attending quarterly learning collaborative meetings for training on how to transform their delivery of care to conform to the patient-centered medical home and chronic care models; •    Hiring staff (certified registered nurse practitioners, case managers, health educators) to create care teams that will coordinate and facilitate care and provide education and self-management skills training; •    Using a practice coach to facilitate transformation of the practice and assist with preparation for National Committee for Quality Assurance (NCQA) Physician Practice Connections-Patient Centered Medical Home (PCC®-PCMH™) recognition; •    Implementing a patient registry with embedded, secure, encrypted e-mail capability for enhanced patient-practice communication, as well as the ability to generate both care gap reminders to patients and monthly reports of performance metrics for monitoring; •    Implementing open access scheduling to improve access to care; and •    Agreeing to apply for and achieve NCQA PCC®-PCMH™ recognition in the first year. Payers support the program financially by making payments to support infrastructure development and staffing. The model has participating payers make payments proportionate to the 1099 revenue received from the payer in relation to total revenue received by the practice. This model allows for fair participation by various coverage models (HMO, PPO, POS) and for commercial, managed Medicaid, and Medicare Advantage products. The Governor’s Office annually collects and validates revenue and periodically generates statements to payers to initiate the reimbursement process as milestones are achieved. Health plans are also paying for health coaches in proportion to revenue. Other related accomplishments of Rx for Pa include: •    New laws to provide transparency in health quality and to protect patients from health facility-acquired infections, which in the first six months helped result in a 7.8 percent decrease in hospital-acquired infections and 300 fewer hospital acquired infection-related deaths than the year before; •    Changes in scope of practice laws to allow physicians’ assistants, certified nurse practitioners, clinical nurse specialists, and dental hygienists to practice to the full extent of their education and training; •    Developing a statewide health information exchange; and •    Payment reform, including the Medicaid program no longer paying for “never events.”

ORIGIN AND MISSION The State of Vermont, under the leadership of its governor, legislature and the bipartisan Health Care Reform Commission, has established a program called the Blueprint for Health. The Blueprint is guiding a comprehensive and statewide process of transformation designed to reduce the health and economic impact of the most common chronic conditions, and to focus on their prevention. The state’s strong commitment is demonstrated in the 2006 statutory codification of the Blueprint as the state’s plan for changing health care delivery. Further legislation in 2007 and 2008 strengthened the involvement of private insurance carriers. The annual state budget supports the health care transformation process, along with expanded use of health information technology and the development of a statewide health information exchange network. The Blueprint is a vision, a plan, and a statewide partnership to improve the state’s health care system and the health of Vermonters. It aims to shift the focus of the health care system to preventing illness and complications. The Blueprint started as an initiative to create a chronic care infrastructure and uniform model for providing chronic care in Vermont (its original pilot sites focused on diabetes). It has developed into a statewide health reform project that spans agencies and addresses the general population. The Blueprint quality improvement components include improved health maintenance, prevention, and chronic care management for a general population; financial reform that aligns incentives with health care goals; expanding the use of health information technology supported by an information exchange infrastructure; and a reporting and evaluation infrastructure that supports individual patient care, population management, quality improvement, and program evaluation. GOVERNANCE The director of the Vermont Blueprint reports to the commissioner of health and is responsible for implementing the program. The director coordinates the program across all levels of state government and with non-government partners. Blueprint goals are defined by the governor and legislation. The Blueprint is expected to work across agencies, sectors of society, and public-private partnerships. The director works with an Executive Committee, and a Planning & Evaluation Committee, as well as with advisory workgroups as needed. The FY 2009 Blueprint budget is about $4.8 million. The FY 2010 budget is just more than $4 million. Funding comes from the state’s global commitment (Medicaid program waiver savings) and the Catamount Fund (which includes Master Tobacco Settlement payments and an increase in cigarette tax). ACTIVITIES AND ACCOMPLISHMENTS Over the last three years, six Blueprint communities (authorized under Act 191) have implemented improved diabetes care and prevention via provider training and incentives, expanded use of health information technology, evidence-based process improvements, statewide self-management workshops, and statewide support for community activation and prevention programs. Legislation (Act 71, 2007 and Act 204, 2008) authorized the Blueprint to select three communities to participate in the Blueprint Integrated Pilot Program (BIPP) to assess the efficacy and sustainability of comprehensive, multi-payer reform for a general population. Blueprint supports participating pilot practices by helping them operate a patient-centered medical home (PCMH). A multidisciplinary Community Care Team provides care support for the PCMHs in a community. BPIPP also includes an infrastructure for multidimensional evaluation that encompasses measures of clinical processes, health status, and health care patterns and expenditures (via claims data from a multi-payer database populated by information from all insurers and third party administrators), as well as return on investment and financial impact. BIPP practices receive: •    Enhanced payment for meeting National Committee for Quality Assurance (NCQA) PCMH standards. •    Local multidisciplinary care support teams called Community Care Teams (CCTs), which include public health prevention specialists. •    A web-based clinical tracking system. •    Health information exchange between electronic medical records, hospital data sources, and a web-based clinical tracking system. BIPP Partners include: •    Private and public payers who share the costs of CCTs and have a common payment structure based on a practice’s NCQA PCMH score. •    Vermont Information Technology Leaders (VITL), a hospital and systems integration effort that supplies the HIE network and provides comprehensive data services that help practices implement EMRs. •    Vermont Program for Quality in Health Care (VPQHC), a private, non-profit corporation formed in 1988 with which the Blueprint has contracted to coordinate provider training and work with communities. VPQHC also provides registry reports via the Vermont Health Record (its chronic disease registry tool) and the web-based clinical tracking system.