09 Apr 2025
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CQI Spotlight: Michigan Collaborative for Type 2 Diabetes

CQI Spotlight: Michigan Collaborative for Type 2 Diabetes

April 9, 2025 | 0 Comments | , , , ,

Type 2 Diabetes (T2D) affects over 1 in 9 adults in Michigan and increases the risk of kidney and cardiovascular disease, hypertension, nerve and eye damage. Although newer interventions have demonstrated effectiveness in treating and preventing T2D, barriers to equitable, widespread dissemination and implementation remain a challenge. Delivering evidence-based diabetes care to all T2D patients in Michigan is essential for creating a future where diabetes is no longer a chronic progressive disease.

With this vision in mind, the Michigan Collaborative for Type 2 Diabetes (MCT2D) launched in 2021 and aims to accelerate implementation of and eliminate barriers to guideline-concordant care, through supporting its participating practices with quality improvement efforts. MTC2D is currently focused on three evidence-based strategies: dietary and lifestyle changes based on the use of continuous glucose monitors (CGMs), guideline-directed antihyperglycemic medications, and low-carbohydrate eating patterns. MCT2D recognizes the importance of utilizing these strategies to reduce T2D incidence and to slow disease progression to improve health in Michigan and lower health care costs.

In three short years, MCT2D’s quality improvement efforts have already resulted in major achievements. As MCT2D Program Director and Associate Professor of Family Medicine at the University of Michigan Lauren Oshman, MD, MPH, stated,

So far, MCT2D has recruited more than 400 primary care, endocrinology, and nephrology practices across the state. Their efforts have resulted in a 12% relative reduction in patients with an A1c greater than 8% from 2021 to 2023, as well as an increase in CGM prescribing from 17% to 31% for patients who were on insulin (2021-2023).

MCT2D’s recent successes stem from its commitment to placing patients at the heart of their efforts. The MCT2D patient advisory board meets six times a year to guide the activities of the collaborative, including reviewing medication handouts, low-carbohydrate meal plans and grocery lists, instructional videos on injectable medications, and guides for using continuous glucose monitoring devices (Figure 1). This ensures materials are accessible and patient friendly. Patients are also invited to attend collaborative-wide and regional meetings to share their stories alongside healthcare professionals, further emphasizing the central role of the patient in MCT2D’s quality improvement initiatives.

Figure 1.

In addition to supporting patients, MCT2D addresses the needs of clinicians by offering guidance on clinical best practices, as well as insurance coverage and cost-related issues. MCT2D also hosts regional meetings twice a year and monthly educational webinars where guest speakers deliver presentations on topics requested by collaborative members. Sessions have covered topics such as “Mental Health and Diabetes,” “Working with Specialists,” and “Metabolic Surgery for Type 2 Diabetes.”

Achieving health equity is essential in all aspects of healthcare, but it is particularly crucial in the prevention and management of chronic diseases. All of MCT2D’s initiatives aim to advance health equity in communities across Michigan, ensuring that everyone—regardless of race, ethnicity, socio-economic status, insurance coverage, or geographic location—has access to high-quality care for T2D. MCT2D has established six health equity goals aimed at reducing the prevalence and complications of T2D, while enhancing the quality of life for all patients (Figure 2). To achieve these goals, MCT2D has launched several equity-focused initiatives, including a collaboration with Michigan Social Health Interventions to Eliminate Disparities (MSHIELD) to complete one-on-one consultations with practices on their social determinants of health screening processes.

Figure 2.

MCT2D’s impact on the quality of T2D care is dependent on strong collaborative partnerships with its 23 participating physician organizations.  While MCT2D brings together physician participants from primary care, endocrinology, and nephrology, it centers the crucial role of other members of the care team, including pharmacists, nurse practitioners and physician assistants, care managers, nurses, and dietitians. As Dr. Oshman explains, "Taking care of people with T2D is a team sport. The strength of our collaborative comes from our diversity."

Over the past year, MCT2D and MVC have collaborated in several ways. MVC provides claims-based data and analytic consultation to support MCT2D in establishing quality improvement benchmarks. MVC also collaborated with MCT2D in 2024 to develop a statewide report on T2D in Michigan. This report provided a comprehensive overview of the demographics, healthcare visits, and prescription utilization patterns of patients with T2D in Michigan. The report highlighted key trends in healthcare utilization within this patient population, including emergency department visits, hospitalizations, and consultations with primary care providers (PCPs) and specialists.

MVC is currently partnering with MCT2D on a value exercise to compare the use of guideline concordant medications and change in cost and outcomes among T2D patients in MCT2D practices compared to non-participating practices. This work significantly enhanced the MVC team's understanding of pharmacy claims data from BCBSM and BCN and provided valuable insights that will inform future projects and analyses using pharmacy claims data.

MVC is proud to partner with MCT2D in advancing T2D care across Michigan. The BCBSM-funded CQIs play a crucial role in driving healthcare quality improvement, and MVC is excited to continue showcasing the innovative contributions of individual CQIs and the ways in which MVC’s data analytics are supporting high-value care initiatives across the portfolio.

20 Nov 2024
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Diabetes Awareness Month: MVC Highlights MCT2D Collaborations to Improve Diabetes Care

Diabetes Awareness Month: MVC Highlights MCT2D Collaborations to Improve Diabetes Care

November 20, 2024 | 0 Comments | , , ,

November is Diabetes Awareness Month, a time to bring attention to the growing prevalence and impact of diabetes as well as the importance of early diagnosis, effective management, and prevention. According to the CDC, diabetes is a leading cause of morbidity and mortality in the United States, affecting vital organs such as the nervous system, kidneys, heart, and eyes. In 2021, it was estimated that 38.4 million people of all ages had diabetes—more than 1 in 9 adults in Michigan alone—a number that continues to rise globally. Additionally, recent studies show that 98 million American adults have prediabetes, putting them at high risk for developing Type 2 diabetes (T2D). The need for increased awareness and proactive care has never been more urgent.

Despite being one of the most prevalent chronic conditions worldwide, T2D is largely preventable. Given its chronic nature, it is essential to advocate for widespread access to patient resources, leverage data analytics to pinpoint areas for improvement, and ensure that all individuals across Michigan have the opportunity to access care that can prevent the disease from progressing.

MVC Offerings for T2D Care

MVC is committed to using claims-based data to improve the health of Michigan through sustainable, high-value healthcare. Recently, MVC expanded its focus to address T2D and its complications. In March 2024, MVC incorporated two high-volume emergency department (ED) conditions into its new ED-based episodes: diabetes with long-term complications (e.g., renal, eye, neurological, and circulatory issues) and short-term complications (e.g., ketoacidosis, hyperosmolarity, or coma). These ED-based episodes were developed in partnership with MEDIC and can be used to generate custom analytics for any MVC hospital or physician organization member.

MVC also has ongoing collaborations with the Michigan Collaborative for Type 2 Diabetes (MCT2D) to identify opportunities to improve care for T2D patients and evaluate the impact of CQI initiatives. Currently, both teams are partnering on a value exercise to assess whether practices participating in MCT2D reduced the use of certain diabetes medications compared to non-participating sites. This work will provide valuable insights into medication utilization.

More recently, MVC’s collaboration with MCT2D led to the creation of a new report on T2D in Michigan. It provided demographics and analyses for patients with T2D in Michigan insured by Blue Cross Blue Shield of Michigan (BCBSM), Blue Care Network (BCN), Medicare Fee-for-Service (FFS), and Michigan Medicaid between 2017 and 2023. The report also integrated pharmacy prescription claims. The report showcased several key trends, including:

  • A notable decrease in ED utilization and hospitalizations for T2D care from 2017-2023 (Figure 1).
  • An increase in visits with primary care providers (PCPs) and specialists, such as endocrinologists and nephrologists (Figure 2).
  • A shift in prescription utilization, with increased use of newer medications like GLP-1 receptor agonists and SGLT2 inhibitors, while the use of older therapies such as insulin and sulfonylureas declined (Figure 3).

Figure 1. Yearly Rates of ED Utilization Among T2D Beneficiaries, 2017-2023

Figure 2. Yearly Rates of Provider Visit Utilization Among T2D Beneficiaries by Provider Type

Figure 3. T2D Medication Utilization Among Beneficiaries with T2D, 2017-2023

The report also highlighted important demographic trends, including that T2D patients in Michigan are, on average, older, more likely to be male, and more likely to be Black, with a higher prevalence of non-commercial insurance coverage. These insights are helping MVC and MCT2D to focus their future efforts.

Looking Towards the Future

Although the prevalence of diabetes is a significant challenge, the innovative efforts of groups such as MCT2D and the American Diabetes Association provide hope for the future. MVC is excited to complete and share its value exercise with MCT2D in 2025, as well as continue to build on its offerings to MVC member hospitals and physician organizations for diabetes-related improvement projects.

Diabetes Awareness Month offers an opportunity to reflect on the challenges faced by millions living with diabetes, while also recognizing the significant progress being made in the fight against the disease. With the continued support of healthcare professionals, organizations, and communities, MVC is committed to improving care, prevention, and education. Together, we can raise awareness, improve outcomes, and provide support for those affected by diabetes.

30 Jul 2024
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Using Human-Centered Design Thinking to Improve Healthcare

Using Human-Centered Design Thinking to Improve Healthcare

July 30, 2024 | 0 Comments | , , , ,

At its foundation, healthcare quality improvement is a process of systematically improving care to better meet the needs of patients. Similarly, the concept of human-centered design thinking asks us to put people at the center of processes meant to address problems and improve outcomes. Although people have leveraged the concept of design to develop innovative solutions for centuries, “human-centered design thinking” is a relatively new approach in healthcare settings that is gaining in popularity.

One leader in this space is IDEO, a global design and innovation company; they launched a series of resources and toolkits to implement design thinking into tangible projects and emphasized the mindset behind the theory—the notion that how one thinks about design directly affects the impact of the solution. Through their design kit, IDEO suggests a three-step guide to cultivate a practical and repeatable approach to arriving at innovative solutions: inspiration, ideation, and implementation. IDEO urges professionals to connect with the population they wish to serve to ensure a project’s goals align with the needs of the intended community, and then to generate tangible ideas and solutions to address identified issues. This connection to a specific community puts the individuals they are designing for in the spotlight.

As the use of human-centered design thinking continues to grow, innovators continue to generate different visualizations of the process. Similar to IDEO’s three steps, another popular approach has been the Design Council’s double diamond model. Created to convey the process of design to designers and non-designers alike, this model (Figure 1) highlights a balance between big-picture thinking and detail-oriented refinements while translating ideas into action. This double diamond model was the guiding framework for the development of the Michigan Cardiac Rehabilitation network (MiCR) NewBeat materials – a partnership effort between MVC, BMC2, and HBOM (Figure 2). Strategically understanding the perspectives and needs of patients after undergoing a major cardiovascular event was pivotal to the success of the project.

Figure 1.

Figure 2.

Leading the NewBeat project was Larrea Young, who works as a multimedia and human-centered design project manager at MCT2D and HBOM. In reflecting back on the success of the cardiac rehab NewBeat project, she said, “One of the first questions we ask people when we talk about design is, what does it mean to design? People’s answers often focus on aesthetics; design makes things pretty or more accessible. While aesthetics is an important aspect of design, it is only one small part. We define design as envisioning and building a preferred future. This is the essence of the human-centered design process, an approach that examines challenges through lenses of aesthetics, culture, society, technology, and economics to define what something should be. In this process, we gain a deep understanding of people’s lived experiences, challenge conventional norms, and pilot innovative solutions. In the realm of healthcare, this process helps us build solutions that contribute holistically to the health and well-being of our providers and patients.”

Further evidence of the value of design thinking can be found in the quality improvement projects that placed critical importance on understanding the population they wished to serve. Many of these also have a heightened focus on patient-centered in the context of social drivers of health. Taking this into account, a number of healthcare initiatives are now incorporating a design thinking framework to ensure the circumstances, needs, and desires of patient populations are understood; and the results are promising.

In another recent study published in JAMA Network, Dr. Alex Peahl and colleagues wanted to determine how prenatal care could be redesigned to improve access and quality for Black pregnant people with low income. Utilizing human-centered design thinking, they interviewed 19 patients and 19 healthcare workers at prenatal care clinics in Detroit, Michigan, focusing on the first two phases of IDEO’s process: inspiration and ideation. In conducting this series of personalized interviews, Dr. Peahl and colleagues not only collected data to prove that current care failed to meet patient needs, but they also gathered ideas from the patient population of ways to redesign prenatal care for pregnant people in the community. By placing the individuals affected by the redesign at the center of a project, the team ensured the solutions they developed would lead to improved outcomes and experiences (Figure 3).

Figure 3.

Recently, Dr. Alex Peahl, MD, MSc, Assistant Professor in Obstetrics and Gynecology at the University of Michigan, led the MVC Coordinating Center through a workshop on design thinking. Dr. Peahl outlined its principles, provided personal and professional examples from her work, and facilitated a space for MVC teammates to collaborate and practice design thinking with one another.

As the MVC Coordinating Center looks ahead, design thinking will be incorporated more frequently to improve the quality and impact of MVC offerings. If your team has successfully adopted human-centered design thinking or other patient-centered frameworks that can be shared with peers across the state, please contact MVC.

23 Feb 2024
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BMC2 Recognized as a 2023 Eisenberg Patient Safety & Quality Award Recipient by NQF, Joint Commission

BMC2 Recognized as a 2023 Eisenberg Patient Safety & Quality Award Recipient by NQF, Joint Commission

February 23, 2024 | 0 Comments | ,

BMC2 (Blue Cross Blue Shield of Michigan Cardiovascular Consortium) has been recognized with the prestigious John M. Eisenberg Patient Safety and Quality Award in the Local Level Innovation in Patient Safety and Quality category.

BMC2 has been honored for its remarkable improvements in the documentation of radiation use, a decrease in high-dose radiation exposure, and reduction in opioid pill prescribing rates. BMC2 is a statewide quality improvement collaborative that develops and administers a portfolio of quality improvement interventions for patients who undergo heart stenting, vascular surgical procedures, and transcatheter valve procedures in Michigan. The consortium is one of 22 Collaborative Quality Initiatives sponsored by Blue Cross Blue Shield of Michigan and Blue Care Network as part of the BCBSM Value Partnerships program.

The Eisenberg Awards honor the late John M. Eisenberg, MD, MBA, and bring together the quality community to recognize groundbreaking initiatives in healthcare that are consistent with the aims of the National Quality Strategy: better care, healthy people and communities, and smarter spending. Dr. Eisenberg was the former administrator of the Agency for Healthcare Research and Quality (AHRQ) and an impassioned advocate for healthcare quality improvement. The award, presented annually by The Joint Commission and the National Quality Forum (NQF), recognizes major individual, local, and national achievements in healthcare that improve patient safety and healthcare quality.

“BMC2’s work impacts 30,000 patients treated by hundreds of physicians from more than 100 hospital teams each year,” shares Dr. Hitinder Gurm, Director of BMC2. “We are fortunate to have this unique partnership between providers, hospitals, and payers, that is focused solely on improving safety, quality, and appropriateness of care. The collaborative creates data-driven quality improvement goals and initiatives, shares best practices, and distributes reports benchmarked to statewide performance, all focused on improving cardiovascular care throughout Michigan.”

In Michigan, documentation of radiation use improved from 73.1% in 2019 to 85.5% in 2021, and BMC2 sites are outperforming national rates, which were 57.5% in 2019 and 74.3% in 2021. BMC2 sites achieved an overall 43% decrease in cases with high-dose radiation exposure (2.8% in 2018 to 1.2% in 2021), affecting hundreds of patients and care teams. BMC2 also reduced opioid pill prescribing; data showed improvement in the rate of patients with a prescription of less than 10 opioid pills by approximately 30% between 2018 (62%) and 2021 (91%). In addition, BMC2 has been exploring strategies to address healthcare disparities and partners with a patient advisory council to create resources for patients and providers.

The Eisenberg Award panel was impressed by BMC2’s dissemination of its work. BMC2 data has supported more than 100 publications in peer-reviewed medical journals and more than 100 presentations at national and international conferences. The panel noted that this kind of collaborative, best-practice approach improved outcomes, reduced costs, and could be replicated by other states. The panel was inspired by BMC2’s inclusive scope across so many clinicians, physicians, teams, and sites, acknowledging the collaborative is “working to improve care, at every institution, and for every patient. It's remarkable.”

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BMC2 is a collaborative consortium of health care providers in the State of Michigan comprised of three statewide quality improvement projects addressing percutaneous coronary interventions (BMC2 PCI), vascular and carotid interventions (BMC2 Vascular Surgery), and transcatheter aortic and mitral valve procedures (MISHC) in collaboration with the Michigan Society of Thoracic and Cardiovascular Surgeons. Learn more about BMC2’s activities and achievements in their 2023 Annual Report.

Like MVC, support for BMC2  is provided by Blue Cross Blue Shield of Michigan and Blue Care Network as part of the BCBSM Value Partnerships program.

02 Feb 2024
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CQI Leader Selected as 2024 Presidential Leadership Scholar

CQI Leader Selected as 2024 Presidential Leadership Scholar

February 2, 2024 | 0 Comments

The Collaborative Quality Initiatives (CQIs) will be represented in this year’s Presidential Leadership Scholars (PLS) program, which invites 60 scholars to participate in a six-month, one-of-a-kind, bipartisan initiative focused on learning from the presidencies of George W. Bush, William J. Clinton, George H.W. Bush, Lyndon B. Johnson, and their administrations.

Scholars are chosen from a highly competitive field and must undergo a rigorous application and review process. They are selected based on leadership growth potential and the strength of their personal leadership projects addressing local, national, or international challenges.

For Amanda Stricklen, RN, MSN, it’s an opportunity to continue her lifelong professional journey of improving healthcare, and she brings robust experience in healthcare quality improvement and patient safety to the PLS program. She earned bachelor’s and master’s degrees from the University of Michigan School of Nursing before gaining years of experience in bedside nursing. Currently, Stricklen serves as the program manager for the Michigan Bariatric Surgical Collaborative (MBSC) and the Michigan Surgical Quality Collaborative (MSQC) focusing on improving clinical outcomes, enhancing patient experiences, and building a statewide community of providers who work together to elevate the care of surgical patients. Like the Michigan Value Collaborative, the coordinating centers for MSQC and MBSC are housed at Michigan Medicine.

“I am honored to be one of 60 scholars for this year’s Presidential Leadership Scholars Program,” said Stricklen. “I look forward to learning new leadership skills and representing the Collaborative Quality Initiatives, Michigan Medicine, Blue Cross Blue Shield of Michigan, and the University of Michigan as a whole. My goal is to learn new leadership goals to empower and provide support to participating hospitals and healthcare providers to enhance care in Michigan and across the nation.”

“Amanda Stricklen is one of the longest serving program managers in Blue Cross Blue Shield of Michigan’s Collaborative Quality Initiative program, the first of its kind, internationally recognized, award-winning model that focuses on a critical challenge – improving health care quality and value,” said Tom Leyden, director of the BCBSM Value Partnerships program, which provides funding for the CQIs. “Amanda is an accomplished leader who demonstrates a strong commitment to the CQIs’ shared principles of transparency, collaboration, trust, and measuring performance.”

Stricklen will join leaders from across the country representing the military, non-profit organizations, public and private sectors. Scholars will travel to each participating presidential center to learn from key former administration officials, business and civic leaders, and leading academics. They will study, put into practice varying approaches to leadership, and exchange ideas to help strengthen their impact in the communities they serve.

“Amanda, a beacon of excellence in Michigan's quality improvement landscape, has earned her place as a Presidential Leadership Scholar, illuminating the path of leadership with dedication and innovation,” said CQI Portfolio Director Michael Englesbe, MD. “We look forward to benefiting from the enhanced skills she will gain through this program.”

The 2024 program kicks off Jan. 24 in Washington, D.C.

About the Presidential Leadership Scholars

The Presidential Leadership Scholars program is a partnership among the presidential centers of George W. Bush, William J. Clinton, George H.W. Bush, and Lyndon B. Johnson. To learn more, visit presidentialleadershipscholars.org.

03 Nov 2023
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MVC, MUSIC Estimate Significant Reduction in Opioid Spending After Kidney Stone Surgery

MVC, MUSIC Estimate Significant Reduction in Opioid Spending After Kidney Stone Surgery

November 3, 2023 | 0 Comments | , , ,

In 2019, more than 71,000 people died from drug overdoses, making it a leading cause of injury-related death in the United States. Nearly 70% of those overdoses involved a prescription or illicit opioid. The economic cost of the U.S. opioid epidemic was estimated to be $1,021 billion as of 2017 and rising. It is for this reason that clinicians and health systems have adopted evidence-based practices for reducing the number and amount of opioid prescriptions ordered for their patients. It is both clinically and economically significant, then, that the Michigan Value Collaborative (MVC) was recently part of an analysis that estimated over $4.8 million in avoided opioid prescription spending after kidney stone surgery.

MVC identified these savings in partnership with the Michigan Urological Surgery Improvement Collaborative (MUSIC), a physician-led quality improvement collaborative comprised of urology practices across the state of Michigan. MUSIC works to evaluate and improve the quality and cost-efficiency of urologic care. Since 2011, the MUSIC team has led prostate-related quality improvement activities such as improving patterns of care in the radiographic staging of men with newly diagnosed prostate cancer, reducing prostate biopsy-related hospitalizations, and enhancing the appropriateness of treatment decisions. In 2016, MUSIC expanded its scope of work to kidney stone surgery and in 2017 to small renal masses.

With kidney stone incidence on the rise affecting both men and women, MUSIC created a program focused on Reducing Operative Complications from Kidney Stones (ROCKS). It focuses on improving the quality of care for kidney stone patients, particularly by decreasing modifiable emergency department (ED) visits for expected symptoms and side effects of ureteroscopy (URS) or shockwave lithotripsy (SWL) surgeries that are typically avoidable. MUSIC ROCKS aims to minimize these by developing resources that help patients manage their pain and urinary tract symptoms following kidney stone surgery.

Since its formation, the MUSIC ROCKS initiative led to the development of stent omission appropriateness criteria, a URS vs. SWL patient-provider shared decision aid, standardized patient education, and recommendations for postoperative pain control regimens. The ROCKS pain control optimization (POP) guidelines were developed in 2019 and recommended prescribing no opioids following kidney stone surgery. The goal of these guidelines is to minimize opioid use in patients undergoing kidney stone surgery while maintaining patient safety and satisfaction.

The MUSIC Coordinating Center reached out to MVC in 2022 to help assess the impact of its ROCKS initiative on opioid prescription use following surgery. The goal was to estimate MUSIC ROCK's impact on opioid utilization and prescribing rates following URS or SWL kidney surgeries in Michigan, as well as the related impact on the value of care.

METHODOLOGY

Data Sources & Study Population

MVC kidney stone surgery episodes were used for this analysis, which compared outcomes between URS and SWL procedures for MUSIC and non-MUSIC providers. It was restricted to kidney stone surgery claims for Blue Cross Blue Shield of Michigan (BCBSM) and Blue Care Network (BCN) Commercial and Medicare Advantage plans between Jan. 1, 2015 and July 31, 2022. The cohort was further restricted to BCBSM/BCN-insured patients with no opioid prescription fills in the 90 days prior to their surgery who were continuously enrolled in a prescription sub-plan 90 days prior to surgery through 30 days post-surgery. The final cohort used in the opioid analysis included 14,967 Michigan patients.

Methodological Approach

The study population was identified using professional claims for MVC kidney stone surgery episodes that occurred within the index dates of the surgery. All professional claims missing a provider NPI on the claim were excluded. The remaining NPIs were characterized by information derived from the National Plan and Provider Enumeration System (NPPES) data set. Claims of providers or facilities outside of the state of Michigan were also excluded. The remaining NPIs were then categorized into MUSIC and non-MUSIC categories. Opioid utilization was assessed through the presence of paid outpatient opioid prescription claims in the 30 days following surgery.

Limitations

Approximately 90% of Michigan urologists participate in MUSIC. However, only 58% of all MVC kidney stone surgery episodes were identified as being performed by a MUSIC provider via National Provider Identifier (NPI). Some MUSIC providers may be performing these procedures on patients with an insurance plan not reflected in MVC data. It could also be related to MVC's episode structure. Episodes are mutually exclusive; therefore, if a patient were to have a hospitalization prior to their surgery that resulted in an MVC episode creation, their care would not be classified as a kidney stone surgery episode. It is also possible that billing NPI was not always a reliable field.

Second, MVC only has outpatient prescription claims for BCBSM and BCN patients with a prescription sub-plan. For this analysis, only BCBSM-insured patients were assessed. As a result, only about 35% of MVC's URS and SWL episodes were included in assessing opioid utilization. Furthermore, the analysis is of opioid utilization, not provider prescribing patterns. Given that a claim is only generated once a prescription is filled, this analysis cannot provide a full picture of changes in provider prescribing patterns.

FINDINGS & NEXT STEPS

Among the BCBSM/BCN-insured patients who underwent kidney stone surgery between 2015 and 2021, 50.3% of patients on average filled an opioid prescription within 30 days of surgery, with a higher average opioid utilization rate among SWL patients (54.9%) than among URS patients (47.4%). There was a strong decline in opioid utilization after 2017 across Michigan for both types of procedures (Figure 1), with lower utilization following URS.

 

Figure 1.

Notably, the rate of opioid utilization after kidney stone surgeries performed by MUSIC providers is consistently lower than those performed by non-MUSIC providers (Figure 2). For example, among URS procedures performed by MUSIC providers after 2016, 43.8% resulted in an opioid fill on average, whereas an average of 53.8% of procedures performed by non-MUSIC providers resulted in an opioid fill. In addition, the absolute decrease in opioid prescription fill rates was greater for MUSIC providers. These trends were similar for SWL surgeries, with consistently lower average opioid utilization rates among patients treated by MUSIC providers (52.1%) vs. non-MUSIC providers (60.9%).

Figure 2.

MVC further estimated cost savings from the reduction in opioid prescription fills by examining differences in 365-day prescription payments among the MUSIC cohort. The changes in opioid prescribing resulted in an estimated yearly average savings of $2,712 per patient from reduced opioid prescription fills post-surgery. Using this estimated savings, MVC multiplied the number of URS procedures performed each year by MUSIC providers combined with the yearly percent reduction from baseline in opioid prescribing to further estimate a savings of over $4.8 million from avoided opioid prescription payments since 2016.

The notable decreases in both prescribing rates and prescription payments demonstrate the substantial impact of the MUSIC ROCKS initiative on opioid utilization after kidney stone surgery, including a likely reduction in the total number of filled opioids circulating in the Michigan community as a result of fewer patients receiving prescriptions. MVC completed a similar analysis in partnership with MUSIC looking at prescribing patterns after prostate surgery, and estimated that MUSIC providers helped avert an estimated $1.6 million in avoided opioid prescription spending.

MVC’s expertise and data frequently result in partner projects like this; MVC completed several CQI impact assessments last year, as well as several more so far in 2024. MVC also participates in collaborative activities with peer CQIs through new condition and report development, data analysis and metric consultation, and data matching exercises that pair clinical and claims-based data. To request a copy of any of MVC’s completed CQI impact assessments, please contact the MVC Coordinating Center.

18 Aug 2023
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MEDIC Helps EDs in Michigan Improve Care for Adults, Children

MEDIC Helps EDs in Michigan Improve Care for Adults, Children

August 18, 2023 | 0 Comments |

Serving a spectrum of functions, emergency departments (EDs) provide essential care and services, operating in the critical space between outpatient and inpatient care. EDs also serve as a safety net within the US healthcare landscape by performing necessary clinical services for populations who may not otherwise have access. Patients visiting the ED may undergo a wide range of rapid diagnostic and treatment options, ranging from unscheduled procedures, laboratory testing, utilization of basic and advanced imaging studies, and admission of patients to the hospital. Despite the ED’s critical role and services, there are few coordinated, scalable efforts to improve care quality in the ED. These realities within emergency medicine made it a prime opportunity for quality improvement (Kocher et al., 2019), which was the impetus for adding an emergency medicine-focused Collaborative Quality Initiative (CQI) to the Blue Cross Blue Shield of Michigan (BCBSM) Value Partnerships portfolio.

The Michigan Emergency Department Improvement Collaborative (MEDIC) was founded in 2015 to address the critical gap in coordinated quality improvement in the ED, including intervention design through implementation and evaluation, at scale, across health systems. Michigan Value Collaborative (MVC) members recently heard about MEDIC and its work as part of the launch of MVC’s new ED-based episodes and reporting; MEDIC and MVC collaborated on the development of this new episode of care data structure.

MEDIC’s quality improvement efforts to date have included initiatives such as improved appropriateness of head CT imaging utilization for children and adults with minor head injuries, greater CT diagnostic yield for adults with suspected pulmonary embolism, decreased use of chest x-rays in children with respiratory illness (i.e., asthma, croup, bronchiolitis), higher rates of ED discharge for children with asthma and adults with low-risk chest pain, and increased distribution of take-home naloxone to patients with opioid use disorder (OUD) or who experience opioid overdose or withdrawal.

MEDIC Success Stories

Since 2017, MEDIC participating sites have significantly improved collaborative-wide performance on all MEDIC quality measures. By reducing unnecessary imaging utilization and decreasing unwarranted hospitalization rates from the ED, MEDIC positively impacted the emergency care experience for thousands of patients in Michigan who received more evidence-based care and fewer low-value services. These improvements also contributed to an estimated total reduction in the ED cost burden in the millions of dollars (Figure 1).

Figure 1.

Zach Sawaya, MD, an emergency physician at MyMichigan Medical Center, reflected positively on the benefits of partnering with MEDIC on specific quality improvement initiatives. "MEDIC has pushed our group to be more cognizant of our imaging use, in particular in the pediatric population,” he said. “We've seen significant improvements in our rates of pediatric head CTs and chest X-rays that have been driven by MEDIC-provided data and decision-making resources.  In particular, we've seen wait times on pediatric head injuries go down as parents have been very open to discussion of PECARN rules and foregoing head imaging.”

The fact that MEDIC’s efforts support patients of all ages within its participating sites is unique; MEDIC is one of only a few CQIs with initiatives focused on pediatric patients. The MEDIC 2023 pay-for-performance incentive program, for example, focused on performance improvement on its pediatric-specific metrics. A key goal of this work was to ensure that children receiving emergency care in community hospital EDs received the same high-quality evidence-based care delivered in a pediatric emergency center. Since there are only three Michigan pediatric centers—all members of MEDIC—most children receive emergency care in community hospital EDs, and MEDIC observed disparities in the quality of emergency care delivered to children treated in community EDs. Children seen in community EDs were less likely to receive evidence-based care, as measured by our quality initiatives, than those seen in pediatric centers. In an emergency, patients can’t often choose which ED to go to, rather they need to go to the closest option. Over time and with participation in MEDIC, the data indicate MEDIC community hospitals improved their collective performance on MEDIC pediatric measures to be nearly on par with that of pediatric specialty hospitals.

The COVID-19 pandemic and its resulting impact on EDs also put MEDIC in a unique position. Within days of the pandemic being declared in the US, the MEDIC team pivoted from its standard work to support the COVID-19 response by leveraging its collaborative-wide learning network to support frontline efforts. MEDIC rapidly assembled a platform for informal and formal discussion between member EDs, which manifested as a series of virtual town halls and Grand Rounds focused on information exchanges among colleagues to rapidly innovate and meet challenges as the situation evolved.

This series began with lessons learned from the experience of its southeast Michigan EDs where the pandemic first unfolded in Michigan. This allowed sites in other areas of Michigan to understand what they would likely experience in the coming weeks or months, giving them valuable preparation time. Over several weeks, these well-attended sessions focused on the following topics: conservation of PPE, management of COVID-19 respiratory failure, special considerations for the pediatric population, and supporting the wellness of the ED workforce.

MEDIC – ED Partnerships

EDs partner with MEDIC in two primary ways: data collection and collaborative engagement in quality improvement. To participate in MEDIC, a partner ED must establish a flow of electronic health data for all ED visits to the MEDIC data registry as well as provide additional abstracted data, facilitated by a data abstractor hired with support from BCBSM. This then allows MEDIC to provide detailed evaluation and performance reporting on all measured quality initiatives, which in turn helps facilitate and inform site quality improvement interventions. MEDIC provides member hospitals with a level of insight into their ED practice patterns that would not be possible without participating in the collaborative.

In addition to being able to understand their data, participating in MEDIC allows hospitals to learn from one another, which significantly shortens the learning curve for improvement. Each site’s emergency medicine physician champion and abstractor(s) lead local intervention design and implementation, participate in MEDIC tri-annual collaborative-wide meetings, and share experiences and lessons learned with collaborative peers. MEDIC provides quality improvement evidence, guidelines, standardized performance measurement, data visualization, evaluation, and support for local intervention efforts.

MEDIC currently partners with hospital EDs across the state. Any sites not currently partnered with MEDIC are encouraged to visit their recruitment page for more information on becoming a member and contacting the team.

As MVC continues to build its offerings for members, the coordinating center is cognizant that hospitals and providers partner with multiple CQIs. MVC posts regular blogs about some of its peer CQIs to showcase their activities and highlight collaborations with MVC. Please reach out to the MVC Coordinating Center with questions.

11 May 2023
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MVC Honors Mental Health Awareness Month with Workgroup

MVC Honors Mental Health Awareness Month with Workgroup

May 11, 2023 | 0 Comments | , ,

Mental illness and related conditions such as depression are increasingly prevalent and costly. More than 50% of patients will be diagnosed with mental illness or disorder at some point in their lifetime, according to a World Health Organization research survey, and one in four adolescents will experience depression by the age of 18, contributing to an estimated $406 billion in medical treatment costs in a single year in the U.S. To bring attention and awareness to this issue, the month of May is celebrated nationally as Mental Health Awareness Month. It represents an important opportunity for healthcare providers and hospitals to evaluate the ways in which they currently support patients experiencing mental health/substance use disorder (MH/SUD) conditions.

To help facilitate this conversation, the Michigan Value Collaborative hosted a workgroup yesterday focused on increasing access to high-quality mental health for patients and increasing support for providers. MVC’s guest speakers hail from the Michigan Collaborative Care Implementation Support Team (MCCIST), including Gregory Dalack, MD, MCCIST Co-Lead and Daniel E. Offutt III Professor and Chair of the Michigan Medicine Department of Psychiatry, and Karla Metzger, LMSW, MCCIST Program Manager.

The presenters highlighted the psychiatric Collaborative Care Model (CoCM), an evidence-based integrated behavioral health model that is primary care based and highly cost-effective. Research evidence suggests that up to $6 are saved in long-term healthcare costs for every dollar spent on collaborative care. The presentation included research evidence of the benefits of CoCM, an introduction to its components, tips for implementation and common challenges, and several success stories from both patients and providers.

The Collaborative Care Model

Those unable to attend Thursday's MVC workgroup can access the full recording on MVC’s YouTube channel. Additionally, the American Psychiatric Association (APA) and Academy of Psychosomatic Medicine (APM) jointly developed a report on the CoCM that reviews current evidence, essential elements of implementation, and recommendations for better meeting the health needs of people with mental health conditions, which is available here.

The American Hospital Association has also compiled a variety of resources on its Mental Health Awareness Month webpage related to mental health information, suicide prevention, opioid stewardship, downloadable posters to help employees adopt respectful language, case studies, and other tools and resources.

For those working in the behavioral and mental health space, there is also a recently formed Collaborative Quality Initiative (CQI) focused on mental health. Established in 2022, the Michigan Mental Innovation Network and Clinical Design (MI Mind) CQI is a statewide partnership with providers and provider organizations that works to prevent suicide and improve outcomes by reducing suicide attempts and deaths. MI Mind offers access to and engagement in evidence-based services for providers with a focus on suicide prevention, with plans to expand into other behavioral health domains, such as depression, anxiety, and substance use disorders. For a closer look at MI Mind, read MVC’s blog about their formation and check out the MI Mind website.

20 Apr 2023
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MVC Evaluates Impact of MOQC Antiemetic Initiative on Healthcare Utilization During Chemotherapy

MVC Evaluates Impact of MOQC Antiemetic Initiative on Healthcare Utilization During Chemotherapy

April 20, 2023 | 0 Comments | , , ,

Chemotherapy-Induced Nausea and Vomiting (CINV) is among the most feared side effects of chemotherapy among cancer patients. It impairs the patient's quality of life and also adds to the morbidity and cost of therapy. That is why the Michigan Oncology Quality Consortium (MOQC)—a physician-led, voluntary collaborative of medical and gynecologic oncologists who work to improve the quality and value of cancer care in Michigan—initiated its Antiemetic Initiative. Through this initiative, MOQC supports participating oncology practices in aligning with current guidelines for use of prophylactic antiemetics, including olanzapine, in patients receiving chemotherapy. The Michigan Value Collaborative (MVC) recently partnered with MOQC to evaluate the impact of this initiative and estimated a cost savings of $334,095 across the course of chemotherapy from the increased use of olanzapine and decreased inpatient admissions in this cohort of patients.

Olanzapine is underused in patients receiving high-emetic-risk chemotherapy, despite evidence of efficacy and good patient tolerance (Navari et al., 2016). Olanzapine is a long-used medication (originally in higher doses for the treatment of psychosis) that is highly effective at decreasing nausea and vomiting. Uptake of olanzapine has been low, however, in part due to oncologists' lack of familiarity with the medication, lack of awareness or agreement with the guidelines, and lack of olanzapine inclusion on prepopulated order sets. The current labeling of olanzapine as an antipsychotic poses an additional barrier since this labeling generates additional concerns about stigma and side effects among patients. A benefit to this medication, in addition to its effect on nausea and vomiting, is its low cost compared with other medicines used to prevent the side effects of chemotherapy; the cost for each pill is about 25 cents.

Practices participating in MOQC’s Antiemetic Initiative receive performance data and baseline assessments in the area of CINV guideline adherence, support in identifying gaps in care and quality improvement measures, and resources for provider and patient education. To help evaluate the impact of this work on guideline-concordant olanzapine use, MOQC first reached out to MVC in 2022 to leverage its robust claims-based data. MOQC hypothesized that patients treated in medical oncology practices with low rates of olanzapine prescribing would have higher rates of healthcare utilization, including hospitalizations, emergency department (ED) visits, and unplanned outpatient visits between treatment cycles. The goal of this analysis was to estimate the initiative's overall impact on healthcare utilization for breast cancer patients undergoing chemotherapy as well as any related cost savings that improved the value of care delivery.

Methodology

The cohort for this analysis was comprised of female patients with a 90-day claims-based MVC episode of care for lumpectomy or mastectomy in 2016-2021 who received combination chemotherapy with doxorubicin and cyclophosphamide as either neoadjuvant or adjuvant chemotherapy. The cohort included patients covered by Blue Cross Blue Shield of Michigan (BCBSM) PPO Commercial, BCBSM PPO Medicare Advantage (MA), Blue Care Network (BCN) HMO Commercial, BCN HMO MA, and Medicare Fee-For-Service. The resulting MVC analysis included episodes for 1,891 patients who had a breast cancer resection, received both chemotherapy drugs on the same day, and were attributed to a MOQC provider/practice. Patients were attributed to 45 of MOQC's participating practices.

Practice-level olanzapine data collected by MOQC was then used to assess whether each patient's first chemotherapy receipt was during a time when their attributed practice had high or low prescribing rates of olanzapine. The threshold for high versus low prescribing at a particular practice was set at a 25% prescribing rate. Once a practice reached 25% prescribing rates of olanzapine in MOQC's data, that practice was considered to have "high" olanzapine prescribing rates in all subsequent months for this analysis. Using that distinction of whether the practice was a high or low prescriber during the course of the patient's chemotherapy regimen, MVC compared post-chemotherapy healthcare utilization among patients treated by high- versus low-prescriber practices. Sub-analyses further restricted the cohort to patients attributed to a practice that ever became categorized as having high olanzapine prescribing rates. When limiting the analysis to practices that became high prescribers at any point, the cohort was narrowed down to patients attributed to 15 MOQC practices.

Limitations

The nature of claims data limited MVC's ability to identify patients attributed to participating oncologists at MOQC practices; the requirement of each patient in the cohort having a MOQC provider NPI on one of their claims reduced the analytic cohort to a smaller size than what would be seen in clinical data. Another limitation is that the findings may include period effects not controlled for in this analysis. Practice behavior and availability of inpatient beds may have differed between when a practice was a low olanzapine prescriber compared to when they began prescribing olanzapine at a higher rate. Finally, payment calculations included in this analysis are limited to dollars saved among the attributed claims-based population and, therefore, do not reflect savings that may be attributed to olanzapine use among the broader population of interest.

Impact & Next Steps

A key finding in the analysis included a significant difference in healthcare utilization across the course of chemotherapy among patients treated by high olanzapine prescribing MOQC practices compared to when they had low olanzapine utilization. Among the patients with cancer who received their first cycle of chemotherapy when their provider's practice had a high prescribing rate (≥25%), 10% were hospitalized (Figure 1). This inpatient admission rate was significantly lower than for those patients undergoing chemotherapy regimens at practices with low olanzapine prescribing rates, 15% of whom were hospitalized (p=0.02). This finding was based on a subset of patients attributed to practices who eventually became high olanzapine prescribers during the study period (922 patients at 15 practices).

Figure 1. Rates of Inpatient Admission Across Patients' Course of Chemotherapy, by Practice's Utilization Rate of Antiemetics at the Start of Chemotherapy (N=922)

This analysis further discovered a significant difference in the percentage of patients who had either an ED visit or inpatient admission. Of the patients receiving chemotherapy at MOQC practices, fewer patients at high-prescribing practices had either an ED visit or inpatient admission (19%) across the course of their treatment compared to patients receiving care at low-prescribing practices (26%).

MVC estimated a cost savings of $334,095 across the course of chemotherapy from the increased use of olanzapine and decreased inpatient admissions in this cohort of patients. Dollars saved were calculated by taking the number of patients whose chemotherapy began when their practice was a high prescriber (525), multiplied by the difference in the percentage of patients with an inpatient admission across the course of chemotherapy attributed to practice antiemetic prescribing rate (5.3%), multiplied by the average price-standardized payment for an inpatient admission during a 90-day episode of care among breast cancer resection episodes for the included payers ($12,007).

This analysis demonstrated further evidence that the use of prophylactic olanzapine is an effective strategy for managing CINV-related ED visits or hospitalizations. It furthermore identified tangible CQI impact in the form of patients who underwent breast cancer treatment being less likely to visit the ED or be hospitalized over the course of their chemotherapy regimen, as well as in the form of dollars saved on facility inpatient costs across the course of chemotherapy. Ongoing work will continue to support practices to make changes in the use of olanzapine, not only in patients receiving combination therapy with doxorubicin and cyclophosphamide but also in other high-emetic-risk regimens.

MVC’s expertise and data frequently result in partner projects like this; MVC completed a number of CQI impact assessments last year, as well as several more so far in 2023. MVC also participates in collaborative activities with peer CQIs through new condition and report development, data analysis and metric consultation, and data matching exercises that pair clinical and claims-based data. To request a copy of any of MVC’s completed CQI impact assessments, please contact the MVC Coordinating Center.

02 Mar 2023
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MVC, MBSC Estimate Significant Diabetes Medication Savings Following Bariatric Surgery

MVC, MBSC Estimate Significant Diabetes Medication Savings Following Bariatric Surgery

March 2, 2023 | 0 Comments | , , ,

Diabetes is commonly cited as the most expensive chronic disease in the U.S., accounting for over $37 billion in 2017. As many as 1 in 10 Americans have been diagnosed, 90-95% of whom have Type 2 diabetes. Management of Type 2 diabetes involves healthy eating, physical activity, and often taking medication prescribed by a doctor, such as insulin, other injectable medications, or oral diabetes medicines to help manage blood sugar. It is both clinically and economically significant, then, that the Michigan Value Collaborative (MVC) was recently part of an analysis that estimated over $76.5 million in insurance savings on prescription diabetes medications after patients underwent metabolic surgery.

MVC identified these savings in partnership with the Michigan Bariatric Surgery Collaborative (MBSC) last year and published their findings in a co-authored research letter in JAMA Surgery. This work was featured recently by the medical news site Medpage Today.

The partner project was initiated by MBSC in 2022 to help assess the impact of bariatric surgery on prescription fills for diabetes medications across the state of Michigan, driven largely by existing evidence in the literature that bariatric surgery resolved or improved Type 2 diabetes symptoms in a large proportion of patients (Varban et al., 2022). MBSC is a regional group of hospitals and surgeons that aim to innovate the science and practice of metabolic and bariatric surgery through comprehensive, lifelong, patient-centered obesity care.

Using its rich administrative claims data sources, the MVC team first analyzed pre-surgery and post-surgery receipt of diabetes medications, which was then used to estimate a high-level snapshot of the overall impact across Michigan. MVC's analysis included estimated cost savings to health insurance providers that could be attributed to a decrease in post-surgery diabetes medication prescription fills.

The analysis used bariatric surgery episodes for Roux-en-Y Gastric Bypass (RYGB) and sleeve gastrectomy hospitalizations. It was limited to bariatric surgery patients with a diagnosis of Type 2 diabetes who filled an outpatient diabetes medication prescription prior to their discharge. The analysis focused on episodes with index admissions between 2015 and 2021 for Blue Cross Blue Shield of Michigan (BCBSM) PPO Commercial and BCBSM Medicare Advantage plans for individuals who were continuously enrolled in a prescription sub-plan. This amounted to 760 patients with Type 2 diabetes undergoing gastric bypass (22%) or sleeve gastrectomy (78%) between 2015 to 2021.

In the 120 days prior to surgery, MVC found that 88% of patients filled an outpatient oral diabetes medication prescription, 30% filled an insulin prescription, and 21% filled a GLP-1 receptor agonist prescription. From the 120 days pre-surgery to the 120 days post-surgery, there was a significant decrease in fills for any diabetes medication (p<.001). The most frequent change in medications between pre- and post-surgery was from oral diabetes medication to no diabetes medication. In the 1 to 120 days following surgery, half (50%) of patients filled no diabetes medication prescriptions, and in the 121 to 240 days following surgery, most patients (63%) filled no diabetes medication prescriptions (see Figure 1).

Figure 1.

This amounted to an average decrease in diabetes prescription payments made by the insurance provider of approximately $4,133 per patient in the first year following surgery. Given that 34% of bariatric surgery patients have diabetes and 54,454 bariatric surgeries were performed in Michigan between 2015 and 2021, MVC estimated that insurance providers in Michigan saved $76.5 million on diabetes medications in the 360 days following bariatric surgeries in 2015-2021. In addition, data suggest that savings would continue to increase in future years due to long-term diabetes remission and cost benefits from optimized diabetes management. These results provide evidence of significant statewide clinical outcome improvement and cost savings for Type 2 diabetes following bariatric surgery.

These findings and their implications were also highlighted recently during an MVC workgroup featuring Dr. Oliver Varban of MBSC as the guest speaker. See below for a complete recording of his insightful presentation about bariatric surgery, its impact on chronic disease management, and more.

MVC’s expertise and data frequently result in partner projects like this; MVC completed three other CQI impact assessments last year (Figure 2). These projects are an example of MVC’s interest in CQI collaboration, which is also demonstrated through new condition and report development, data analysis and metric consultation, and data matching exercises that pair clinical and claims-based data.

Figure 2.

To request a copy of any of MVC’s completed impact assessments from 2022 or prior, please contact the MVC Coordinating Center.