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MVC Celebrates National Rural Health Day with MyMichigan Workgroup Presentation

MVC Celebrates National Rural Health Day with MyMichigan Workgroup Presentation

Today is National Rural Health Day. Since 2010, the National Organization of State Offices of Rural Health set aside the third Thursday of every November to highlight the unique healthcare challenges facing residents within rural communities and celebrate providers who deliver innovative, affordable, and coordinated rural healthcare. MVC’s current membership includes 44 hospitals based in rural communities, 22 of which are designated as Critical Access Hospitals (CAHs). In tribute to National Rural Health Day and the needs of its growing rural membership, MVC hosted a special rural health workgroup yesterday.

The workgroup featured a guest presentation by Stephanie Pins, MSA, CPHQ. Pins is the Director of Quality, Risk, and Compliance for MyMichigan Medical Center Sault, formerly War Memorial Hospital, and is co-leading the Health Equity Council for MyMichigan Health. She led the creation of a transportation program for War Memorial Hospital by working with local transportation companies and applying for grants to cover the cost of the program.

This guest presentation focused on how MyMichigan is supporting rural communities through their Non-Emergency Medical Transportation (NEMT) Project, and the steps their team took to develop this program. Beginning in 2024, CMS will require that hospitals screen admitted patients for five social determinants of health (SDOH) domains. One of those five required domains is transportation needs since access to transportation and distance to care have a significant impact on healthcare outcomes.

MyMichigan Medical Center Sault primarily services the very rural communities of Chippewa, Luce, and Mackinac counties, located in the eastern Upper Peninsula of Michigan. A resident of Drummond Island—part of Chippewa County—may have to drive as many as 70 miles each way to get to an appointment at MyMichigan Medical Center Sault. Limited vehicle access in this part of the state was highlighted recently at MVC’s fall collaborative-wide meeting; the eastern Upper Peninsula had some of the highest rates in the state for housing units with no vehicle (Figure 1).

Figure 1.

While presenting, Pins emphasized that once MyMichigan identifies a need through screening, the next step is to find a way to connect those patients with the assistance they need to access medical care. One transportation solution utilized by MyMichigan Medical Center Sault is the Road-to-Recovery program, offered in partnership with McLaren Northern Michigan in Petoskey. The MyMichigan Medical Center Sault location offers some oncology cancer treatment services, but not radiation, so patients may need to travel to Petoskey—a distance of over 90 miles—to receive radiation therapy as part of their cancer treatment. The fully funded Road-to-Recovery program is available five days a week free of charge to anyone in the eastern Upper Peninsula. A hospital-owned van is driven by a volunteer driver from the MyMichigan Medical Center Sault location to scheduled pick-up locations along the I-75 corridor to Petoskey. Service times are coordinated with McLaren Northern Michigan’s oncology group so all the patients using this service have aligned appointment times. Pins shared that one noteworthy ancillary benefit of this program has been the peer support and relationship building that resulted from patients traveling together for extended periods while going through a similar treatment experience.

A second transportation solution utilized by MyMichigan Medical Center Sault is the Rides-to-Wellness Program, a partnership effort with local transportation companies and Connect UP. Patients can use this service to travel to other appointments or patient care services and serves as a critical stopgap in ensuring patients have somewhere to turn for time-sensitive transportation needs. Pins shared that the patient testimonials from those utilizing the service are helpful evidence of its value to the eastern Upper Peninsula (Figure 2).

Figure 2.

MyMichigan Medical Center Sault identified several lessons learned from delivering its Rides-to-Recovery Program over the last 10 years and applied many of those lessons to the development of its more recent Rides-to-Wellness Program. Pins also shared several tips for starting similar hospital-based transportation support programs at other locations throughout the state (Figure 3).

Figure 3.

Those who missed the workgroup and would like to learn more about these two programs, how they are managed, and how they were developed can review the full recording here. MVC is excited to offer a new rural health workgroup series quarterly in 2024. Contact MVC if you are interested in receiving invitations to those workgroups.

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Study Shows Lasting Impact of a Modifier 22 Initiative on Opioid Use Among Vasectomy Patients

Study Shows Lasting Impact of a Modifier 22 Initiative on Opioid Use Among Vasectomy Patients

The opioid epidemic continues to harm individuals and communities worldwide; over-prescribing, overuse, and related overdose deaths persist in the United States and abroad. Without proper intervention, the proliferation of opioid use disorder and its negative impact on population health will continue. Healthcare professionals and stakeholders eager to stem this crisis are investing in the development and iteration of interventions that improve control of opioid distribution. As part of this effort, one team of healthcare researchers recently published a paper in Urology investigating the impact of an insurance payer’s novel opioid reduction intervention on the adoption of opioid-sparing pathways.

The authors of this publication, including lead author Dr. Catherine S. Nam, M.D., and her colleagues from Michigan Medicine, sought to compare the percentage of patients who filled peri-procedural opioid prescriptions before and after Blue Cross Blue Shield of Michigan (BCBSM) launched a modifier 22 incentive for opioid-sparing vasectomies in Michigan. This program incentivized the utilization of an opioid-sparing post-operative pathway developed by the Michigan Opioid Prescribing Engagement Network (OPEN) by allowing the use of the modifier 22 reimbursement code for vasectomies performed with minimal or no post-operative opioids. Previous literature has demonstrated success in this approach for other medical procedures. The use of modifier 22 as an opioid reduction intervention was first launched by BCBSM in 2018 for select procedures and was expanded to include vasectomies in 2019. Typically, modifier 22 can be applied to select insurance claims with the primary procedure code when the work attributed to that procedure or medical intervention exceeds the typical amount of required labor. When approved, insurance companies may provide additional reimbursements of up to 35%.

The expanded eligibility for the modifier 22 into vasectomy presented substantial quality improvement potential given both how commonly this procedure is performed—approximately half a million times annually across the US—and the fact that a 2019 survey indicated more than half of urologists prescribed opioids for patients receiving a vasectomy, even though the procedure can be completed without them. For a vasectomy procedure to qualify for the modifier 22 program, a surgeon must intend to follow an opioid-free peri-procedural course as well as provide additional counseling to patients about post-procedural pain expectations, proper opioid disposal, and non-opioid pain management strategies.

Given the novel quality incentive for opioid-sparing pathway application to vasectomy with implications for payers, providers, patients, and policymakers, Dr. Nam and her colleagues were interested in evaluating the impact this policy change had within the state of Michigan.

To perform this analysis, Dr. Nam and colleagues leveraged Michigan Value Collaborative (MVC) administration claims data from beneficiaries in BCBSM’s preferred provider organization (PPO) plan. The data provided by MVC included men ages 20 to 64 who participated in urologic procedures between Feb. 1, 2018, and Nov. 16, 2020.

Between these dates, Dr. Nam and colleagues identified 4,559 men who underwent office-based vasectomies and 4,679 men in the control group, which consisted of men who underwent cystourethroscopies, prostate biopsies, circumcision, and transurethral destruction of prostate tissue. These procedures are all office-based and not eligible for opioid-sparing modifier 22, thus providing a point of comparison.

The results of the analysis demonstrated a strong association between the implementation of modifier 22 for vasectomies and filled opioid prescriptions. Before July 1, 2019—prior to the implementation of the expanded modifier 22 policy—32.5% of men filled an opioid prescription after receiving a vasectomy, whereas after implementation only 12.6% of men filled an opioid prescription post-procedure (see Figure 1). As highlighted in the figure below, Dr. Nam and colleagues found a 19.9% absolute reduction and 61% relative reduction in the percentage of vasectomy patients who filled peri-procedural opioid prescriptions.

Figure 1. Percent of Patients Filling Opioid Prescriptions Before and After Implementation of Modifier 22

Among the vasectomy patients in the analysis, for every three opioid prescriptions filled before the implementation of modifier 22, only one was filled after the initiative was implemented. They did not find a significant decrease in the percentage of patients who filled peri-procedural opioid prescriptions in the control group.

In addition to the decreased frequency of men filling peri-procedural opioid prescriptions for vasectomies, Dr. Nam and colleagues also found a significant decrease in the prescribed amount. After the implementation of modifier 22 for vasectomies, the oral morphine equivalents (OME) of peri-procedural opioid prescriptions fills dropped from 89.7 OME per prescription to 27.1 OME per prescription. Dr. Nam and colleagues estimated that this decrease in prescription size led to the distribution of approximately 8,473 fewer oxycodone 5mg pills in Michigan.

When asked about the significance of these findings, Dr. Nam explained, “This estimate helped us grasp the impact of the Modifier 22 policy change for patients as well as the community. If this was the impact in a bit over a year for a single procedure in one state, how large could this impact be annually? What could the impact be when quality incentive is expanded to additional procedures? What if the quality incentive could be expanded to other states?”

These findings suggest that the modifier 22 incentive does decrease the percentage of patients who fill peri-procedural prescriptions after a vasectomy and its implementation correlates with a reduction in the number of opioids circulating within the community. In addition to reducing the unnecessary presence of opioids in communities, this initiative also emphasizes a shift to refocus healthcare interactions on the patient. The required additional education about pain management and proper use of pain management medications implemented as part of the modifier 22 initiative provides patients with a better understanding of their care and encourages physicians to consistently deliver high-value care.

Despite the significant findings of this study, a question remained. If these practice changes were initiated by incentivized modifier 22 interventions, what would happen if BCBSM terminated the incentive? Since the publication of Dr. Nam and colleagues’ original study, BCBSM terminated the financial incentive using modifier 22 for opioid-sparing vasectomies on Dec. 31, 2021. This termination provided the group with an opportunity to observe the long-term impact modifier 22 had on physician prescribing patterns and patient opioid use after the incentive was no longer in place.

Dr. Nam and colleagues performed another interrupted time series analysis before and after the termination of modifier 22 using the same vasectomy and control groups. After analyzing the data provided by MVC, they observed no significant changes in the opioid fill rate compared to the rate observed when the modifier 22 program was in effect. This was true for both the vasectomy group and the control group (see Figure 2). The persistence of reduced opioid prescription sizes was also observed following termination of modifier 22. Prior to incentive termination, the mean opioid prescription amount was 59 OME, and after termination the mean further reduced to 36 OME.

Figure 2. Percent of Patients Filling Opioid Prescriptions Before and After Termination of Modifier 22

These critical findings demonstrate that physician opioid prescribing behavior remained constant after the removal of financial incentives. More research still needs to be done on the long-term impact of programs such as modifier 22; however, Dr. Nam and colleagues suggest that other payers could implement incentive programs like BCBSM’s modifier 22 initiative in order to spur similar changes in prescribing patterns and are hopeful that short-term financial incentives are part of the solution to creating lasting practice changes.

“This is the first example of a novel quality incentive targeting physicians to provide high-value care by incentivizing opioid-sparing pain pathway,” she said. “However, this incentive can be adapted to incentivize other high-value care – could we recognize physicians that are providing guideline-based care? How about ensuring that appropriate lab and imaging tests are ordered for patients as part of their care plan? And if so, could it be possible for there to be an investment made from the insurance companies to champion high-value care for a short period of time to have lasting effects?”

MVC is committed to using data to improve the health of Michigan through sustainable, high-value healthcare. Therefore, one of MVC’s core strategic priorities is intentional partnerships with fellow Collaborative Quality Initiatives (CQIs) and quality improvement collaborators. In partnering with clinical, administrative, and CQI experts to leverage MVC data for analyses, MVC aims to identify best practices and innovative interventions that help all members improve the quality and cost of care.

Publication Authors

Catherine S. Nam, MD; Yen-Ling Lai, MSPH, MS; Hsou Mei Hu, PhD, MBA, MHS; Arvin K. George, MD; Susan Linsell, MHSA; Stephanie Ferrante; Chad M. Brummett, MD; Jennifer F. Waljee, MD; James M. Dupree, MD, MPH

Full Citation

Nam, C. S., Lai, Y.-L., Hu, H. M., George, A. K., Linsell, S., Ferrante, S., Brummett, C. M., Waljee, J. F., & Dupree, J. M. (2022). Less is more: Fulfillment of opioid prescriptions before and after implementation of a modifier 22 based quality incentive for opioid-free vasectomies. Urology, 171, 103–108. https://doi.org/10.1016/j.urology.2022.09.023.

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MVC Honors Mental Health Awareness Month with Workgroup

MVC Honors Mental Health Awareness Month with Workgroup

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.

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MVC to Honor Medical Pioneers for February’s Black History Month

MVC to Honor Medical Pioneers for February’s Black History Month

Black History Month is an opportunity to celebrate the triumphs and reflect on the struggles of African American or Black persons throughout the history of the United States. In honor of this celebration, the MVC team is highlighting some of the Black pioneers who opened doors to medical fields and advanced the field of health through research.

It seems logical to begin by highlighting the work of James McCune Smith (Figure 1), notably America’s first Black physician. He received a medical degree from the University of Glasgow in 1837, when African Americans were denied admission to medical schools in the U.S. He also later became the first Black man to operate a pharmacy as well as the first Black author to be published in a medical journal. He applied his scientific mind and expertise to debunking poor science, outdated assumptions, and racist theories related to African Americans. As an abolitionist and close friend of Frederick Douglass, he wrote the introduction to Douglass' book, My Bondage and My Freedom.

Figure 1.

He was followed by many inspiring African American and Black healthcare providers who made history in their respective fields. There were leaders such as Daniel Hale Williams (1856-1931), who founded the Provident Hospital and Training School for Nurses in Chicago, America’s first Black-owned and interracial hospital. He is also known for having performed the world’s first successful heart operation, which saved the life of a man who had been stabbed in the chest.

Then there was Robert F. Boyd (1858-1912) who in 1895 co-founded the National Medical Association, the nation’s oldest and largest organization representing Black physicians and health care professionals. He served as its first president.

Alexa Canady (Figure 2), born in 1950, is also a Black physician of great strength and impact. She fought her way into one of the most competitive and exclusive fields of medicine when she became the first Black female neurosurgeon in the U.S. in 1981. She is an alumnus of the University of Michigan Medical School who specialized in pediatric surgery. She became chief of neurosurgery at the Children’s Hospital of Michigan from 1987 until her retirement in June 2001.

Figure 2.

As representation and institutional support grew, so too did the voice of African Americans in published medical research. Prominent physician and researcher Charles Richard Drew (1904-1950) studied blood transfusions and helped develop large-scale blood banks deployed during World War II. Patricia Bath (1942-2019), an ophthalmologist dedicated to blindness prevention in marginalized communities, was the first Black female physician to be awarded a medical patent for her invention of a laser cataract treatment.

A wealth of researchers working today dedicate their expertise to studying disparities, race, and ethnicity in healthcare. The Agency for Healthcare Research and Quality (AHRQ) honored Black History Month recently by highlighting the work of its grantees. Dr. Fabian Johnston, for instance, studies early utilization of palliative care for African Americans using culturally informed patient navigation, and Dr. Mya Lee Roberson evaluates geographic variation in breast cancer surgical outcomes among Black women in the South. AHRQ’s spotlight for Black History Month also includes an expansive list of recent research findings and publications related to race and health equity.

These professionals and countless others had a profound impact on medicine, research, and society. However, Black History Month is also a time to acknowledge the struggles and ongoing challenges experienced by the African American and Black communities. While much of the 20th and 21st centuries allowed for a series of “firsts,” they also bore witness to abhorrent racism that resulted in gruesome experiments, forced sterilizations, harmful research studies, and undertreatment for pain. As a result, there is rampant mistrust of the healthcare system within the Black community, even among some medical professionals. This was evident throughout the COVID-19 pandemic; hospitalized patients who did not trust healthcare providers were less likely to believe they were at increased risk of severe illness and were less likely to become vaccinated.

The MVC Coordinating Center is committed to emphasizing equitable care in Michigan by providing members with equity metrics and collaboration opportunities. The MVC team set several concrete goals to share research findings and resources throughout 2023 in service of members’ equity-related initiatives. Some of these resources may be used to build communication and trust with patients and solicit their input on healthcare practices.

In addition, those who follow MVC on Twitter or LinkedIn will see additional stories about African American medical pioneers throughout the remainder of February. If you have a colleague or individual you would like to nominate to be featured this month, please contact the MVC Coordinating Center at Michigan-Value-Collaborative@med.umich.edu.

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Happy Thanksgiving from the MVC Coordinating Center

Happy Thanksgiving from the MVC Coordinating Center

The Michigan Value Collaborative wishes you a happy Thanksgiving holiday. Thank you to all Michigan hospitals and physician organizations for working tirelessly every day to improve healthcare quality across Michigan. We are grateful for your partnership and your efforts on behalf of Michigan patients.

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MVC Fall Semi-Annual Summary: Prescribing Health in Michigan

MVC Fall Semi-Annual Summary: Prescribing Health in Michigan

The Michigan Value Collaborative (MVC) held its second semi-annual meeting of 2022 last Friday, marking MVC’s first in-person collaborative-wide meeting since 2019. A total of 90 leaders registered for the meeting, representing 25 different hospitals, seven physician organizations (POs), and five stakeholder organizations from across the state of Michigan. This meeting’s theme of “Prescribing Health in Michigan” showcased strategies to drive evidence-based medication utilization and support patient access to medications through the implementation and evaluation of quality improvement projects.

MVC Director Hari Nathan, MD, kicked off Friday’s meeting with an update from the MVC Coordinating Center. He welcomed one new collaborative member, Bronson Lakeview (Paw Paw), as well as MVC’s newest team members, Associate Program Manager Erin Conklin and Statistician Lead Usha Nuliyula. Dr. Nathan also highlighted the successes delivered by the Coordinating Center since May’s Semi-Annual Meeting. For instance, MVC launched its Qualified Entity registry pages to provide authorized users with more granular data than is available in the Medicare FFS reports, incorporated Distressed Community Index data into push reports as part of MVC’s commitment to emphasizing equity in healthcare, and distributed three new push reports (chronic obstructive pulmonary disease for POs, emergency department and post-acute care utilization for acute and critical access hospitals, and a hysterectomy report for hospital members).

Dr. Nathan also provided an update on the MVC Component of the Blue Cross Blue Shield of Michigan (BCBSM) Pay-for-Performance (P4P) Program, noting that final scorecards for Program Year 2022 will be distributed in quarter one of 2023. Attendees also learned about P4P changes coming with Program Years 2024 and 2025 (see Figure 1).

Figure 1.

Based on member feedback, MVC will be rolling out an updated methodology to improve the actionability of the program. Along with the existing 30-day episode of care component, MVC is introducing new value metrics and engagement metrics for PYs 2024 and 2025. The value metrics will incentivize evidence-based and actionable high-quality services, such as increasing cardiac rehabilitation utilization after percutaneous coronary intervention (PCI), increasing follow-up rates after hospitalizations for pneumonia, or decreasing preoperative testing prior to low-risk procedures. The engagement metric will award points to hospitals for attending and contributing to MVC engagement activities, such as attending both semi-annual meetings or presenting at a workgroup. Stay tuned for additional details on PYs 2024 and 2025; informational webinars on the program changes are coming soon.

Showcasing MVC’s new pharmacy claims data from BCBSM and Blue Care Network was a focal point for the meeting. MVC Senior Analyst Monica Yost led attendees through an overview of MVC’s current pharmacy claims data along with an unblinded data session focused on opioid overprescribing after joint surgery (see Figure 2 for a blinded version of utilization across the collaborative). Leveraging opioid prescribing recommendations from the Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI), the data session allowed hospitals and POs to see their opioid prescribing rates in the 30 days following hip and knee replacements compared to their peers. Hospitals and POs performing well were invited to offer insights as to how this was achieved and what mechanisms other members could adopt to improve performance levels.

Figure 2.

With the scene set, MVC welcomed keynote speaker Lindsey Kelley, Associate Chief of Pharmacy at Michigan Medicine. Dr. Kelley provided attendees with an overview of the challenges patients face accessing high-cost, complex medications as well as opportunities to improve access and patient experience through integrated health system specialty pharmacy. Walking through Michigan Medicine’s model, Dr. Kelley noted that simplifying the workflow for specialty pharmacies reduces strain on clinic staff (i.e., physicians, nurses, medical assistants) and eliminates the instances of prescriptions being sent that cannot be filled, thereby reducing gaps in therapy starts. Sharing the model’s evaluation strategy, Dr. Kelley highlighted the project’s collaboration with MVC, which led to a larger proportion of all target specialty medication prescription fill data being tracked and extended the evaluation’s reach.

Following Dr. Kelley’s presentation, Troy Shirley, PharmD, MBA, System Director of Pharmacy for Bronson Healthcare, presented Bronson’s efforts to improve health equity through pharmacy-supported discharge initiatives. One initiative focused on medication reconciliation at discharge, which leveraged unit-based pharmacists to complete medication reconciliation for patients hospitalized with chronic obstructive pulmonary disease, pneumonia, heart failure, and acute myocardial infarction. Additionally, Bronson’s “Meds to Beds” program engaged a multi-disciplinary team that included a retail pharmacist, pharmacy, technician, unit nurse, and care manager to hand-deliver patients’ medications at the bedside and provide medication counseling prior to discharge.

Next on the agenda was a presentation from Tiffany Jenkins, PharmD, BCACP, Director of Population Health Pharmacy at Trinity Health Alliance of Michigan, who shared insights about population health pharmacy initiatives within a physician organization, including a diabetes medication management initiative focused on evidence-based diabetes management to improve quality of care, reduce inappropriate use of pharmaceuticals, and lower cost of care; a pharmacy tech-led medication adherence monitoring strategy to engage patients, providers, and care teams in appropriate medication use; an obesity medication management initiative focused on evidence-based utilization of chronic weight management medications to lower cost of care; and a comprehensive medication management project that leverages pharmacist-care team collaboration to support medication management.

Closing out the morning session, Mark Bicket, MD, PhD, Co-Director of the Opioid Prescribing Engagement Network (OPEN) and Assistant Professor with the Division of Pain Research, Department of Anesthesiology at the University of Michigan, presented information on shifts to prescribing recommendations after surgery to decrease opioid use, techniques to promote the adherence of non-opioid medications and non-pharmacological approaches to pain management, and strategies to maximize safe storage and disposal of controlled substances.

In the afternoon following a networking lunch, the presenters participated in a panel discussion moderated by MVC Co-Director Michael Thompson, PhD, MPH. The group discussed strategies to change provider behavior and navigate the challenges of pharmacy-related improvement initiatives. The meeting concluded with a summary of the day and upcoming MVC activities, led by MVC Associate Program Manager Erin Conklin. The slides from Friday’s meeting have been posted to the MVC website. If you have questions about any of the topics discussed at the fall 2022 semi-annual meeting or are interested in finding out more, please reach out to the Coordinating Center at Michigan-Value-Collaborative@med.umich.edu. MVC’s next semi-annual meeting will be in person on Friday, May 19, 2023, at the Vistatech Center in Livonia.

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First Annual MiCR Meeting Draws Cardiac Rehab Stakeholders

First Annual MiCR Meeting Draws Cardiac Rehab Stakeholders

Since its inception earlier this year, the Michigan Cardiac Rehabilitation Network (MiCR) has sought to equitably increase cardiac rehabilitation (CR) participation for all eligible individuals in Michigan. A key step in this process has been to assemble an engaged group of stakeholders that share this vision from around the state, which culminated in the first MiCR Annual Meeting on October 7, co-hosted by MVC and the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2). Over 40 attendees representing institutions throughout Michigan came to Ann Arbor to present and discuss ongoing challenges facing CR utilization, and to brainstorm solutions that could be implemented across the state.

The first session of the meeting discussed strategies to cultivate buy-in from clinicians and administrators to support CR for their patients and health systems. Dr. Frank Smith, MD, from Trinity St. Joseph Mercy Ann Arbor discussed the importance of identifying and educating the key administrators and clinicians within the organization and developing a rigorous financial plan for a growing CR program. Jacqueline Harris, BS, CCEP, from McLaren Northern Michigan discussed how she developed small, laminated cards that mapped out the process to get eligible patients to CR, which she distributed to clinical teams within her institution. Rob Snyder, EP, MSA, from McLaren Greater Lansing emphasized the importance of continual monitoring and engagement with clinical and administrative leadership to ensure CR program growth.

Following the presentations, small group discussions among attendees identified other challenges related to achieving buy-in from clinicians and administrators. The referral phase was a consistent source of frustration for many attendees, including delays in referral from qualifying events, inefficient referral processes that require physician action, and limited staffing to close the gap from referral to enrollment. The session panelists noted that implementing automatic referrals and recruiting a physician champion can help facilitate referrals among colleagues with lower referral rates.

The second session of the day focused on navigating challenges with insurance coverage for CR programs. Robert Berry, MS, ACSM-CEP, FAACVPR, from Henry Ford Health discussed strategies to minimize insurance delays in starting CR. It is critical to know the regulations and policies that guide CR so that staff can work within them to reduce delays to enrollment. Like the prior session, implementing automatic discharge order sets that include CR for eligible patients can minimize delay, but more work may be needed within an institution to work through pre-authorizations that often accompany CR use. Dedicated liaisons can be a critical resource for addressing insurance issues and securing enrollment during the hospital stay. Jacqueline Evans of Covenant HealthCare reiterated the importance of understanding the regulations and policies of major insurers and developing tools to educate colleagues and patients. Being the local expert can ensure the financial health of the CR program and minimize the insurance burden for patients.

The day's final session featured discussions about how to better engage patients and providers in CR. Greg Merritt of Patient is Partner discussed his experience with CR—having survived a cardiac event and benefitted from participating in CR—and how patients could be involved to improve the CR experience. Integrating former graduates of CR programs into the orientation process may help alleviate fear and concerns facing new attendees. He also challenged the group to think about how CR could be reshaped to reflect the patient population or foster better adherence through engaging with community partners such as dog shelters or social groups. Patients are often an untapped resource and can help innovate CR to improve participation.

The Healthy Behavior Optimization for Michigan (HBOM) collaborative closed out the day with a brainstorming session on how attendees might innovate the current CR system to create better experiences and outcomes for all patients. Attendees raised challenges that face vulnerable populations, such as access to nutritional foods and health literacy. Solutions to these issues could include standardized and accessible resources for patient education and opportunities to provide nutritional support to patients such as grocery delivery services. Developing peer support systems and community-building among CR graduates may also facilitate a better introduction to new patients and improve long-term adherence to behavior changes developed during the program.

Several next steps were identified at the conclusion of the meeting. First, the MVC and BMC2 collaboratives will continue to work towards broader dissemination of CR reports to relevant stakeholders in Michigan. MVC’s latest CR reports were distributed to MVC and BMC2 members this week. In these reports, members can see how their CR utilization rates compared to their peers throughout Michigan within 90 days of discharge following transcatheter aortic valve replacement (TAVR), surgical aortic valve replacement (SAVR), coronary artery bypass graft surgery (CABG), percutaneous coronary intervention (PCI), acute myocardial infarction (AMI), and congestive heart failure (CHF). The reports also included figures for the mean number of days to a patient’s first CR visit and the mean number of CR visits within 90 days. Since these reports were the first version released following the May announcement of new collaborative-wide CR goals, the reports also include figures detailing a hospital’s rates relative to those goals (see Figure 1). The first goal is to reach 40% CR utilization for TAVR, SAVR, CABG, PCI, and AMI patients. Currently across the collaborative, 30% of patients utilize CR following one of these “main five” procedures. The second statewide goal is a collaborative-wide utilization rate of 10% for CHF patients since only about 3% of CHF patients currently utilize the program.

Figure 1.

In addition to report dissemination, several other next steps were identified at the conclusion of the recent MiCR meeting. A second next step was to collate resources that have been developed by individual institutions for broader dissemination. In addition, continued collaboration between the MiCR and HBOM teams will seek to develop solutions that address key behavioral factors and barriers to CR. Lastly, the MiCR team will continue to develop relationships and provide content that works towards its mission of improving CR participation for all eligible individuals in Michigan. If you are interested in collaborating with the MiCR team, please reach out to MVC or BMC2.


MVC Celebrates Achievements for National Healthcare Quality Week

As the conclusion of National Healthcare Quality Week approaches, MVC is proud to honor healthcare quality professionals for their unique contributions toward service delivery and improvements in healthcare facilities. Thus far in 2022, much was achieved by MVC staff, members, and partners. Collectively, these teams work to improve outcomes for patients in a way that doesn’t add to the burden of healthcare costs. This week is an opportunity to celebrate those achievements and express gratitude to the dedicated professionals whose hard work made them possible.

MVC strives to help its members better understand their performance using robust multi-payer data, customized analytics, and at-the-elbow support. MVC has been active in each of these areas (summarized in Figure 1) thanks to MVC’s dedicated Coordinating Center staff. Of note is the fact that MVC distributed 16 push reports to 100+ hospitals and 40 physician organizations (POs) so far this year, and prepared 19 custom analytic reports in response to specific member requests. These data help identify areas of opportunity and trends over time that—in conjunction with other internal and external data sets—inform quality improvement initiatives underway at hospitals and POs across the state.

Figure 1.

MVC previously published a detailed mid-year summary of its activities from January to June of 2022, which is available here. Since then, MVC distributed five additional push reports, three of which were new to the collaborative in recent months:

  • Hospital hysterectomy report – new push report!
  • Preoperative testing report refresh
  • Emergency department and post-acute care report – new push report!
  • MVC Pay-for-Performance (P4P) Program Year 2022 mid-year scorecards
  • Chronic obstructive pulmonary disease report for POs – new push report!

MVC’s P4P Program mid-year scorecards also highlighted the extraordinary work taking place at hospitals across Michigan. The MVC Component of the BCBSM P4P Program evaluates each participating hospital’s risk-adjusted, price-standardized episode payments for two selected conditions by measuring improvement over time and achievement relative to their peers. At the conclusion of Program Year 2021, hospitals in the collaborative contributed to an overall price-standardized decrease in payments from 2018 to 2020 for the selected P4P conditions of $7.7 million.

Figure 2.

The average points scored for the recent mid-year scorecards was 5.9/10 before including the survey bonus points—0.9 points higher than the average points scored at the conclusion of Program Year 2021. These points reflect tangible improvements to service delivery and patient outcomes, such as reduced readmissions or shifting post-acute care in skilled nursing facilities (SNF) to home health following joint replacement surgery.

To help facilitate practice sharing among members, MVC workgroups have continued to be a valuable activity, with 28 virtual workgroups completed as of this week. Workgroup topics offered in 2022 include chronic disease management, diabetes, health equity, health in action (ad hoc topics), joint replacement, and sepsis. Quality improvement is a team effort, so MVC is extraordinarily grateful to the long list of members and partners who shared their expertise and time by presenting. Thank you to the following organizations for presenting to the collaborative at an MVC workgroup thus far in 2022:

  • Area Agency on Aging
  • Ascension Genesys
  • Beaumont Dearborn
  • Bronson Healthcare
  • Henry Ford Health
  • Michigan Social Health Interventions to Eliminate Disparities (MSHIELD)
  • Munson Healthcare
  • Olympia Medical, LLC
  • Sparrow Health System
  • Spectrum Health
  • Spectrum Health Medical Group
  • Trinity Health Muskegon
  • Washtenaw County Health Department

As hospitals and POs press ahead to improve the quality of care delivered in 2022, MVC is eager to support your important work. If you have a follow-up question about a report, please contact MVC to discuss a custom analysis. If you have benefitted from or are looking for guidance on a quality initiative, please reach out so MVC can connect you with members undertaking similar initiatives. MVC thanks you for your tireless work, and looks forward to a continued partnership in 2023.


Welcoming Fall with Quality Improvement Week

October brings celebrations of Fall – with pumpkins, trips to the orchard for apple picking, and Halloween - and also Healthcare Quality Week (October 16 – 22), a time for healthcare teams to highlight their efforts to improve the quality of care for patients and families.

Over the years, various improvement methodologies have been applied in healthcare settings to advance the quality of care, reduce costs, and improve patient outcomes. Here is a look at some of the models and how they could bring value to your organization.

Six Sigma uses statistics and data analysis to reduce errors and improve processes. Originally developed in the 1980s, Six Sigma has grown over the years into an industry standard, with training and certification programs too. The Six Sigma methodology leverages the DMAIC (Define, Measure, Analyze, Improve, Control) approach (Figure 1). Following the five steps of DMAIC provides teams with a framework for identifying, addressing, and improving processes.

Figure 1: The Six Sigma DMAIC

Lean, a methodology borrowed from the automobile industry, optimizes an organization’s people, resources, and effort to create value for customers (Figure 2). Lean’s focus is on sustaining improved levels of quality, safety, satisfaction, and morale through a consistent management system. With a goal to promote, evaluate, and implement ongoing process improvements, Lean uses Value Stream Mapping (VSM) to create a visual map of each step in a workflow, allowing teams to identify opportunities for efficiency.

Figure 2: Lean Process Improvement

Additionally, Lean encourages teams to focus on continuous improvement through the Plan Do Check Act (PDCA) model, an interactive form of problem-solving used to improve processes and implement change. In a PDCA cycle, teams work through four key steps: 1) identify the problem and create a solution plan (Plan), 2) implement a small-scale test (Do), 3) review the test performance (Check), and 4) decide to adjust or implement the test on a larger scale or adjust (Act/Adjust).

Figure 3: PDCA Cycle

Total Quality Management (TQM) is a management approach for long-term success through customer satisfaction. Originally used by the Naval Air System Command, TQM is based on the principles of behavioral sciences; qualitative and quantitative analysis; economic theories, and process analysis. Using the TQM methodology allows organizations to be customer-focused, with all employees participating and engaging in continual improvement. By utilizing strategy, data, and effective communication, TQM becomes integrated into the organizational culture and activities (Figure 4).

Figure 4: Total Quality Management

With a goal to optimize activities that generate value and reduce waste, the Kaizen approach is based on the belief that continuous, incremental improvement adds up to substantial change over time (Figure 5).

Figure 5: Kaizen (Continuous Improvement) Principles

The MVC Coordinating Center supports hospital and physician organization members across the state in identifying opportunities for improvement and facilitating a collaborative learning environment for members to exchange best practices. If you are interested in discussing improvement opportunities for your site, please contact the MVC Coordinating Center at michiganvaluecollaborative@gmail.com.

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MVC Releases Its Fall Semi-Annual Agenda, Speaker Topics

MVC Releases Its Fall Semi-Annual Agenda, Speaker Topics

The MVC Coordinating Center recently released the full agenda for its forthcoming Fall 2022 Semi-Annual Meeting, which takes place in Lansing at the Radisson Hotel on Friday, October 28, 2022, from 9 a.m. to 2:30 p.m. MVC holds collaborative-wide meetings twice each year to bring together quality leaders and clinicians from across the state. This meeting’s theme of “Prescribing Health in Michigan” will support attendees in learning strategies to drive evidence-based medication utilization and support patient access to medications through the implementation and evaluation of quality improvement projects.

Speakers at semi-annual events are often members who share their successes, challenges, barriers, and solutions in pursuing a higher value and quality of care. The speakers this fall represent a variety of stakeholder groups, including member hospitals and physician organizations (POs), pharmacy experts, pain management experts, and of course MVC Coordinating Center leadership.

The keynote presentation will be given by Dr. Lindsey Kelley, Associate Chief of Pharmacy at Michigan Medicine. She also serves as Program Director for the PGY1 Community Pharmacy Residency and adjunct faculty at the University of Michigan College of Pharmacy. Dr. Kelley earned her Doctor of Pharmacy degree from the University of Arizona in Tucson. She completed a pharmacy practice residency at Abbott Northwestern Hospital in Minneapolis, MN, and received her MS from the University of Minnesota College of Pharmacy while completing a two-year Health-System Pharmacy Administration and Leadership residency at the University of Minnesota Health. Dr. Kelley has been an active member of national pharmacy associations, state affiliates, and advisory councils. She was also honored with the ASHP New Practitioners Forum Distinguished Service Award in 2010 and recognized as a fellow in 2019. Her presentation will focus on improving patient care through better access to high-cost and complex medications.

MVC members will also hear presentations from their peer hospitals and POs about pharmacy initiatives implemented at other sites. Dr. Troy Shirley, System Director of Pharmacy at Bronson Healthcare, will present on improving health equity through pharmacy-based initiatives. Dr. Tiffany Jenkins, Director of Population Health Pharmacy at Trinity Health Alliance of Michigan, will present on population health pharmacy initiatives within a PO.

The Opioid Prescribing Engagement Network (OPEN) will touch on pain management best practices and resources. They are represented by Dr. Mark Bicket, Co-Director of OPEN and Assistant Professor in the Division of Pain Research in the Department of Anesthesiology at the University of Michigan. His presentation will focus on improving medication adherence for surgical pain management.

Attendees can also expect to hear from MVC Coordinating Center leadership and staff about the MVC Component of the BCBSM Pay-for-Performance (P4P) Program, unblinded data on prescribing practices across the collaborative, new conditions and data sources that are available to members on the registry and in push reports, MVC’s new Qualified Entity status and resulting patient-level Medicare data, and updates about other upcoming MVC events. The guest presentations will be followed by a panel discussion about medication adherence facilitated by MVC leadership.

At the conclusion of the meeting, attendees will have learned approaches to improving medication access and utilization, patient experience, treatment adherence, care transitions, post-discharge support, patient education, reduced readmissions, and health equity. The full agenda can be accessed online here.

These presentations would be informative and applicable for any of the following stakeholders who are invited to attend:

  • MVC hospital site coordinators
  • MVC PO site coordinators
  • Quality leadership
  • Physicians
  • Nurse practitioners
  • Pharmacists
  • Community-based organizations or social workers
  • CQI staff


The University of Michigan Medical School is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The University of Michigan Medical School designates this live activity for a maximum of 4.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Those interested in attending this informative and collaborative meeting should register here. The MVC Coordinating Center looks forward to a fantastic meeting. See you there!

Activity Planners

Hari Nathan, MD, PhD; Deborah Evans, RN; Erin Conklin, MPA; Chelsea Pizzo, MPH; Chelsea Andrews, MPH