22 Sep 2022
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MVC Showcases Recent Work at Obesity Summit, Poster Session

MVC Showcases Recent Work at Obesity Summit, Poster Session

September 22, 2022 | 0 Comments | , , , ,

Michigan Value Collaborative data and efforts were on display this week as Coordinating Center staff attended the Learning Health System (LHS) Collaboratory Seminar Series Poster Session on Thursday and the Michigan Bariatric Surgery Collaborative (MBSC) / Blue Cross Blue Shield of Michigan 2022 Obesity Management Summit on Friday. At each event, MVC was able to highlight some of its recent work.

At the LHS Collaboratory poster session, MVC presented on behalf of the Michigan Cardiac Rehabilitation Network (MiCR), a partnership recently established by MVC and the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2) with the aim to equitably increase cardiac rehabilitation participation for all eligible individuals in Michigan. Cardiac rehabilitation is highly beneficial to patients and cost-saving for the healthcare system, yet it is significantly underutilized in Michigan with only about 30% of eligible patients enrolling following a cardiac procedure. Using claims data, MVC can assess whether and when someone enrolls, and how long they keep going. There is wide variability in enrollment between MVC’s member hospitals as well as across cardiac conditions. The focus of the poster (see Figure 1) was a recent publication co-authored by MVC and BMC2 staff, which evaluated the feasibility of a statewide collaboration to improve cardiac rehabilitation participation. The poster summarized the key services provided by the MiCR collaboration and some of the lessons learned thus far about barriers to and facilitators of improvement. It also promoted the new statewide goal of 40% cardiac rehabilitation participation by 2024 for all eligible conditions - a goal set by MVC and BMC2. More details on this statewide goal and MiCR’s activities are summarized here.

Figure 1.

For Friday’s Obesity Summit, several MVC products were on display, including two recent analyses performed in partnership with MBSC. The two CQIs recently collaborated on a statewide improvement assessment about the impact of bariatric surgery on prescription fills for diabetes medications. Much of the evidence in the literature suggests that bariatric surgery may resolve or improve Type 2 diabetes symptoms in a large proportion of patients. MVC used its claims data to compare pre- and post-surgery receipt of diabetes medications, as well as the estimated cost savings to health insurance providers that could be attributed to a decrease in post-surgery diabetes medication prescription fills. There was a significant decrease in prescription fills for any diabetes medication (p<.001) from the 120 days pre-surgery to the 120 days post-surgery (see Figure 2).

Figure 2.

Furthermore, insurance providers in Michigan saved an estimated $76.5 million on diabetes medications in the 360 days following bariatric surgeries in 2015-2021, based on the average decrease in diabetes prescription payments per patient, the number of bariatric surgeries performed in that timeframe, and the proportion of bariatric surgery patients who have diabetes. These results provided evidence of statewide clinical outcome improvement and cost savings for Type 2 diabetes patients following bariatric surgery. The full summary of this analysis is available here.

MVC partnered with MBSC on a similar analysis of opioid medication use that was also highlighted at the 2022 Obesity Summit. MBSC has been working to reduce opioid utilization and prescribing following bariatric surgeries across Michigan for the past five years. Some of their strategies include an opioid value-based metric and a voluntary enhanced recovery initiative that incorporates evidence-based guidelines for pre-, peri-, post-operative, and post-discharge care of bariatric surgery patients. This includes a recommendation of prescribing no more than 75 morphine milligram equivalents (MME) of oral opiate following surgery - a recommendation consistent with surgery-specific guidelines set by the Michigan Opioid Prescribing Engagement Network (OPEN).

In evaluating the impact of MBSC’s opioid reduction work, analysts identified that the average amount of opioids received in 30-day post-surgery outpatient prescriptions decreased from 297.0 MME in 2015 to 65.4 MME in 2021. The percentage of patients receiving more than the recommended threshold of 75 MME decreased from 75.8% to 17.9% of bariatric surgery patients. Furthermore, hospitals that participated in MBSC’s enhanced recovery initiative saw the rate of patients receiving opioid amounts above 75 MME decrease more sharply than the rate at other hospitals (p=0.02) (see Figure 3). Given these findings, MVC estimated that MBSC’s efforts resulted in $12.5 million in cost savings because of reduced opioid prescribing after bariatric surgery. The full summary of this analysis is available here.

Figure 3.

MVC will continue to leverage its robust claims data to further the goals of fellow Collaborative Quality Initiatives as well as MVC member hospitals and physician organizations. To stay informed about newly released analyses, resources, or projects, follow MVC Coordinating Center updates on Twitter or LinkedIn. To learn more about these projects or MVC’s reporting capabilities, contact the Coordinating Center at michiganvaluecollaborative@gmail.com.

15 Sep 2022
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MVC and Members Promote Sepsis Awareness Month

MVC and Members Promote Sepsis Awareness Month

September 15, 2022 | 0 Comments | , , ,

Throughout the month of September, providers and advocacy groups are calling attention to the prevalence and signs of sepsis, the body’s life-threatening response to infection. It is the leading cause of death in U.S. hospitals, taking the life of a patient every two minutes and affecting an estimated 49 million people every year worldwide. Despite this, at least one in every three adults has never heard of sepsis. That is why in 2011 the Sepsis Alliance officially designated September as Sepsis Awareness Month.

To support its member hospitals in improving their outcomes related to sepsis, MVC collaborated with the Michigan Hospital Medicine Safety Consortium (HMS) in 2019 to develop a sepsis episode definition for its registry. MVC then began distributing sepsis push reports in 2020 with regular refreshes each year. Hospitals received their latest sepsis reports in April, which showcased wide variation across the Collaborative for measures such as total episode payments and 90-day readmission rates (see Figure 1). In addition, hospitals received details on their inpatient mortality and discharge to hospice rates compared to their geographic region and the Collaborative as a whole (see Figure 2). More information about this report was detailed in a previous MVC blog post.

Figure 1.

Figure 2.

MVC also began hosting a sepsis workgroup in June 2019 to help facilitate idea and practice sharing among Collaborative members. MVC has continued to host sepsis workgroups since then, with the most recent workgroup taking place last week on September 8. That workgroup honored Sepsis Awareness Month with a member panel featuring guest speakers from several health systems in Michigan. Attendees learned about current sepsis initiatives underway at hospitals throughout the state as well as insights on the impact of COVID-19, sepsis screening, sepsis bundle compliance, transitions of care, and other related topics. Those unable to attend can view the complete recording of this panel and discussion here.

One area of focus for this year’s Sepsis Awareness Month is a Sepsis Alliance tool to help providers remember the signs and symptoms. Their acronym approach asks providers to remember, “It’s about T-I-M-E,” with the word “time” representing temperature, infection, mental decline, and extremely ill (see Figure 3).

Figure 3.

This resource and many others have been created, collated, and packaged by the Sepsis Alliance in their yearly Sepsis Awareness Month Toolkit. Hospitals and providers are encouraged to utilize these resources to help educate their staff and patients. The hope is that through public education we can raise awareness of the signs and symptoms of sepsis so people in our communities know when to seek emergency care. Together, we can help save lives and limbs from sepsis. Learn more at sepsisawarenessmonth.org. To contact the MVC Coordinating Center about your sepsis reports, future workgroup speakers, or other questions, please email michiganvaluecollaborative@gmail.com.

08 Sep 2022
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MVC Welcomes Usha Nuliyalu to Coordinating Center Team

MVC Welcomes Usha Nuliyalu to Coordinating Center Team

September 8, 2022 | 0 Comments |

I am excited to join the Michigan Value Collaborative (MVC) team as a data analyst, where I look forward to utilizing MVC’s robust data to support the vision and goals of the team. Along with a 50% effort at MVC, I am working at the Center for Healthcare Outcomes and Policy analyzing healthcare claims data for health policy research.

I earned a Master’s in Public Health degree in epidemiology from the University of Michigan (U-M) School of Public Health in 2009. I have worked at U-M since then analyzing data for various research projects. In the early part of my career, I worked for U-M’s School of Nursing and the Michigan Medicine Addiction Research Center, where I had many opportunities to work on data management and build on my knowledge. For the past six years, I have had the opportunity to work with Medicare and commercial claims data, performing statistical analysis and preparing summaries. I also have co-authored several research papers related to health policy.

I am passionate about improving health care quality and reducing disparity. I feel I can utilize my data analysis skills to help providers and policymakers understand what works best and support MVC and its members in achieving their goals. I am also looking forward to learning new research and analytic skills and growing as an analyst. When I am not working, I enjoy hiking, biking, gardening with my family, and music. If you have any questions, please reach out to me at nuliusha@med.umich.edu.

01 Sep 2022
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Hospitals Receive PY22 Mid-Year Scorecards for MVC Component of BCBSM P4P Program

Hospitals Receive PY22 Mid-Year Scorecards for MVC Component of BCBSM P4P Program

September 1, 2022 | 0 Comments |

This week the Michigan Value Collaborative (MVC) Coordinating Center distributed the Mid-Year Scorecards for Program Year (PY) 2022 of the MVC Component of the Blue Cross Blue Shield of Michigan (BCBSM) Pay-for-Performance (P4P) Program. These were the first scorecards for the new two-year program cycle for PYs 2022 and 2023.

PY2022 evaluates the index admissions from 2021 as the performance year against admissions in 2019 as the baseline year. MVC is using an improved z-score methodology to calculate both improvement and achievement scores. Hospitals will continue to receive the better of the two scores for each of their two selected conditions. For a description of how the program has changed from the last two-year cycle see the Change Document.

Additionally, this cycle offers hospitals bonus points for completing and submitting a survey for each selected condition by November 1, 2022. These surveys will be used by the MVC Coordinating Center to improve the program for future years and elicit improved best practice sharing between members. The full methodology for the new program can be found in the PY2022-2023 Technical Document.

Figure 1 below illustrates the distribution of total hospital points out of 10. The average points scored for the Mid-Year Scorecards was 5.9/10 before including the survey bonus points. This is 0.9 points higher than the average points scored at the conclusion of PY21 excluding all bonus points.

Figure 1.

Figure 2 below illustrates the breakdown of average points by condition out of five. Consistent with previous years, joint replacement was the highest scoring condition with an average of 4.5 points earned. The success of the joint replacement condition can be attributed to the shift from post-acute care in skilled nursing facilities (SNF) to home health and the move towards outpatient surgeries. Pneumonia was the lowest scoring condition with hospitals earning less than one point on average. The MVC average payment for a 30-day pneumonia episode increased by $792 from the baseline in 2019 to the performance year in 2021. The largest contributors to this increase were the base payment and readmission payments.

Figure 2.

The Mid-Year P4P scores are subject to change as new data is added. The final scorecards will be distributed after all 2021 claims have been added to the data in quarter one of 2023. Hospitals can track their score through the new P4P PY2022-2023 reports on the MVC registry. These new reports provide all relevant scoring information for both improvement and achievement points in one place except for the survey bonus points. They can be filtered by selected conditions to make the tracking of P4P points easier. For a walkthrough of your hospital’s Mid-Year P4P Scorecard or P4P registry reports, please contact the MVC Coordinating Center.

25 Aug 2022
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BCBSM Initiative Incentivizes Data Collection on Social Factors

BCBSM Initiative Incentivizes Data Collection on Social Factors

August 25, 2022 | 0 Comments | , , ,

Health equity is a top priority for providers across the country, who are keenly aware of the prevalence and exacerbation of existing health inequities. The state of Michigan in particular ranks poorly in measures of population health and social determinants of health (SDOH), which represent a huge opportunity to improve equity and health outcomes for patients. Health equity is currently a key strategic focus of the Michigan Value Collaborative (MVC) Coordinating Center in the years ahead, as well as for Blue Cross Blue Shield of Michigan (BCBSM). As work in this area grows, some suggest that better data collection is the next critical step to improving health equity.

Data collection is the focus of BCBSM’s latest initiative - the SDOH Standardized Data Collection and Aggregation Initiative - which offers incentives to physician organizations (POs) for collecting and submitting SDOH screening data. Its goal is to increase SDOH screening by primary care physicians during annual wellness visits as well as enhance SDOH data submitted to the Michigan Health Information Network (MiHIN), Michigan's nonprofit statewide health information network.

This data will be used in the short term to improve data conformance and SDOH definitions within the Michigan provider community. Ideally, this initiative will help BCBSM to improve care coordination between providers, identify gaps in resources and community-level social need trends, and provide analytics and reporting to the provider community. The long-term goal is to reduce disparities and improve health outcomes.

There are multiple pathways for POs to participate, primarily by either submitting screening data through MiHIN’s SDOH use case, or by developing infrastructure to enable participation in MiHIN’s SDOH use case. BCBSM sees this incentive program as an important step toward ensuring all patients receive the care they need.

“The SDOH initiative is valuable for both patients and providers because it encourages providers to screen for SDOH needs in patients and also encourages that the data from these screenings is exchanged in an interoperable way,” said Karolina Skrzypek, MD, Medical Director of Clinical Partnerships at BCBSM. “It is very important that providers across the state of Michigan have the ability to access SDOH screening data regardless of where the screening took place. Screening for SDOH needs by providers is the first step in helping to address these needs in our patients.”

These points were echoed by Martha M. Walsh, MD, MHSA, FACOG, Medical Director of Clinical Partnerships and Engagement at BCBSM, who said, “We know that when patients have SDOH needs, that it is more difficult for them to have their healthcare needs met and for patients to care for their chronic conditions. Our initial goal in having providers screen for SDOH needs is for patients to have their needs addressed at the point of care.”

Some POs are already actively submitting this data to MiHIN and can receive incentive payments for continuing to do so. The other pathways are focused on those who have capacity to store and extract SDOH data but are not submitting it to MiHIN, or those POs who don’t yet have the digital infrastructure in place. Helping all POs to achieve a similar capacity and submit their data to the same vendor will allow for a broader understanding of the gaps and communities in need of further funding.

“By aggregating this data, we hope to learn more about specific domains of need and geographic areas with the most needs so that we can start to address these more broadly,” said Dr. Walsh. “We hope that by screening for and addressing SDOH needs, we will start to be able to decrease disparities in care for our most vulnerable patients.”

Incentives for the MiHIN SDOH use case pathways are paid out of the BCBSM Physician Group Incentive Program (PGIP) reward pool. Therefore, any deadlines related to participation are based on PGIP payment cycles. Those POs wishing to participate in the October 2022 cycle should submit their opt-in form and any other required materials by the end of August.

A separate value-based reimbursement (VBR) reward was created specifically for patient-centered medical home (PCMH) designated primary care physicians for completing SDOH screenings using Z codes. This VBR payment was available when the SDOH initiative launched in January. Provider offices had six months to work towards meeting the criteria to receive VBR effective 9/1/2022. Criteria for the 2023 cycle was previously announced and updates to the criteria will be provided during the upcoming BCBSM September PGIP quarterly meeting.

Any POs or providers interested in learning more about this initiative and the pathways for participating can read the full brochure here and submit questions directly to BCBSM at POPrograms@bcbsm.com. In addition, if your PO or hospital has success stories or insights that have resulted from collecting SDOH screening data, please consider sharing your story and insights with the MVC Coordinating Center at michiganvaluecollaborative@gmail.com.

Support for MVC is provided by Blue Cross Blue Shield of Michigan as part of the BCBSM Value Partnerships program. Although BCBSM and MVC work collaboratively, the opinions, beliefs, and viewpoints expressed by the author do not necessarily reflect the opinions, beliefs, and viewpoints of BCBSM or any of its employees. To learn more about the Value Partnerships program, visit www.valuepartnerships.com.

18 Aug 2022
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Roll Up Your Sleeve to Save a Life

August 18, 2022 | 0 Comments | , ,

After declaring the nation’s first-ever blood crisis in early 2022 and the worst shortage in over a decade, the American Red Cross and other blood donation organizations continue to plea for blood donors. In Michigan, blood donations fell with the start of COVID-19 and continue to lag pre-pandemic levels.

Based on data from the Red Cross, someone in the United States needs blood or platelets every two seconds, resulting in approximately 29,000 units of red blood cells, 5,000 units of platelets, and 6,500 units of plasma required daily. And, while an estimated 6.8 million people in the U.S., or 3% of eligible individuals, donate blood each year, more donors are always needed!

Figure 1.

According to the Association for the Advancement of Blood and Biotherapies, donating blood is a safe, simple, and rewarding experience that usually only takes 45-60 minutes. During a typical whole blood donation, approximately 0.5 liters of blood is collected. For donations of other blood products, such as platelet or plasma, the amount collected is based on the donor’s height, weight, and platelet count.

Along with helping others in need, blood donation also has some surprising health benefits, including:

  • A free mini health screening: before donating, potential blood donors receive a brief physical exam that includes taking blood pressure, body temperature, and pulse to ensure they are fit for donation.
  • A healthier heart and vascular system: in hypertensive individuals, regular blood donation has been linked to lower blood pressure and may lower the risk for heart attacks.
  • A happier, longer life: people usually donate because it feels good to help others and altruism has been linked to positive health outcomes, including a lower risk for depression and greater longevity.

Figure 2.

Alternatively, to help protect the limited supply of blood, reduce costs associated with the collection and administration of blood products, and reduce patient complications of allergic, febrile, and hemolytic reactions, restrictive transfusion practice or conservative blood use can be considered. This practice, recommended by the National Institute for Health and Care Excellence and the Choosing Wisely campaigns, uses the two major clinical decision points of hemoglobin concentration when transfusion should be considered and the number of units being transfused.

Whilst evidence suggests there is no increase in morbidity or mortality by following restrictive transfusion practices, outcomes related to the quality of life, symptoms of anemia, and length of hospital stay are not as well studied.

Some examples of multimodal interventions to reduce unnecessary blood transfusions include the START (Screening by Technologists and Auditing to Reduce Transfusions) study which produced guideline development, education for clinicians, prospective order screening, and immediate feedback to physicians for potentially inappropriate orders, and monthly feedback to the clinical teams on appropriateness. Secondly, an Australian system-wide initiative focusing on education, practice audits, and feedback for individuals and a policy promoting single-unit red blood cell transfusions showed success. Other blood management approaches including anemia prevention, iron supplementation for iron deficiency, and a reduction in blood loss during procedures are other methods that can be used.

To implement strategies for reducing the unnecessary use of transfusions, individuals should assess their own practice against evidence-based standards. Additionally creating a multidisciplinary team to discuss and set guidelines and protocols based on evidence, auditing practices against identified evidence-based standards and tailoring interventions to the institutional setting and context can help with the implementation of restrictive transfusion practices.

Until we can find an alternative source or increase supply, we will continue to need people to step up and donate.

If you plan to donate blood, a few helpful tips can make for a better experience:

  • Drink plenty of water. Staying hydrated makes it easier to find your veins and prevents you from becoming light-headed after donating
  • Eat well beforehand and be sure to eat snacks offered to you.
  • Get a good night’s sleep and, if you are planning to exercise, do so before donating, not after.
  • Take iron tablets. The American Red Cross recommends individuals who donate blood frequently take an iron supplement or a multivitamin with iron.

Typically, donors are eligible to donate blood every 56 days or up to six times per year. To find a blood donation site near you, visit the American Red Cross or your local donation center. Every drop helps!

11 Aug 2022
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Breastfeeding Awareness Month: The Value of Hospital Initiatives

Breastfeeding Awareness Month: The Value of Hospital Initiatives

August 11, 2022 | 0 Comments | ,

As August is National Breastfeeding Month, many healthcare professionals and hospitals across the country are joining in to promote its benefits. Currently, the American Academy of Pediatrics (AAP) recommends exclusive breastfeeding of infants for the first six months of life and then alongside solids as long as mutually desired by mother and child for two years and beyond. This updated recommendation – the AAP previously recommended breastfeeding through age one and beyond – acknowledges its continued benefits for mother and child.

Many experts suggest that it is an investment in the health of current and future patients, not just a lifestyle choice. In updating its guidance, the AAP clarifies that breastfeeding beyond one year and up to two years has significant benefits to the mother in particular; lower rates of diabetes, high blood pressure, and breast and ovarian cancers are associated with long-term breastfeeding. In breastfeeding infants, some studies indicate there are fewer respiratory and gastrointestinal infections, incidents of severe respiratory disease or sudden infant death syndrome (SIDS), development of chronic illnesses, doctor visits, hospitalizations, and prescriptions. The Centers for Disease Control and Prevention (CDC) estimates that an additional $3+ billion in medical costs per year can be attributed to low breastfeeding rates.

Breastfeeding is a personal choice – not everyone wants to or even can breastfeed their baby. For those who choose to, however, being successful is linked to the presence of interventions and support along the way. Evidence-based practices at the hospital level are a critical component for establishing breastfeeding.

The Agency for Healthcare Research and Quality (AHRQ) cited a systematic review of 38 randomized controlled trials that found short- and long-term increases in breastfeeding as a result of direct assistance and education across a variety of providers and settings in conjunction with structured training for health professionals. The AHRQ and the AAP also both cite increases in breastfeeding initiation and duration as a result of the Baby-Friendly Hospital Initiative, which gives a special designation to facilities that successfully complete an assessment and implement the World Health Organization’s 10 Steps to Successful Breastfeeding.

Some of the evidence-based practices linked to higher breastfeeding rates include individualized support in the first few hours and days following birth, rooming-in, and education and support. Additionally, the CDC’s 2018 national survey of Maternity Practices in Infant Nutrition and Care (mPINC) identified institutional management as an area with the widest range of scores across all states, with 45 being the lowest state score and 95 the highest state score (see Figure 1). As this category is defined by activities such as nurse training and clinical competency, record keeping, and policy setting, it is clear that some important breastfeeding initiatives extend beyond the maternity ward.

Figure 1. National score and state score ranges for mPINC subdomains in 2018

According to the AAP, there are also significant opportunities for more equitable gains in breastfeeding outcomes. The United States continues to see evidence of disparities in success rates – none of the Healthy People 2020 objectives for breastfeeding were met for non-Hispanic black mothers and infants. The rates for any breastfeeding are approximately 10% lower in non-Hispanic black mothers compared to the average for all races/ethnicities (see Figure 2). Similarly, there are disparities in mothers who are younger than 20, low income, or less educated. Hospitals interested in health equity initiatives likely have an opportunity in the realm of breastfeeding support that accounts for socioeconomic and cultural differences.

Figure 2. Rates of any breastfeeding in U.S. by race/ethnicity

A summary of recommendations, provider implementation tools, and other resources are summarized for healthcare providers in the AHRQ breastfeeding provider fact sheet. In addition, MVC would like to spotlight those members with ongoing or completed improvement efforts around breastfeeding. If your site has achieved the Baby-Friendly Hospital designation or has tools for addressing patient disparities in breastfeeding, please consider sharing your story with the Coordinating Center for the benefit of the larger collaborative.

04 Aug 2022
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MVC Launches New Push Report on ED and Post-Acute Care Use

August 4, 2022 | 0 Comments | , , ,

The emergency department (ED) is a unique and critical component of the healthcare system in the U.S., treating acute injuries or illnesses and acting as a safety net for patients who are uninsured or low income. ED visits are also very expensive, and that spending is growing according to a recent retrospective study of ED trends. This week the Michigan Value Collaborative (MVC) is distributing its newest push report on ED and post-acute care (PAC) utilization to support members' efforts in this space.

Since the ED serves as a safety net for patients experiencing barriers to healthcare access, the Coordinating Center report purposefully integrates measures tied to social determinants of health and health equity. Reports contain a patient population snapshot table showcasing several patient characteristics by payer (see Figure 1), including age, race, comorbidities, zip code, dual-eligibility status, and economic distress scores. Dual-eligible patients are those who qualify for both Medicaid and Medicare; these patients tend to have a higher prevalence rate for chronic conditions, disabilities, and other care needs that substantially increase healthcare utilization.

Figure 1.

Economic distress scores range from 0-100 with a higher score indicating greater economic distress. These scores come from the Economic Innovation Group’s Distressed Communities Index (DCI), which is derived from the U.S. Census Bureau’s Business Patterns and American Community Survey. The DCI combines seven complementary economic indicators (see Figure 2) to provide a single, holistic, and comparative measure of economic well-being across communities in the U.S. In MVC’s report, there is a proportion of patients living in an “at-risk” or “distressed” zip code across all payers, as classified by the DCI. However, as the literature often indicates, the Medicaid population has the highest average distress score and a larger proportion of patients living in an “at-risk” or “distressed” zip code.

Figure 2.

The bulk of MVC’s latest report aims to provide its members with more granular insights into PAC utilization in the 30-day post-discharge period than is available on the MVC registry. Using index admissions for medical conditions from 1/1/18 through 12/31/20, the report focuses predominantly on ED utilization, which is categorized as either “ED to Home” or “ED to Readmission.” ED to Home represents ED visits that do not occur on the same day as readmission, and ED to Readmission refers to those visits occurring on the same day as readmission.

The report includes figures illustrating trends in 30-day ED to Home rates between 2018 and 2020, top reasons for ED visits at a given hospital, the number of ED to Home visits within 30 days post-discharge, the number of days until the first ED visit post-discharge, the ED to Home rate and the breakdown of total PAC spending for a hospital’s three highest-volume conditions, and the average ED facility payment. MVC included the following payers in this report: Blue Cross Blue Shield of Michigan (BCBSM) PPO Commercial, BCBSM Medicare Advantage (MA), Blue Care Network (BCN) HMO Commercial, BCN MA, Medicare Fee-for-Service, and Medicaid.

Overall, the MVC report confirms published findings that Medicaid patients utilize the ED at a higher rate than patients insured by other payers. The Coordinating Center also finds that ED use differs between types of providers. For acute care hospitals, for example, over half of ED visits occur on the same day as readmission, whereas these visits account for 40% at Critical Access Hospitals (CAHs).

MVC also finds that ED to Home visits most often occur once in the 30 days following discharge for most of the collaborative (see Figure 3). There are some members, however, with three or more ED to Home visits within the 30-day post-discharge period.

Figure 3.

The Coordinating Center envisions this report being of particular importance to its CAH members, whose structures, services, and patient populations make the ED and PAC a top priority. As such, MVC prepared versions of this report for both CAHs and acute care hospitals using their respective comparison groups throughout. In other words, the CAH version of the report includes comparison points for all other CAHs in the collaborative. Acute care hospitals can see their traditional collaborative-wide and regional comparison data, not including hospitals with a CAH designation.

As members review and discuss the findings in their report(s), MVC encourages providers to utilize the Michigan Emergency Department Improvement Collaborative (MEDIC), which is dedicated to improving the quality of ED care across the state of Michigan. In addition, if members wish to discuss additional custom analyses on ED and PAC utilization, please contact the MVC Coordinating Center at michiganvaluecollaborative@gmail.com.

28 Jul 2022
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Latest MVC Preop Testing Report Features New Figures and Data

Latest MVC Preop Testing Report Features New Figures and Data

July 28, 2022 | 0 Comments | ,

This week MVC distributed its second preoperative testing push report of 2022, providing members with another opportunity to benchmark their testing practices. MVC first introduced its preoperative testing push reports in 2021 to help members reduce the use of unnecessary testing for surgical procedures. Preoperative testing, especially for low-risk surgeries, often provides no clinical benefits to patients but is ordered regularly at hospitals across Michigan.

The report distributed this week had many similarities to the version distributed earlier this year in April, namely that members continued to see their rates across a variety of tests for three elective, low-risk procedures performed in outpatient settings: laparoscopic cholecystectomy, laparoscopic inguinal hernia repair, and lumpectomy. Claims were evaluated for the index event as well as 30 days prior to the procedures for the following common tests: electrocardiogram (ECGs), echocardiogram, cardiac stress test, complete blood count, basic metabolic panel, coagulation studies, urinalysis, chest x-ray, and pulmonary function.

The latest report has a few key differences from the spring version, the most significant of which is that it utilizes claims from Blue Cross Blue Shield of Michigan (BCBSM) and Blue Care Network (BCN) plans exclusively. This allows members to see MVC’s most up-to-date data; the report includes index admissions from 1/1/2019 through 12/31/2021. In addition, since the report contains BCBSM/BCN data only, there is no case count suppression, whereas members would only see their data in the spring version if they had at least 11 cases in each year of data for the three combined conditions.

The reports received by members this week included several new figures. Similar to other MVC push reports, members will now see a patient snapshot table that provides additional information about the report’s patient population. For this, MVC chose to include patient characteristics such as age, zip code, and comorbidities. Generally speaking, there were more comorbidities among patients who underwent preoperative testing compared to patients with one or no comorbidities (see Figure 1). However, the majority of patients who complete a preoperative test do not have multiple comorbidities. There were also observed differences in testing rates by age. In general, patients who had preoperative testing were older on average than patients who had no preoperative testing.

Figure 1.

Another new figure showcased the overall preoperative testing rates by year. This trend graph showed members how their overall rate for any preoperative testing compared in 2019, 2020, and 2021, and it included data points for the MVC average and regional comparison groups (see Figure 2). The key finding for this figure was that there has been very little change in testing rates over time when looking at overall preoperative testing practices. This means that, in general, the prevalence of low-value preoperative testing has remained consistently high overall across the collaborative for three years and likely longer.

Figure 2.

The latest report also included a new figure for absolute change in any preoperative testing from 2019 to 2021. For each hospital, this appears as a caterpillar plot of absolute change percentages for their highest-volume procedure among the three low-risk surgeries in the report. Members can see the percentage change—positive or negative—in their testing rate for that surgical condition, as well as how their absolute change compares to the rest of the collaborative. For example, hospitals that perform more cholecystectomies than hernia repairs or lumpectomies saw a wide range of both increases and decreases in preoperative testing rates from 2019 to 2021 (see Figure 3).

Figure 3.

The blinded hospital in this example observed very little change in its testing rate for cholecystectomy (-1.6%), and the MVC average was similar (-2.2%). This showcases that although the collaborative is not seeing much change to overall rates for any testing over time, individual members might see greater variability over time for specific tests or procedures, especially in instances of low case counts.

Members will be able to take those deeper dives into their rates for specific tests in the figures that make up the remaining pages of the report. Viewing one’s preoperative testing rates for each specific test can help members understand if any specific tests are driving their overall testing rate. One area of opportunity, for example, could be to reduce one's rate of cardiac testing, specifically ECGs; the rate of ECGs is very variable across the collaborative (see Figure 4) and could lead to a cascade of care.

Figure 4.

MVC is eager to drive improvement in this area. For more information on how MVC is working to reduce unnecessary preoperative testing, visit its Value Coalition Campaign webpage here. If you are interested in a more customized report or would like information about MVC’s preop testing stakeholder working group, please contact the MVC Coordinating Center at michiganvaluecollaborative@gmail.com.

21 Jul 2022
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Ambulatory Surgical Centers Transforming Surgery Market

July 21, 2022 | 0 Comments | ,

Surgery in the United States is transforming, with as many as 70% of surgeries currently performed in an outpatient setting. Ambulatory Surgical Centers (ASCs) have grown significantly over the past decade and are now a critical part of the healthcare system. The Ambulatory Surgery Center Association now represents more than 6,000 centers across the United States. ASCs account for more than half of the outpatient surgery market with roughly 23 million procedures per year. The growth of these centers has had a significant impact on hospitals. As the number of ASCs has grown and hospital outpatient departments (HOPDs) have taken on fewer cases, many hospitals have elected to set up ASCs as part of their business.

This growth has been driven in part by greater scheduling flexibility and lower costs. Since most surgeries performed in outpatient settings are elective, patients are enabled to “shop” for their facility of choice prior to treatment. ASCs exclusively provide same-day surgical services that do not exceed 24 hours or require hospitalization. They are often – but not always – specialty-specific. Some of the most common specialties serviced by ASCs are orthopedics, pain, and ophthalmology (see Figure 1).

Figure 1.

A recent study of Medicare patients evaluated the scope of practice, number of patients treated, number of procedures, and revenue for ASCs. The study found that across the United States there was a 7% increase in the number of ASCs certified to service Medicare patients. In 2018 there was an 11% increase in the number of services performed and a 6.5% increase in patients. The median number of surgeries performed at each ASC was 1,050 per year. Payments collected rose from $3.6 billion in 2012 to $5.1 billion in 2018, with cataract surgery accounting for 24% of all payments. The study concluded that the increased revenue was most likely due to the increasing complexity of procedures being performed and, thus, higher reimbursement.

The increase in more complex surgeries at ASCs can most likely be attributed to better anesthesiology methods that allow for improved pain control and reduced post-operative recovery time, as well as new technologies and techniques that make surgeries safer and more comfortable. The Leapfrog Group identified over 50 different procedures performed across 10 disciplines in their 2022 ASC outpatient surgery fact sheet (see Figure 2).

Figure 2.

Associated with this rise in complexity is the need for ASC staff to accurately identify high-risk patients who are not appropriate candidates for ASCs. Many ASCs have created their own methods for identifying these high-risk candidates since there are no universal or ready-to-use published criteria. Although no preoperative screening system is perfect, the average national ASC transfer rate to an inpatient facility is just 0.42%, and in one study the use of a criteria checklist (see Figure 3) helped the facility achieve a 0.17% transfer rate.

Figure 3.

To assist the growing number of patients in their selection of a surgical provider, several organizations now publish evaluations about the quality and safety of various ASC facilities. For example, Newsweek published their rankings of "America's Best Ambulatory Surgical Centers" earlier this year in partnership with the global research firm Statista. The list spotlights 470 facilities in the 25 states with the most ASCs, with up to 10 ranked centers by state. Michigan's highlighted ASCs (see Figure 4) received scores of 74% - 83%, which was based on a "reputation score" and KPI data score.

Figure 4.

As ASCs continue to have a transformative impact on the surgery market, the Michigan Value Collaborative is interested in learning more about the metrics and data being utilized by these stand-alone or hospital-affiliated centers. If you have any information to share, please reach out to the MVC Coordinating Center at michiganvaluecollaborative@gmail.com.