01 Apr 2021
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Introducing Bradley Raine, MVC Analyst

Introducing Bradley Raine, MVC Analyst

April 1, 2021 | 0 Comments | ,

I am happy to join the Michigan Value Collaborative (MVC) in the role of Analyst and am looking forward to working with the MVC team to help improve the quality and value of healthcare provided in the state of Michigan.

I graduated from the University of Michigan with my Bachelors of Science in Biology in 2015, and spent nearly three years working in the prep lab for the Michigan Clinical Research Unit (MCRU) based at the Cardiovascular Center. There I developed an interest in research methodology and wanted to learn more about how research teams use their data to publish their findings. Therefore, I decided to pursue a degree in Statistics, and graduated from Central Michigan University in August 2020 with a Master’s of Science degree.

In order to complete my graduate degree, I worked on a visualization project for COVID-19 data using Tableau. I found this product to be a great tool for creating dashboards to tell stories about data, and am hoping to take the skills learnt and implement them in a professional setting.

As an analyst for MVC, I am excited to learn how to analyze data using medical claims information to identify areas for improvement in quality of care. This has been important to me ever since having worked at MCRU and seeing how much data can do towards improving patient outcomes.  I am looking forward to taking the knowledge and experience gained at Central Michigan University and using it for this purpose. If you have any questions or wish to get in touch, please feel free to email me at bjraine@med.umich.edu.

25 Mar 2021
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Reducing Admissions and Readmissions in the COPD Patient Population

March 25, 2021 | 0 Comments | , , , ,

At a recent MVC chronic obstructive pulmonary disease (COPD) workgroup, representatives from McLaren Physician Partners presented on their recent quality improvement initiative involving their COPD patient population. McLaren Physician Partners worked to identify areas for improvement within this specific patient population and found some common patient struggles consisted of higher utilization of the emergency department and in-patient settings, as well as higher readmission rates, specifically among their Medicare patients (38%). Five nurse managers were tasked with doing case reviews in order to identify possible areas for improvement. Five to ten patients that had three or more encounters in the last six months were taken from each nurse managers case load. Around 83% of those patients had other significant comorbidities (e.g. Diabetes Mellitus, Congestive Heart Failure, Hypertension.) Additionally, the reason for readmission was most often related to either respiratory insufficiency or a cancer treatment side effect.

Care managers then engaged the patients and went over a questionnaire with them. Approximately 68% of these patients had a misunderstanding of their medication, 26% had environmental barriers, 14% were not compliant with medication, and less than 15% reported an inability to afford medication/devices. Readmissions related to disease progression and inappropriate medication use were the major contributing factor to higher utilization of the in-patient setting and emergency department. Additionally, all admissions and readmissions were related to some form of respiratory insufficiency or a cancer treatment side effect.

Due to the time of implementation, COVID-19 impacted the type of intervention that could be put into place. McLaren Physician Partners opted to adopt a telephonic intervention in order to address education needs and remove barriers. Specific needs related to managing medications and compliance, triggers that led to an exacerbation, and developing a plan of action at the onset of first symptom were addressed. Additionally, the intervention sought to minimize and remove barriers where possible (e.g. cost of medications, transportation issues for visits). Lastly, a consideration was made if a patient was a candidate for palliative care.

Nurse navigators looked into possible ways to engage patients differently in order to hopefully prevent an exacerbation that caused an admission or a readmission. They were aware that what they were doing wasn't working, and needed some sort of upgrade. A toolkit was developed that was sent to the patient prior to a one to two-hour phone call scheduled in order to  help the patient understand this toolkit. The kit requires active participation and helps the patient develop specific goals and actions to take when they see signs of a potential exacerbation.

After implementation of this pilot program, all navigators came together to discuss their findings. Many things were noted, including the fact that patients did not know the difference between their inhalers (long-acting vs. rescue). Additionally, patients often didn't know that by identifying certain triggers, some symptoms may have been preventable. Of the patients who received and engaged in this telephonic intervention, the readmission rate for those who had been recently discharged decreased by more than 20%. Overall, McLaren Physician Partners saw a decrease in their hospitalizations due to the implementation of this program.

11 Mar 2021
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Michigan Value Collaborative Value Coalition Campaign. Introducing the Preoperative Testing VCC and Report Series.

March 11, 2021 | 0 Comments | , , ,

In 2020, the Michigan Value Collaborative (MVC) introduced the Preoperative Testing Value Coalition Campaign (VCC) with the aim of reducing the use of unnecessary preoperative testing for surgical procedures.  As part of this new campaign to improve quality, reduce cost, and improve the equity of care delivery in Michigan, the Coordinating Center developed and distributed preoperative testing reports to collaborative members earlier this week. The goal of these reports is to introduce the VCC and provide benchmarking data for some of the common preoperative tests to members.

Currently, the VCC is focused on three elective, outpatient, low-risk surgeries. This includes cholecystectomy, lumpectomy, and inguinal hernia repair. These surgeries were chosen to identify a population unlikely to require much, if any preoperative testing. Metrics included in the reports evaluate hospital testing rates for electrocardiography (EKG), trans-thoracic echocardiography (TTE), cardiac stress tests, chest X-ray (CXR), urinalysis, complete blood count (CBC), basic metabolic panel, coagulation tests, and pulmonary function tests (PFT).  As shown in Figure 1, there is wide variation across the collaborative for overall preoperative testing rates, ranging from 20% to 96%.

Whilst the report provides the MVC all and regional averages as benchmarks, the variation suggests that there is significant room for improvement among Michigan hospitals, and even facilities that are average likely have the possibility to reduce preoperative testing. Furthermore, to allow hospitals to identify areas of opportunity, a more granular grouping of laboratory testing including CBC, basic metabolic panel, coagulation tests, and urinalysis for the three low-risk surgeries is depicted in Figure 2.  To allow hospitals and physician organizations to view more comprehensive preoperative testing data, the MVC Coordinating Center is in the preliminary stages of developing a new preoperative testing report for the MVC registry.

Although many preoperative tests are relatively low cost, large-scale overuse when not necessary can increase episode costs. For these three low-risk procedures, an annual preoperative testing payment of $3.2 million dollars was noted in 2019 across MVC hospitals and according to MVC data, annual preoperative testing payments for these conditions has increased steadily over the last 5 years. In addition, overuse of preoperative testing has the potential to harm patients. Patients with borderline or false positive tests may be subjected to additional testing, have their surgeries postponed, or even experience unnecessary harm from invasive follow up tests.  Questions about appropriate preoperative testing  guidelines can be answered at the Choosing Wisely website.

Please provide us with your feedback on the utilization of these or any other MVC reports, or if you would be interested in joining the MVC Preoperative Testing Stakeholder Group, please reach out to MichiganValueCollaborative@gmail.com.

05 Mar 2021
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The Michigan Value Collaborative’s Refreshed Cardiac Service Line Reports

March 5, 2021 | 0 Comments | , ,

The Michigan Value Collaborative (MVC) Coordinating Center disseminated it’s long-running customized cardiac service line report to hospital and physician organization (PO) members on February 23, 2021. These reports provide hospital-level information on congestive heart failure (CHF), acute myocardial infarction (AMI), and coronary artery bypass graft (CABG) conditions. To receive information on any one of these conditions, a hospital must have at least 20 cases per year over the three-year reporting period (1/1/17 – 12/31/19).

Since the last iteration of the cardiac service line report sent in June 2020, the Coordinating Center has defined four distinct regions within Michigan, allowing members to make regional comparisons. These comparisons have been incorporated into the 30-day risk-adjusted total episode payment trend chart, the post-acute care utilization bar graph, and the 30-day readmission rate trend chart of the reports as shown in the following AMI figures for a fictional institution, Hospital A.

Acute Myocardial Infarction Figures. Hospital A

Figure 1 shows the 30-day risk-adjusted total episode payments broken up into six-month intervals, illustrating that episode payments for AMI hold steady across the Collaborative at an average of around $22,000. Please note that as with all MVC reports, this represents price standardized dollars to allow for fair comparisons between hospitals. The price standardized dollars can be thought of as a measure of utilization as opposed to true dollar amounts.

Figure 2 displays the percentage of AMI patients who utilized home health (15.0% across MVC), rehab (14.1% across MVC), or skilled nursing facilities (9.9% across MVC). Figure 3 illustrates that, between 2017 and 2019, approximately 14% of AMI patients were readmitted within 30 days. Finally, Figure 4 shows Hospital A that based on the most recent claim before a readmission occurred, 90.9% of readmitted patients were coming from home, 8.8% were coming from Skilled Nursing Facilities (SNF), and very few were coming from inpatient rehabilitation (0.3%). Hospitals can use this information to observe if they are an outlier in any of the categories and where they may have an opportunity to improve, to benchmark themselves against the MVC all and regional averages, and to notice trends in their performance

These combined-payer push reports are distributed twice a year, meaning the next iteration is likely to be sent out in the summer of 2021. In the meantime, single-payer information is always available on the MVC registry, allowing for continued monitoring of these metrics. Data is added every month for Blue Cross payers and quarterly for Medicare. Michigan Medicaid data will be live on the registry at the start of Q2 this year.

If you need registry access, if you have ideas on how these reports can be made more versatile, or if you are using these data for a quality improvement project at your institution, please contact michiganvaluecollaborative@gmail.com. Additionally, please reach out if you want further information in the way of custom analytics.

25 Feb 2021
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Opportunity to Share your Perspective in Institutional Participation in the MVC Component of the BCBSM P4P Program

February 25, 2021 | 0 Comments | , ,

MVC Senior Advisor and former Director, Dr. Scott Regenbogen recently received funding from The Donoghue Foundation to lead a team of investigators to learn more about institutional participation in the MVC Component of the BCBSM P4P Program.

As part of this study, Dr. Regenbogen is interested in conducting virtual interviews with lead administrators who were involved with selecting service lines for performance year 2017-2018

What is the value of participating? While participation in this study is completely voluntary and does not carry any bearing on P4P scoring, the insights gleaned from this work will help us to continue improving the MVC measure for the benefit of our members, and improve our understanding of successful strategies in commercial episode-based payment incentives.

What is The Donoghue Foundation? The Foundation supports a diverse portfolio of research projects, from understanding the mechanisms of disease, to improving clinical treatments, to public health initiatives that prevent illness – all founded on excellent science. To learn more about the organization and their mission, please visit https://donaghue.org/

Meet the Key Study Personnel

  • Scott Regenbogen, MD, MPH.  Dr. Regenbogen is an Associate Professor of Surgery and Chief of the Division of Colorectal Surgery at the University of Michigan (UM), and a Senior Advisor of the Michigan Value Collaborative (MVC). His research has focused on the role of perioperative care protocols in the costs, outcomes, and value of care around episodes of inpatient surgery, with a particular focus on older adults.
  • Shelytia Cocroft, PhD.  Dr. Cocroft is an applied medical sociologist and mixed-methodologist (qualitative and quantitative research designs).  She is currently a qualitative research analyst at the University of Michigan’s Center for Healthcare Outcomes and Policy (CHOP) and is collaborating on qualitative centric projects designed to identify systemic and structural mechanisms within surgical care that perpetuate inequalities in access, quality, and delivery of care.
  • Ashley Duby, MS.  Ms. Duby is the Research Director for the Division of Colorectal Surgery within the Department of Surgery and has been working with Dr. Regenbogen for the past 6 years. She has extensive experience in development and deployment of fieldwork protocols in diverse settings – including patient and provider populations.

If you have any questions or would like further information related to this project, please contact Ashley Duby, Research Director at agay@med.umich.edu.

18 Feb 2021
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Michigan Value Collaborative: Sepsis Reports

February 18, 2021 | 0 Comments

In early 2020, the Michigan Value Collaborative (MVC) Coordinating Center created a new sepsis service line with the help of the Michigan Michigan Hospital Medicine Safety Consortium (HMS). Initially the service line began with 215,447 episodes and has since grown to 229,673 episodes. In conjunction with the creation of the sepsis service line, reports customized to each collaborative member hospital were developed. The most recent iteration of these, shared in two volumes, were disseminated to members in February 2021.

Each volume of the sepsis reports serves their own unique purpose. The first volume provides a detailed review into specific components of a sepsis episode with the ability for each member to compare individualized information to regional and statewide averages. These metrics help members garner a better understanding of the sepsis patient population from admission to 90-days post discharge with data on length of stay, causes for readmission, and post-acute care utilization. Figure 1 shares information on length of stay, and this example shows Hospital A’s (a fictional institution) average length of stay to be higher than both the regional and collaborative-wide average. Additionally, metrics such as total episode payment and readmission rates are displayed as trends over time as shown in Figure 2 and Figure 3.

Figure One.

Figure Two.

Figure 3 shows that the individual hospital trend for the 90-day readmission rate is higher than both the regional and MVC averages which mirror each other closely. Initially, the overall hospital trend decreases towards the regional average, but climbs again in 2019. MVC members may wish to use this information to investigate the root causes leading to increased readmissions.

Figure Three.

The second volume of MVC’s sepsis reports provides benchmarking for members to identify how they compare to all other MVC hospitals. Figure 4 shows information on a hospital’s total episode payment compared to the regional and MVC averages. In addition, it shows the range of the average total episode payments across the collaborative. By using previously sent reports, hospitals can compare how the metrics have changed - such as an increase or decrease in collaborative-wide or individualized total episode payments. As these reports are disseminated every six months, when comparing, it is important to take notice of the reporting period covered in each report which can be located in the associated cover letter and footnotes. Members can also access their own sepsis related data on the MVC registry.

Figure Four.

If you have any suggestions on how these reports can be improved or the data made more actionable, we would love to hear from you. We are also seeking feedback on how collaborative members are using this information in their quality improvement projects. Please reach out to the Coordinating Center at michiganvaluecollaborative@gmail.com to share your story. If you have any questions or are interested in custom data for your facility, contact us at the aforementioned email address.

11 Feb 2021
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MVC Component of the BCBSM P4P Program: PY20 in Review

MVC Component of the BCBSM P4P Program: PY20 in Review

February 11, 2021 | 0 Comments | , , , ,

In early January, the Michigan Value Collaborative (MVC) distributed 2020 Program Year (PY) scores to hospitals for the MVC Component of the Blue Cross Blue Shield of Michigan (BCBSM) Pay for Performance (P4P) program. This marked the completion of the first year of a two-year cycle for which hospitals have selected two service lines (out of seven) to be scored on their episode spending using MVC data. These service lines include chronic obstructive pulmonary disease (COPD), colectomy, congestive heart failure (CHF), coronary artery bypass graft (CABG), joint replacement, pneumonia, and spine surgery. Figure 1 shows the frequency of hospital service line selections for the two-year program cycle.

Figure 1.

The program evaluates hospital’s risk-adjusted, price standardized, average 30-day episode payments for their two selected conditions through two methods. One way that hospitals earn points in the program is by reducing their payments from the baseline period (index admissions in 2017) to the performance period (index admissions in 2019). These are termed ‘improvement points’. Alternatively, hospitals are able to earn points by being less expensive than the other hospitals in their cohort. These are referred to as ‘achievement points’. The MVC cohorts are groups of hospitals determined to be peers using bed size, case mix index, and teaching status.

While participants are scored on both improvement and achievement, members receive the higher of the two scores for each service line. Hospitals are also eligible to earn a bonus point for each service line provided all hospitals in their respective cohort who selected the same condition reduce spending by five percent. A maximum of ten points can be awarded for participating members. Figure 2 shows the distribution of total points earned by hospitals for Program Year 2020.

Figure 2.

On average, hospitals earned six points, an increase of around one point from the 2019 program year average. Twenty-four hospitals received bonus points within the COPD, colectomy, joint replacement, and pneumonia service lines. Consistent with previous years, joint replacement had the average points, with pneumonia coming in a close second (see Figure 3).

Figure 3.

If you have any questions regarding the MVC Component of the BCBSM P4P program, please refer to the P4P Technical Document for Program Years 2020 and 2021 and the MVC P4P FAQ PY 2020-2021 . If you would like to set up a meeting to review your hospital’s performance, please contact the Coordinating Center at MichiganValueCollaborative@gmail.com.

 

04 Feb 2021
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Henry Ford Health System – Cardiac Rehab

Henry Ford Health System – Cardiac Rehab

February 4, 2021 | 0 Comments

At the most recent congestive heart failure MVC workgroup, Dr. Steven Keteyian, Section Head of the Cardiac Rehabilitation/Preventive Cardiology Unit at Henry Ford Medical Group, presented on exercise-based cardiac rehabilitation in patients with heart failure. Dr. Keteyian started out by discussing the importance of cardiac rehabilitation and adhering to a program in order to improve exercise tolerance and disease-specific outcomes. Exercise intolerance is measured and the information gathered can be used to stratify a patient’s future risk. If the measurement improves over time, Dr. Keteyian discussed the potential for a decrease in risk of death and re-hospitalization. This shows a tie to directly improving outcomes and symptoms in cardiac rehabilitation. Also, in the words of Dr. Keteyian, “functionally, the more they don’t do, the less they can do.”

Cardiac rehab is a Class I recommendation from The American College of Cardiology for all of the traditional cardiac disorders. Henry Ford has a 36-visit program that is anchored on exercise training. Between four and fifteen people are in each class and each person receives an individual treatment plan with a focus on bio-behavioral components. Six core components make up the program which include outcome assessments, supervised exercise, dietary/weight management, tobacco abuse, psychological support, and medication adherence. All participants participate in 30-minute behavioral education sessions which cover topics such as nutrition, dining out, proper exercise, medication compliance, and other relevant disease-management self-care activities. These same topics are also available on YouTube and can be found here, all of which are available for use in your cardiac rehab program. Currently, Henry Ford is working on bringing their time to enrollment after hospital discharge to less than 21 days and increasing adherence to the 36-visit program. The goal is to achieve a participation rate of 70% or more in cardiac rehab for Henry Ford’s patient population.

After discussing the program specifics at Henry Ford, Dr. Keteyian discussed the barriers that one may face in relation to participation in cardiac rehab. These barriers include:

  • Demographic
  • Difficulty contacting patient after hospitalization
  • Return to work demands
  • Transportation
  • Co-payment obligations
  • Dependent care responsibilities

Henry Ford is working at a system level in order to increase the percent of patients who gain access to cardiac rehab. This includes increasing the use of electronic medical record (EMR) driven automatic referrals, with an option for users to opt-out if necessary. Additionally, a member of the cardiac rehab team goes to the inpatient setting and talks to patients to establish a touchpoint before they leave the hospital. This five-minute conversation is all some patients need in order to see the importance and benefits of rehab. Lastly, Henry Ford is working to shorten the discharge to start time. Each day after discharge, the chance of getting patients started in rehab decreases by 1% for each day that passes. Henry Ford is working diligently in order to help decrease this risk.

In 2016, Henry Ford launched a hybrid home-based cardiac rehabilitation service. This includes some visits at the clinic and other virtual sessions. Previously being tied to a single visit at a time on their current streaming platform, Henry Ford will roll out a WebEx model in February 2021 that will allow up to six cardiac rehab appointments to occur at one time. This will provide more of a group setting. Currently, a randomized controlled trial is being done on center based cardiac rehab versus hybrid cardiac rehab. Improvements in fitness and the number of sessions attended are being assessed.

If you are interested in watching the entire workgroup, please click here.  If interested in any information about this workgroup, or other MVC workgroups please email michiganvaluecollaborative@gmail.com

28 Jan 2021
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Learning Health Systems and Quality Improvement

January 28, 2021 | 0 Comments

The mission of the Michigan Value Collaborative (MVC) is to improve the health of Michigan through sustainable, high-value healthcare with a vision to help provide the right care, at the right time, at the right cost. As part of this, MVC helps its members better understand their performance using robust multi-payer data, customized analytics, and at-the-elbow support. In addition, MVC fosters a collaborative learning environment to enable providers to learn from one another and share best practice. All of this is designed to help members respond to change, drive quality improvement, and improve performance.

Improving performance is often easier said than done – a phenomenon often referred to as the “60.30.10 Challenge”. Following the review of health learning systems in Australia, this phenomenon was identified as a key challenge that the healthcare system has faced for three decades. Despite change and areas for improvement being identified throughout healthcare, only 60% of evidenced based care is provided to patients, 30% of care is identified as waste or duplication, and at least 10% of patients experience adverse events or medical harm. With this in mind, can the current healthcare system embrace the many new technologies and advancements in medicine on the horizon?

While these new advances in technology have the ability to improve care and prolong life, there is conversely an addition of complexity and increased risk with utilizing them. It is important to understand that healthcare systems are complex and typically do not respond in a linear way to change. A collaboration of healthcare providers set up in Australia realized some key activities for improvement   initiatives within health care systems . These activities were included in the setting up of the collaborative known as the Translational Cancer Research Network and involved incentives, resources, administrative support to provide encouragement, collaboration and reduced constraints, data support, and expertise in implementation science. A number of new projects such as increased consumer engagement and improvement in diagnosis for various cancers came out of involvement in this network.

While root-cause analysis has long been used to identify medical failures, this may not be the best method to effectively establish safety protocols to prevent further harm due to the complex pathways within healthcare that are infrequently repeated. Instead, healthcare needs to take a different approach by introducing models of care that promote collaboration, exceed independent specialties, and advocate for combining hospital, primary care, community agencies, and elder care to navigate well-informed patients through evidenced based healthcare pathways along the continuum of care. There is a need to shift the paradigm and learn from what is going well and those that are successful. By spreading good practices across all healthcare systems, allowing healthcare teams to effectively improve processes in real time, and teaching clinicians to manage data and understand continuous improvement methods, a learning system can be developed.

By creating a learning system, efforts to improve care can be better aligned. Drivers of the system include a commitment to improvement, being ready and prepared for change, being aware of the capacity of and barriers to progress, knowledge of implementation strategies, and lastly providing leverage and resources to learning. In addition, data can be utilized by these fluid learning systems to aid patient and clinician decision-making. It is hoped that a flexible system with relevant information and data to make the right decision, and the ability to adjust processes will help to reenergize clinicians, enabling them to provide increasingly appropriate, safer, and higher quality care with less waste.

The Michigan Value Collaborative (MVC) can help you by providing claims data across 40 different medical and surgical conditions. Additionally, we have regular workgroups that meet to share best practices. If you are interested in custom analytics for your institution, joining a workgroup or want to learn more about what MVC has to offer, please contact the Coordinating Center at michiganvaluecollaborative@gmail.com.

 

21 Jan 2021
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Building Resilience

January 21, 2021 | 0 Comments

Following on from last week’s blog discussing burnout in the healthcare profession, this week we look at resilience and how to build it in the workforce, particularly during times of high stress. Resilience can be defined as “the capacity to recover quickly from difficulties” (Oxford Languages), while the American Psychological Association believe resilience to be “the process of adapting well in the face of adversity, trauma, tragedy, threats or significant sources of stress”. Due to recent events, resilience among healthcare workers has become a highly publicized topic and is often in the forefront of the news. Currently, everyone has a need to build resiliency and be treated with compassion and empathy.

Although a number of articles have depicted an increase in anxiety, depression and substance use, studies done following other traumatic events such as the attacks on the World Trade Center and the Severe Acute Respiratory Syndrome (SARS) outbreak have shown a common outcome to be long-term resilience in the majority of those impacted rather than post-traumatic stress disorder (PTSD). Resilience is not a one size fits all and everybody will respond to an event in their own way. However, taking steps to adapt behavior while struggling and experiencing intense grief, fear or anxiety will impact a person’s resilience. It is continuing to show up and move forward even while facing adversity.

Additionally, resilience is not something one has or not, it is an acquired and learned behavior that is constructed actively and created through dynamic behavioral, cognitive, and environmental processes. Resilience can be cultivated through the influence of individuals and communities. By propagating togetherness and behaviors that are beneficial to others, resilience can be built within a neighborhood and each other.

Building resilience within a community takes individuals, but how can resilience be nurtured within these individuals? In a systematic literature review looking at the factors affecting resilience, the following themes were identified:

  • Influence of individual factors such as a sense of purpose, identifying the need for self-care, and holding a positive outlook
  • Influence of environmental and organizational factors indicated by workplace culture, and including identification and measurement of resilience especially within high-risk groups
  • Individual approaches to professional circumstances covering workload management, work-life balance, social support, and use of coping strategies
  • Educational interventions

Effective educational interventions may include resilience workshops along with cognitive behavioral training, stress reduction programs using mindfulness techniques, and healthcare simulation.

While we continue to undergo challenges and face adversity, it is important we take the time for self-care and also to support work colleagues and neighborhoods to build individual and community resilience. The MVC Coordinating Center is available to support, please feel free to reach out at michiganvaluecollaborative@gmail.com