10 Aug 2023
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MVC Rural Health Meeting Summary: Delivering Value in Rural and Northern Michigan

MVC Rural Health Meeting Summary: Delivering Value in Rural and Northern Michigan

August 10, 2023 | 0 Comments | , ,

This Wednesday, the Michigan Value Collaborative (MVC) held its first collaborative-wide rural health meeting for members. With over 50 participants representing rural and critical access hospitals (CAH), physician organizations (POs), and participating quality networks, this virtual meeting was dedicated to discussing the unique quality improvement efforts and challenges that exist within rural healthcare.

MVC Director Hari Nathan, MD, PhD, kicked off Wednesday’s meeting with an update from the MVC Coordinating Center (see slides). Honoring MVC’s 10-year anniversary, Dr. Nathan highlighted important milestones from the last decade that contributed to MVC’s continued efforts to deliver high-value healthcare in all areas of Michigan. Dr. Nathan shared updates pertaining to the launch of MVC’s new emergency department (ED)-based episodes, the recent addition of a CAH comparison group in its reporting, expanded CAH membership (Figure 1), and MVC’s plan to offer a rural health workgroup series in 2024.

Figure 1.

Following Dr. Nathan’s introduction and collaborative-wide updates, MVC Senior Analyst Julia Mantey, MPH, MUP, provided an in-depth presentation of MVC’s new ED-based episodes, which were developed in collaboration with the Michigan Emergency Department Improvement Collaborative (MEDIC). Read this recent blog post for more information on MVC’s ED-based episode structure and utilization or view Ms. Mantey’s slides here.

After introducing the components of MVC’s ED-based episodes, Ms. Mantey presented an unblinded data session illustrating ED-based episode data for MVC’s rural hospital members. When considering both rural non-CAH ED-based episodes and CAH ED-based episodes, chest pain was the most frequent condition observed. Due to its high volume in the ED, MVC produced unblinded rural hospital data using ED-based episodes for 30-day secondary ED visits among patients with a primary diagnosis of chest pain. In analyzing this data, MVC analysts discovered a correlation between patient follow-up rates and 30-day secondary ED visit rates. Patients who receive follow-up care are less likely to return to the ED in the 30 days following their initial index discharge, and the rate of secondary ED visits is smallest among patients who received follow-up care within one week of discharge (Figure 2).

Figure 2.

Following the unblinded data presentation, MVC received input from participants about additional analyses that would be useful, such as evaluating the correlation between the availability of nearby urgent care facilities and the rates of primary and secondary ED visits. Such suggestions were noted as MVC works to expand its CAH and ED-based episode data reporting.

Following the unblinded data session, Ross Ramsey, MD, CPEM, FAAFP, President and Chief Executive Officer of Scheurer Health, delivered a presentation on common rural health challenges and Scheurer Health’s recent efforts to improve the quality of care for its rural population. Dr. Ramsey emphasized that rural areas are associated with higher poverty rates, larger proportions of elderly individuals, a higher percentage of patients who are uninsured, and a higher prevalence of chronic health problems such as substance abuse and illnesses related to environmental exposures. Dr. Ramsey highlighted several focus areas at Scheurer Health to improve the value of care for its patients: wellness visits, transitional care management, remote patient monitoring, and ED follow up. As seen in Figure 3, Scheurer Health increased wellness visit participation by 32.8% over the last six years. For more details about Scheurer Health’s strategies and success stories, view Dr. Ramsey’s slides here.

Figure 3.

After Dr. Ramsey’s insightful presentation, MVC welcomed Mariah Hesse, MSN, CENP, President of the Michigan Critical Access Hospital Quality Network (MICAH QN) and Chief Nursing Officer at Sparrow Clinton Hospital. Her presentation (see slides) provided an overview of core components of the quality network, highlighting its foundational pillars of success (Figure 4), in addition to featuring the network’s accomplishments and the benefits of participation by Michigan’s 37 CAHs. MICAH QN ensures representation for CAHs on national and state committees and serves as a resource to Michigan CAHs on performance improvement tools and measures. Her presentation also referenced several key priorities for healthcare in rural Michigan, such as meaningful benchmarking focused on outpatient care, recovery from challenges experienced during the pandemic, and improving healthcare access and equity.

Figure 4.

MVC looks forward to continued partnership with members based in rural communities to support the delivery of sustainable, high-value care through high-quality data analytics, collaboration, and innovation.

The slides from Wednesday’s meeting have been posted to the MVC website and a recording of the meeting is available here. If you have questions about any of the topics, contact the MVC Coordinating Center. MVC’s next collaborative-wide meeting will be in person on Friday, October 20, 2023, in Lansing, MI.

03 Aug 2023
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MVC Develops PO Post-Discharge and ED-Based Episode Reports

MVC Develops PO Post-Discharge and ED-Based Episode Reports

August 3, 2023 | 0 Comments | ,

The Michigan Value Collaborative (MVC) recently completed the development of two new push reports tailored to physician organizations (POs). Both reports mirrored hospital-level push reports distributed earlier this summer and reflect MVC’s ongoing approach to refining and tailoring its analytic offerings to the patient populations and needs of its diverse membership. The first new PO report of 2023 was released in July and focused on post-discharge care, and the second is set to be released next week using new emergency department (ED)-based episodes.

PO ED-Based Episodes Report

The forthcoming PO ED-based episode report features MVC’s new ED-based episode data for five high-volume ED conditions: chest pain, abdominal pain, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), and cellulitis. A hospital-level version was distributed in June.

ED-based episodes are a new episode of care structure developed by MVC in collaboration with the Michigan Emergency Department Improvement Collaborative (MEDIC). These episodes are initialized by a patient’s visit to the ED and include all claims-documented care received in the 30 days following a patient’s index ED visit.

For each of the five index conditions included in this forthcoming report, POs will receive information on risk-adjusted and price-standardized 30-day total episode payments, same-day inpatient admission rates over time, utilization of healthcare services across an attributed patient’s 30-day episode of care, and the hospitals where a PO’s attributed patients most frequently presented to the ED for a given index condition. Patient claims data were included for adult patients aged 18 and older who had an ED visit between 1/1/21 and 8/31/22 and were insured by Blue Cross Blue Shield of Michigan (BCBSM) PPO Commercial, BCBSM Medicare Advantage (MA), or Medicare Fee-for-Service (FFS).

Among POs receiving a report, average risk-adjusted, price-standardized 30-day total episode payments for the five reported conditions were highest for CHF ED-based episodes ($16,936) followed by COPD ED-based episodes ($10,286), and lowest for unspecified chest pain ($3,714). Within each condition, MVC 30-day total episode payments were consistently higher for episodes in which the attributed patient had a same-day inpatient admission compared to episodes in which the attributed patient did not have an inpatient stay begin on the date of their ED visit.

A key goal for these ED-based episode reports was to provide insight into healthcare utilization following index ED visits. Therefore, reports included a dot plot (Figure 1) comparing each PO’s post-ED utilization for their attributed patients compared to the average across all 40 MVC member POs.

Figure 1.

PO Skilled Nursing Facility & Home Health Report

In July, MVC distributed PO-level reports on post-discharge care that included metrics on skilled nursing facility and home health utilization. A hospital-level version was distributed in June. The purpose of this report was to support understanding of care coordination opportunities and benchmark post-discharge care utilization.

This report highlighted various SNF and home health utilization metrics using 30-day claims-based episodes for MVC’s medical conditions: acute myocardial infarction (AMI), atrial fibrillation, COPD, CHF, endocarditis, pneumonia, sepsis, small bowel obstruction, and stroke. A PO’s attributed patient episodes were included if they had an inpatient admission between 1/1/2021 and 6/30/2022 and were insured by BCBSM PPO Commercial, BCBSM MA, or Medicare FFS.

As with other PO-level push reports, MVC included several comparison groups to aid individual POs in benchmarking their performance for select report metrics. Each PO can compare their data to the average for POs of a similar size, the average for POs located within the same geographic region of Michigan according to MVC’s region designations, and the collaborative-wide average for all MVC member POs. Only POs with 20 or more episodes in 2021 and 11 or more in 2022 received a report and were included in comparison group calculations.

Similar to the hospital-level version, the first page of the report contained a SNF and home health profile table (Figure 2), which provided an overall look at post-discharge utilization patterns by payer as well as information about a given PO's patient population. The first three metrics reflected all attributed patients treated for medical conditions in this time period for the included payers and the metrics in gray were comprised only of attributed patients who utilized SNF in the 30 days post-discharge from their episode's index hospitalization. Overall, MVC found that Medicare FFS patients utilized SNF and home health services more often.

Figure 2.

Measures in this report include SNF and home health utilization rates overall and by condition, SNF and home health utilization rates among patients discharged to their home, inpatient readmission rates for SNF and home health utilizers, and a list of the most frequently utilized SNFs and home health providers to help POs understand where their attributed patients are going when receiving SNF or home health care after discharge. MVC presented 30-day overall SNF and home health utilization rates in a caterpillar plot format to showcase variation across POs. These rates varied between roughly 9% and 16% for SNF utilization (Figure 3) and between 19% and 32% for home health utilization (Figure 4).

Figure 3.

Figure 4.

MVC observed average 30-day inpatient readmission rates of 21% among attributed PO patients discharged to SNF (Figure 5) and 17.2% among attributed patients discharged to home health (Figure 6).

Figure 5.

Figure 6.

New Report Distribution Process

MVC piloted a new method for distributing its push reports when sending out the PO SNF/HH reports and is continuing that method for the distribution of its PO ED-based episode reports. Over the summer, PO site coordinators received an email from Dropbox as well as from MVC with a link to their PO’s designated Dropbox folder. Since then, MVC has been working to confirm that contacts are able to successfully access their designated folder and reports.

This new report distribution process will allow MVC’S contacts to access all available MVC reports in a single, secure location, and address some of the email firewall issues experienced by some members. Going forward, members may access and download their individualized reports using Dropbox rather than receiving reports through email. When a new report is made available to members, MVC will still notify all recipients via email with the details of the report. MVC plans to launch this new report distribution process with its hospital partners in the coming months, beginning with Program Year 2023 mid-year scorecards for the MVC Component of the BCBSM Pay-for-Performance (P4P) Program.

If you have any follow-up questions about your site’s latest push reports or the new report distribution process, please contact the MVC Coordinating Center at Michigan-Value-Collaborative@med.umich.edu.

27 Jul 2023
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MVC Welcomes New Analyst, Kim Fox, MPH

MVC Welcomes New Analyst, Kim Fox, MPH

July 27, 2023 | 0 Comments |

It is a privilege to be welcomed to the Michigan Value Collaborative (MVC) team as a Senior Data Analyst! As a new member of the MVC team, I am excited to learn from and work alongside a talented team of MVC coordinators, administrators, and analysts to help improve the health of Michigan through creating sustainable, high-value healthcare.

My public health journey began after discovering the field of Medical Anthropology. Medical anthropologists show us that medical practices are shaped not only by scientific knowledge, but also by sociocultural, environmental, and economic factors. These factors lead to substantial variation in healthcare practices both globally and in our own neighborhoods. It is this principle that underlies my work in public health and keeps me inspired. My goal is to help find compassionate, creative, and robust healthcare approaches that consider and balance these factors to help improve the health and well-being of communities and populations.

Prior to joining MVC, I served in roles that have ranged from research operations and disease surveillance to global healthcare consulting. I received my Master of Public Health (MPH) degree in Epidemiology from the University of Michigan (U-M) School of Public Health and a Bachelor of Arts in Psychology with a minor in Medical Anthropology from U-M.

I am looking forward to working with MVC and its members to identify best practices and opportunities for continuous improvement through the analysis of clinical and claims data. If you have any questions or wish to get in touch, please feel free to email me.

20 Jul 2023
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MVC Calls Attention to Research, Resources During Week-Long Preoperative Testing Campaign

MVC Calls Attention to Research, Resources During Week-Long Preoperative Testing Campaign

July 20, 2023 | 0 Comments | ,

Prior to surgery, most Michigan patients will undergo a series of tests, such as blood draws, urinalysis, chest x-rays, or electrocardiograms (ECGs/EKGs). Many of these tests are unnecessary for healthy patients undergoing low-risk procedures such as groin hernia repair. Routine preoperative testing is widely considered a low-value service, and yet a majority of hospitals continue to order these tests. In an effort to drive improvement in this area, MVC hosted its second annual preoperative testing awareness campaign this week.

“For a patient, it is key they get the right amount of preoperative assessment,” said Dr. Michael Englesbe, professor of surgery at the University of Michigan, director of the Blue Cross Blue Shield of Michigan-funded Collaborative Quality Initiatives, director of the Michigan Surgical Quality Collaborative (MSQC), and co-director of the Michigan Opioid Prescribing and Engagement Network (Michigan OPEN). “Too little testing and important risks may be missed, too much and patients may be exposed to critical risks of unnecessary testing and delays in care.”

MVC’s Coordinating Center supports preoperative testing de-implementation in several ways. One is providing opportunities for MVC’s members to collaborate and learn from one another. This year MVC launched a workgroup series focused on preoperative testing, the first of which took place in March. As part of its campaign this week, MVC promoted the next session in this workgroup series, set to take place Tues., Aug. 1, from 1-2 p.m. featuring guest speaker Nick Berlin, MD, MPH, MS. Those interested in this topic should register to attend here.

Another key strategy MVC uses to support preoperative testing de-implementation is through data analysis and reporting. MVC analysts utilize administrative claims data to calculate testing rates in the preoperative period, and then share these results with members as reports or as unblinded data at collaborative-wide meetings. More recently, MVC partnered with MSQC to distribute these reports more widely to support cross-collaboration between clinical and quality personnel at a given site.

These reports are an invaluable resource in benchmarking the extent of the issue statewide, says Dr. Hari Nathan, MVC’s director and the chief of hepato-pancreato-biliary surgery at Michigan Medicine. “MVC data can be used by hospitals and providers to understand how their rates of preoperative testing compare to those of other hospitals in Michigan,” he said. “By focusing on a homogeneous cohort of healthy patients undergoing common, low-risk surgical procedures, MVC benchmarks can help all hospitals understand where they have an opportunity to improve, regardless of facility size, resources, or patient population.”

Across the collaborative, MVC sees wide variation in preoperative testing for low-risk elective surgeries like hernia repairs and lumpectomies, with testing rates among young, healthy patients ranging from 10% to 97% across MVC hospitals. This level of interhospital variation is evidence that many hospitals in Michigan are safely performing low-risk surgeries without widespread preoperative testing and that even those hospitals with average rates likely have room to safely reduce their testing further.

MVC also sees quite a bit of intrahospital variation, with certain surgeries driving the overall preoperative testing rate at a given site. Based on the findings of its latest report, one potential area of focus for sites may be reducing the rate of cardiac testing; the rate of ECGs is quite variable across the collaborative and could lead to a cascade of care.

MVC shared its refreshed preoperative testing push report with members in April and also held a report review webinar in June to review the measures included. This webinar also included advice from Dr. Nathan about how to take action using this data. Dr. Nathan promoted several new resources developed in partnership by MSQC, the Michigan Program on Value Enhancement (MPrOVE), and MVC. These include a customizable decision aid (Figure 1), which sites can download to add their branding or modify. It is accompanied by a similarly customizable preoperative testing reference chart (Figure 2).

Figure 1.

Figure 2.

Both of these resources are currently housed on a new Waive the Workup de-implementation resource website managed by MPrOVE, MSQC, and MVC. In addition to pages for the decision aid and chart, the site also offers talking points for debunking common myths about preoperative testing. For instance, one common counterargument to reducing preoperative testing prior to low-risk surgery is a perception that there’s no harm in ordering them, either because they are relatively inexpensive or because they are not invasive tests.

On the contrary, research has established substantial financial costs and risks to patient harm because of preoperative testing, which can and should be safely reduced. Mihir Surapaneni, BBA, a medical student at the University of Michigan Medical School, has been conducting research with MVC on preoperative testing and its impact. “One of the major theories for why there’s so much variability—and indeed just a high utilization rate—for preoperative testing is that there’s no perceived downside,” Surapaneni said. “Many of these tests are relatively cheap compared to the total cost of healthcare and indeed most of them cost no more to the patient than a stick of blood, but we really have to consider that there are costs. Preoperative testing costs billions of dollars in the United States healthcare system annually, and when you consider how strained the healthcare system is and how much of an onus there is on payers and the government to decrease costs, this really adds up. And secondly, we have to consider the possibility of testing cascades—which has been well-documented—in that a patient comes in having an abnormal lab value or test that actually had nothing to do with their intended surgery, and this leads to more and more tests which are expensive and potentially invasive. And finally, we have to consider that there’s established literature showing that even when an abnormality is found in a routine preoperative test, these abnormalities: 1) rarely impact the clinical course of the patient, and 2) rarely lead to actual substantive change in that patient’s care. And I think that we really have to consider these when we’re deciding whether or not we want to test our patients routinely.”

In addition to registering for the Aug. 1 workgroup, MVC has a third preoperative testing workgroup session scheduled for Oct. 26, 11 a.m. - 12 p.m. The Oct. session will be a forum for sharing current successes or initiatives underway across the collaborative. If your hospital has a current initiative underway on preoperative testing de-implementation or has a low average testing rate, MVC would love to learn from you. Please reach out to the MVC team if you’d be interested in sharing your site’s story on Oct. 26.

13 Jul 2023
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MVC Reflects on 2023 Mid-Year Progress and Successes

MVC Reflects on 2023 Mid-Year Progress and Successes

July 13, 2023 | 0 Comments |

As the Michigan Value Collaborative continues its activity in the second half of 2023, the MVC team is taking a moment to pause and reflect on the tremendous work accomplished over the past six months. Here is a look back at some of the highlights.

NEW ED-BASED EPISODE DATA

MVC spent significant time and effort in Q4 of 2022 and Q1 of 2023 developing a new episode-of-care data structure initialized by index visits to the emergency department (ED). This work was done in collaboration with MEDIC—the ED-focused CQI—and the data science portion was completed by ArborMetrix. ED-based episodes were created for 15 high-volume, ED-relevant conditions from January 2017 through the present using all BCBSM, BCN, and Medicare plans for which MVC has claims data. Episodes were created for index events at all qualifying hospitals in Michigan. Over two million ED-based episodes have been created thus far, with plans to update and add additional claims data on a regular cadence. These data were used in the creation of a new ED-based episodes push report and are also available for use in custom reports for members.

ANALYTICS & REPORTING

Since Jan. 1, the MVC team has completed a total of 11 custom requests as well as six push reports, three of which were new:

  • ED-based episodes report (hospital version) - new
  • Skilled nursing facility (SNF) and home health report (hospital and PO versions) - new
  • P4P final scorecards for PY 2022
  • Preoperative testing report refresh
  • Cardiac rehabilitation report refresh

MVC COMPONENT OF THE BCBSM P4P PROGRAM

So far in 2023, MVC has been busy implementing and adjudicating the MVC Component of the Blue Cross Blue Shield of Michigan (BCBSM) Pay-for-Performance (P4P) Program. In March, MVC finalized and evaluated PY 2022, sending final scorecards to participating hospitals. PY 2022 was the first year of a two-year cycle for which MVC data was used to evaluate hospitals on two of seven selected episode spending conditions, including chronic obstructive pulmonary disease (COPD), colectomy, congestive heart failure (CHF), coronary artery bypass graft (CABG), joint replacement, pneumonia, and spine surgery. The average total points scored was 6/10 before including bonus points, one point higher than the previous PY average. Consistent with previous years, joint replacement was the highest-scoring condition with an average of 4.6 points earned, while pneumonia was the lowest-scoring condition with hospitals earning 1.5 points on average (Figure 1).

After finalizing the methodology for the PY 2024-2025 cycle, MVC collected selections from all hospitals in early Feb. for one of five episode spending conditions and one of seven value metric options. MVC hosted two explainer webinars and five one-on-one meetings to support sites with their episode spending metric and value metric selections. The most common episode spending selection was for joint replacement and the most common value metric selection was seven-day follow-up after CHF.

Figure 1.

QUALIFIED ENTITY PUBLIC REPORT

MVC was approved as a qualified entity (QE) in 2022 under the Qualified Entity Certification Program (QECP) and continues to fulfill requirements to maintain QE status. In the first half of 2023, MVC continued to provide authorized hospital users with registry access to QE Medicare data that met program requirements. In Jan., MVC also published its 2022 Annual Public QECP Report. MVC’s first public report as a QE provides information on hospital performance for two sets of measures: rehospitalization following post-discharge home health use, and outpatient follow-up receipt following CHF/COPD inpatient hospitalization. The public report was published on the MVC website and shared with MVC contacts via email. MVC will refresh and publish its next annual public report this fall, adding two new years of data.

MAY COLLABORATIVE-WIDE MEETING

MVC held its spring collaborative-wide meeting on May 19. A total of 86 leaders from a variety of healthcare disciplines attended representing 50 different hospitals and 13 POs from across the state of Michigan. “Connecting the Dots: Celebrating 10 years of value-based care” was the theme, putting the spotlight on care transitions, care coordination, and MVC’s 10 years of supporting data-driven quality improvement. MVC was joined by guest speakers from Trinity Health IHA Medical Group and the new lung health CQI, INHALE. MVC also offered a poster session highlighting the work of several members and partner CQIs. MVC staff prepared a variety of unblinded data presentations, including a first look at its new ED-based episode data as well as unblinded breakout session presentations on its new P4P value metrics. Save the date for MVC’s fall collaborative-wide meeting, scheduled for Friday, October 20 at the Radisson Hotel Lansing.

WORKGROUPS

Over the last six months, MVC delivered a total of 14 workgroups, which were designed to provide a highly accessible online platform for hospital and PO leaders to come together, collaborate, and learn from peers. MVC offers workgroups on six topics this year: cardiac rehabilitation, chronic disease management, diabetes, health equity, health in action, and preoperative testing. Visit the MVC 2023 Events Calendar to check upcoming dates and topics and to register.

In addition, MVC launched a new Lunch and Learn series dedicated to MVC-focused activities and topics. The kickoff session in March included an overview of MVC and its offerings for new site coordinators or partners. The next session in June featured an introduction to MVC’s data sources, its episode structure and methodology, and an analyst-led walkthrough of one of MVC’s most recent push reports. MVC plans to host two more Lunch and Learn sessions later this year on other topics.

NEW COORDINATING CENTER STAFF

In June, MVC welcomed two new data analysts to the Coordinating Center: Kushbu Narender Singh, MPH, and Jiaying (“Janet”) Zhang, MPH. MVC published welcome blogs about Kushbu and Janet last month and looks forward to introducing them to members and partners in the coming months.

AND COMING SOON…

The MVC team is hard at work preparing for its first Rural Health Meeting, scheduled for Wednesday, August 9, from 10 a.m. to 12 p.m. via Zoom. The purpose of the meeting is to provide presentations and MVC data tailored to its rural or Critical Access Hospital members. This meeting will feature presentations by leaders from MVC, Scheurer Health, and the Michigan Critical Access Hospital Quality Consortium. RSVP here.

06 Jul 2023
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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

July 6, 2023 | 0 Comments | , , ,

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.

29 Jun 2023
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MVC Welcomes New Analyst, Kushbu Narender Singh, MPH

MVC Welcomes New Analyst, Kushbu Narender Singh, MPH

June 29, 2023 | 0 Comments |

I would like to introduce myself as the Michigan Value Collaborative’s (MVC) newest data analyst. I am very thankful to be a part of this incredible team! I am an internationally trained dentist from India with over eight years of clinical and research experience. From childhood, I have been motivated to help people improve their health by overcoming barriers and getting timely access to quality healthcare. This led me to pursue a degree in health science and I greatly enjoyed treating dental diseases and conducting oral cancer research. My thesis research focused on studying the role of nestin - the cancer stem cell marker - in the initiation and progression of oral carcinogenesis.

After a few years of clinical practice, my curiosity about disease prevention increased. I wanted to be involved in providing data-driven healthcare solutions that would create a more significant impact on the community. I recently earned a Master of Public Health degree in epidemiology from the University of Michigan School of Public Health, which provided me with valuable knowledge and opportunities to explore the applications of data-driven research in solving real-world healthcare problems. My most recent research work focused on studying the association of statin usage with the incidence of head and neck cancer.

With this background and experience, I am excited to continue my journey - to integrate my research and clinical skills - working towards MVC’s mission. I look forward to learning and growing in my role as an analyst and continuing to fulfill my passion for improving people’s health outcomes. When not working, I enjoy gardening, bird watching, and hiking, and live by the motto ‘Live and Let Live.’ Please feel free to reach me at kushbu@med.umich.edu.

22 Jun 2023
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MVC Welcomes New Analyst, Jiaying (“Janet”) Zhang, MPH

MVC Welcomes New Analyst, Jiaying (“Janet”) Zhang, MPH

June 22, 2023 | 0 Comments

Hello, I'm Jiaying Zhang (张佳莹), also known as Janet, and I am thrilled to join the remarkable team at the Michigan Value Collaborative (MVC) as an analyst. Hailing from China, my global and diverse experiences have shaped my approach to problem-solving and provided me with a unique perspective.

I recently earned a Master of Public Health (MPH) degree with a focus on global health epidemiology from the University of Michigan School of Public Health and earned a Bachelor of Medicine in public health from Capital Medical University in China. I also learned and grew from several incredible research and volunteering experiences in China, India, and Nicaragua that broadened my horizons and strengthened my adaptability and cultural awareness. Working in different sociocultural contexts has taught me the value of empathy, collaboration, and the power of embracing diverse perspectives.

Drawing from my international background and experiences, I bring a rich tapestry of insights and ideas to MVC. Data analysis is not just a job for me; it's my passion. During my previous work, I had the opportunity to contribute to critical projects that addressed significant public health challenges, including one such project that involved studying the norovirus epidemic in China. By examining large data sets and applying statistical models, I was able to identify key factors influencing the outbreak and propose targeted intervention strategies. As part of an international collaboration, I also worked closely with local healthcare professionals to assess the efficacy and reliability of the Sophia testing system for diagnosing infectious diseases.

I am excited to bring this expertise to MVC, where I can continue to contribute to impactful projects that inform strategic decision-making and drive positive change for patients and communities. If you have any questions, please reach out to me at janetzjy@med.umich.edu.

15 Jun 2023
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MVC’s SNF and HH Push Report Latest in Post-Discharge Insights

MVC’s SNF and HH Push Report Latest in Post-Discharge Insights

June 15, 2023 | 0 Comments | , ,

MVC released another new push report recently with the first iteration of a skilled nursing facility (SNF) and home health focused report. MVC members frequently identify post-discharge care and SNF utilization as focus areas for quality improvement; therefore, this report was developed to help hospitals benchmark their performance in this area and identify opportunities to improve care coordination. Critical access hospitals (CAHs) received a tailored version of the report to allow for metric comparisons to only other CAHs.

This report highlighted various SNF and home health utilization metrics using 30-day claims-based episodes for MVC’s medical conditions: acute myocardial infarction (AMI), atrial fibrillation, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), endocarditis, pneumonia, sepsis, small bowel obstruction, and stroke. Patient episodes were included if they had an inpatient admission between 1/1/2021 and 6/30/2022 and had one of the following insurance plans: Blue Care Network (BCN) HMO Commercial or Medicare Advantage (MA), Blue Cross Blue Shield of Michigan (BCBSM) PPO Commercial or MA, or Medicare Fee-for-Service (FFS).

The first page of the report contained a SNF and home health profile table (Figure 1), which included nine metrics designed to give an overall look at post-discharge utilization patterns as well as information about a given hospital’s patient population. The first three metrics reflected all patients treated for medical conditions in this time period for the included payers and the metrics in gray were comprised only of patients that utilized SNF in the 30 days post-discharge from their episode's index hospitalization. Overall, MVC found that Medicare FFS patients utilized SNF and home health services more often than other payers. For CAHs, this table was not separated by payer.

Figure 1.

On the subsequent pages, 30-day overall SNF and home health utilization rates were provided in a caterpillar plot format to showcase variation across the collaborative (Figure 2). These rates varied between 5% and 25% for SNF utilization and between 10% and 40% for home health utilization.

Figure 2.

MVC also provided 30-day SNF and home health utilization rates broken out by condition to allow each hospital to benchmark rates across their site’s medical service lines and compared to the MVC average rate for each condition (Figure 3). Medical conditions were only included in this figure if a hospital had at least 11 cases between 1/1/2021 and 6/30/2022. On average across the collaborative, the highest 30-day post-discharge SNF utilization rates were observed in endocarditis (28%), sepsis (19.5%), and stroke (19.5%) patients.

Figure 3.

Hospitals also received a table identifying the most frequently utilized SNFs from a medical condition episode to help sites understand where their patients are going when receiving SNF care after discharge. A similar table was shown for home health providers.

The final page of the report included four caterpillar plots tailored to specific denominators. This included 30-day SNF and home health utilization rates for the cohort of patients discharged home. It also included readmission rates for patients who were discharged to SNF and readmission rates for patients discharged to home health. These plots were included to inform each hospital about patterns in their transitions of care and readmissions. There was significant variability in readmission rates following discharge to either a SNF or home health facility, with some hospitals averaging close to 5% readmission rates and some hospitals seeing an average of nearly 40% of patients readmitted during the 30-day post-discharge window (Figure 4).

Figure 4.

As part of its new Lunch & Learn series, MVC recently hosted a session focused on MVC data that included a walkthrough of its SNF/HH report and a deeper dive into those report metrics using MVC’s registry. Those who were unable to attend can watch a recording of the presentation here, which demonstrates how to replicate aspects of the push report on MVC’s registry in order to view additional episode spending and patient-level data.

If you have any questions or feedback about this report, please reach out to the MVC Coordinating Center.

07 Jun 2023
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MVC Uses New ED-Based Episode Data in Latest Push Report

MVC Uses New ED-Based Episode Data in Latest Push Report

June 7, 2023 | 0 Comments | , ,

The MVC Coordinating Center recently distributed its first-ever report based on new emergency department-based episodes (“ED-based episodes”), sharing versions with site coordinators and quality improvement staff at 102 participating MVC member hospitals across Michigan. Reports featured each hospital’s own attributed ED-based episode data for five high-volume ED conditions: chest pain, abdominal pain, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), and cellulitis.

ED-based episodes are a new episode of care data structure developed this past year by MVC in collaboration with the Michigan Emergency Department Improvement Collaborative (MEDIC), a BCBSM-funded Collaborative Quality Initiative with the goal of improving care and patient outcomes in Michigan emergency departments. MVC and MEDIC team members worked closely to develop 30-day episodes of care initialized by a patient’s visit to the ED and including all claims-documented care received in the 30 days following a patient’s index ED visit. MEDIC program director Dr. Keith Kocher, MD, talks more about the collaboration as well as advice on leveraging this data from an emergency medicine perspective in the video below.

These ED-based episodes are built using medical claims data from Medicare Fee-for-Service, Blue Cross Blue Shield of Michigan PPO Commercial and Medicare Advantage plans, and Blue Care Network HMO Commercial and Medicare Advantage plans. MVC’s ED-based episodes of care include both adult and pediatric patients, providing new opportunities for quality improvement insights at Michigan hospitals. Though this report provides metrics for five specific index conditions, MVC currently offers data for 15 ED-based index conditions, including abdominal pain, asthma, atrial fibrillation, cellulitis, unspecified chest pain, COPD, CHF, deep venous thrombosis, diabetes mellitus (short- and long-term complications), gastrointestinal bleed, pneumonia, pulmonary embolism, pyelonephritis/urinary tract infections, and syncope.

For each of the five index conditions included in the recent reports, hospitals received information on risk-adjusted and price-standardized 30-day total episode payments, same-day inpatient admission rates over time, utilization of healthcare services across the patient’s 30-day episode of care, and each hospital’s most frequent reasons for inpatient readmissions. Patient claims data were included for adult patients aged 18 and older who had an ED visit at a given hospital between 1/1/21 and 8/31/22, were insured by one of the insurance plans mentioned above, and had a primary diagnosis on their index claim matching standardized definitions for the five included conditions.

Among general acute care hospitals receiving a report, the average risk-adjusted, price-standardized 30-day total episode payments (Figure 1) for the five reported conditions were highest for CHF ED-based episodes ($17,455) followed by COPD ED-based episodes ($11,001), and lowest for unspecified chest pain ($3,792). Within each condition, MVC 30-day total episode payments were consistently higher for episodes in which the patient had a same-day inpatient admission compared to episodes in which the patient did not have an inpatient stay begin on the date of their ED visit. With that information in mind, hospital members can also use their individualized reports to track their same-day inpatient admission rate by six-month intervals using trend graphs for each included ED-based condition (Figure 2).

Figure 1.

Figure 2.

A key goal for these ED-based episode reports was to provide insight into healthcare utilization following index ED visits. Therefore, reports included a dot plot (Figure 3) comparing their own hospital’s patient post-ED utilization to that of the appropriate general acute care hospital or Critical Access Hospital MVC comparison group. Dot plots provided information on what percent of episodes had a same-day inpatient admission, what percent did not have a same-day inpatient admission but did see the patient admitted in the 1 to 30 days following the index ED visit, and what percent of patients had two or more inpatient admissions (thus, at least one readmission) during the episode of care. Also provided are rates of subsequent ED visits, receipt of outpatient services, home health, and skilled nursing facility care.

Figure 3.

Please share your feedback with the MVC team if certain report measures were helpful or if you’d be interested in seeing future ED-based episode reporting for certain conditions and metrics. MVC is now also accepting custom report requests using its new ED-based data. Contact MVC to learn more.