Cardiac Rehab -

16 Feb 2024

MVC Celebrates Heart Month, Annual Cardiac Rehab Week

February 16, 2024 | 0 Comments | BMC2, Cardiac Rehab, MiCR

Throughout February’s American Heart Month, the Michigan Value Collaborative (MVC) has and will continue to provide cardiac rehab resources and information on behalf of the Michigan Cardiac Rehab Network (MiCR). This week, MVC also shared content as part of National Cardiac Rehabilitation Week, joining other organizations across the country to promote the benefits of the program and share information on statewide initiatives. As cardiac rehab week comes to a close, MVC is proud to highlight recent activity.

The MiCR partnership was established by MVC and the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2), who have partnered in recent years to support quality improvement and innovation around cardiac rehabilitation participation. Although the strategies and initiatives have changed and expanded over time, the key goal remains: to equitably increase cardiac rehabilitation utilization among eligible patients across the state of Michigan. This week, MiCR sought to educate providers within the BMC2 and MVC collaborative about the benefits of the program, current statewide participation rates, and novel initiatives in place to support improvement.

One product highlighted this week was the MiCR cardiac rehab hospital-level push reports, which benchmark cardiac rehabilitation participation across the collaborative. The 2023 report highlighted significant variation in performance and also demonstrated that several hospitals in Michigan are already successfully reaching or exceeding goals for utilization (Figure 1).

Current MiCR resources, including both hospital-level cardiac rehab benchmarking reports and the MiCR Best Practices Toolkit, were designed to serve members in tracking hospital cardiac rehabilitation utilization and provide guidance to improve enrollment and adherence to the program; however, neither resource specifically investigated patient barriers to participation. To bolster successful referrals to cardiac rehabilitation in Michigan, MiCR recently partnered with Healthy Behavior Optimization for Michigan (HBOM) to launch a new program titled NewBeat. Designed to deliver heartfelt, pragmatic support to new cardiac rehabilitation patients, NewBeat is a multi-component intervention designed to address three common barriers to patient enrollment and participation: lack of education, unclear physician endorsements, and transportation access.

To address the first barrier, MiCR recently launched its website, which houses patient and provider-facing resources, MiCR event dates, and publications in one convenient location. The website already includes features such as a cardiac rehabilitation location finder and unified cardiac rehabilitation resources, but over the coming months will continue to expand.

There is research evidence that strong, personal physician referrals increase the likelihood of cardiac rehabilitation participation. For many patients, in fact, a personal referral is the only reason they sign up. Following the data, NewBeat’s second intervention component is its Cardiac Care Cards, which leverage the influence of cardiovascular providers in encouraging cardiac rehabilitation enrollment in a memorable and personal way. The cards, which can be saved and displayed on kitchen tables and refrigerators, serve as a reminder to patients that the care team understands their recovery process and supports them as they enter cardiac rehabilitation as the next step in their recovery (Figure 2). Hospitals and rehab program staff can request on the MiCR website.

As the initiative continues to develop, NewBeat will grow to include patient success stories, provider-facing videos, and an informational handout on transportation resources.

One of MiCR’s key strategies in promoting the benefits of cardiac rehabilitation is fostering collaboration between providers and program staff. One of these opportunities is through an MVC workgroup series focused on cardiac rehabilitation, with the next session taking place at noon on Thurs., Feb. 22 (Figure 3). The workgroup will include a guest presentation by Devraj Sukul, MD, MSc, Co-Director of MiCR and Associate Director of BMC2 PCI. The presentation will feature recent findings about cardiac rehabilitation liaisons and their impact on patient enrollment. Register here to participate. MiCR also recently sent a save the date for its next stakeholder meeting, which will take place virtually on Fri., April 5, 10-11 a.m.

MVC would like to thank everyone who contributed to Cardiac Rehabilitation Week this year. Advocating for cardiac rehabilitation continues to be a high priority for the MVC team, and the Coordinating Center is inspired by the recent growth and interest in this endeavor. Collectively, by promoting cardiac rehabilitation we can save lives and help patients in Michigan get back on their feet faster. Please contact the MVC team with any questions about attending future cardiac rehabilitation events or receiving related materials.

30 Nov 2023

Cardiac Rehab Michigan Cardiac Rehabilitation Network

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Michigan Cardiac Rehab Network Hosts In-Person Stakeholder Meeting at Trinity Health

November 30, 2023 | 0 Comments | Cardiac Rehab, Michigan Cardiac Rehabilitation Network

The Michigan Value Collaborative (MVC) and the Blue Cross Blue Shield Cardiovascular Consortium (BMC2) recently held a successful 2023 Fall Michigan Cardiac Rehab Network (MiCR) Stakeholder Meeting on Fri., Nov. 17. This was the second in-person MiCR Stakeholder Meeting since MVC and BMC2 founded the MiCR partnership in 2022. The meeting brought together 63 individuals representing 28 organizations and was co-hosted by Trinity Health Ann Arbor’s cardiac rehab team.

The day’s agenda accounted for a variety of topics, including updates and material releases by the MiCR team, presentations and panel discussions about the new MVC and BMC2 pay-for-performance measures for cardiac rehab (see slides), advice and updates about cardiac rehab billing (see slides), recent findings about liaison-mediated referrals and their impact on cardiac rehab participation after percutaneous coronary intervention (see slides), and breakout groups to help brainstorm opportunities within various focus areas.

One unique and memorable aspect of the day was the ability to learn from the meeting’s hosts, Trinity Health Ann Arbor. Professional representatives from the site included Frank Smith, MD, Medical Director of the Intensive Cardiac Rehabilitation Program for the Ann Arbor and Livingston locations, and Mansoor Qureshi, MD, Medical Director of the Cardiac Catheterization Lab and Structural Heart Program for Ann Arbor, who provided opening remarks about the importance of facilitating provider buy-in and referrals. They emphasized cardiac rehab as a key high-value service to improve patient lives. Their slides can be viewed here.

They were also joined by Amy Preston, BS, CEP, Cardiac Rehab Manager and Exercise Physiologist, who organized optional tours of the Trinity Ann Arbor rehab space. Nearly all the meeting’s attendees opted to participate in the tours to learn about the unique spaces and strategies utilized at Trinity.

The MiCR team was also thrilled to announce the launch of New Beat, a multi-component intervention developed in partnership with the Healthy Behavior Optimization for Michigan (HBOM) team (see slides). The New Beat program’s interventions address specific barriers to patient participation, such as gaps in patient or physician knowledge about benefits, the need for stronger physician endorsement, and access issues resulting from transportation barriers. The offerings developed by MiCR and HBOM to support these New Beat strategies include MiCR’s new website (MichiganCR.org), patient- and provider-facing educational materials, cardiac care cards that can be signed by providers and delivered to patient rooms prior to discharge (Figure 1), and an Uber Health pilot. In particular, please note that the interest form on the MiCR website is now open for those interested in accessing these resources or requesting others.

01 Jun 2023

Cardiac Rehab Michigan Cardiac Rehabilitation Network MVC Push Reports

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MVC’s 2023 Cardiac Rehabilitation Reports Shared with Hospitals

June 1, 2023 | 0 Comments | Cardiac Rehab, Michigan Cardiac Rehabilitation Network, MVC Push Reports

Participation in cardiac rehabilitation (CR) programs is a crucial strategy for improving cardiac health outcomes. Participation reduces the risk of all-cause and cardiovascular-specific mortality, reduces readmissions, and enhances the patient’s quality of life. Despite the identifiable benefits, Michigan patients underutilize this high-value program, falling well below the 70% participation goal set by the Million Hearts Initiative. Therefore, the Michigan Value Collaborative (MVC) and several of its partners have identified CR as a high-value service for which they endeavor to drive improvement.

In support of this effort, MVC recently distributed the 2023 version of its CR reports to members with data on CR-eligible patients following discharge for heart attack (AMI), heart valve repair or replacement (TAVR or SAVR), coronary artery bypass procedure (CABG), percutaneous coronary intervention (PCI), and congestive heart failure (CHF). These reports were generated using MVC claims-based episodes of care with patient index admissions between 1/1/19-12/31/21 for multiple insurance plans, including Blue Care Network (BCN) HMO Commercial, BCN Medicare Advantage, Blue Cross Blue Shield of Michigan (BCBSM) PPO Commercial, BCBSM Medicare Advantage, and Medicare Fee-for-Service.

Hospitals received data on a specific procedure or condition if they had no fewer than 20 cases in the reporting period for that condition/procedure. The report pages include figures for a variety of CR metrics, including participation rates after discharge, quarterly trends in participation between 2019-2021, mean days to first CR visit among participating patients, and the mean number of visits completed among participating patients.

MVC generates these hospital-level reports as a product of the Michigan Cardiac Rehabilitation (MiCR) Network, a partnership between MVC, Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2), and the Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative (MSTCVS-QC). The MiCR Network strives to increase participation in CR for all eligible individuals in Michigan.

Given the current status of CR participation across the state, the MiCR Network is tracking progress toward two utilization goals: 1) for 40% of all eligible AMI, TAVR, SAVR, CABG, and PCI (referred to as the “Main 5”) patients to attend at least one CR session within 90 days of their hospital discharge, and 2) for 10% of all eligible CHF patients to attend a single CR session within one year of a CHF-related hospitalization.

In developing these reports, MVC found that the collaborative-wide average participation rate within 90 days of discharge for the "Main 5" procedures was approximately 36%, below the statewide goal of 40%. Similarly, MVC’s analysis found 3.2% of eligible CHF patients participated within 365 days of discharge, 6.8% below the statewide MiCR goal of 10%.

The report also offers patient population demographics intended to help hospitals identify disparities in participation. Research evidence suggests that white males are more likely to utilize CR than women or patients of color, likely due to several socioeconomic and cultural factors. Hospitals are encouraged to consider any gaps showcased in their demographic snapshot and consider the provision of additional, tailored strategies that increase referral and participation among those patients.

Other high-level findings from the report included varying averages in CR participation by the procedure type. CABG and SAVR, more clinically invasive procedures, had the highest utilization rates at 54.9% and 51.3% respectively, whereas patients being treated for the chronic condition of CHF were the least likely to attend (3.2%). There is also wide interhospital variation in utilization rates for each procedure. For example, the collaborative-wide CR utilization rate after PCI is 32%, but hospital rates range from just above 10% to nearly 60% (Figure 1).

This variation aligns with published research on hospital-level variation in CR referral, even after accounting for patient characteristics, insurance status, and clustering within operators and hospitals. It also demonstrates that quality improvement is possible, with multiple sites in the collaborative excelling.

Several of the Collaborative’s top-performing sites and experts worked together last year to develop the MiCR Best Practices Toolkit. It includes several evidence-based strategies for increasing enrollment and participation, with step-by-step guidance and resources. Among the various best practices, there are pages dedicated to automating inpatient referrals, early and flexible scheduling approaches, and strategies that help reduce participation barriers for patients (e.g., lack of transportation, lack of reimbursement for CR sessions, etc.).

MVC encourages those working in this space to save the date for the MiCR Fall Stakeholder Meeting in Ann Arbor on Friday, October 27, from 10 a.m. to 3 p.m. It is a valuable opportunity to connect with peers and experts who can offer support or resources. Please contact the MVC Coordinating Center if you are interested in attending and haven't received the event's Save the Date, or if you would like more details on this report and other upcoming CR events.

26 Jan 2023

Cardiac Rehab MVC P4P MVC workgroup

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MVC Workgroup Planned to Support Members Focused on Cardiac Rehabilitation Rates

January 26, 2023 | 0 Comments | Cardiac Rehab, MVC P4P, MVC workgroup

Next week marks the kickoff of American Heart Month, commemorating the more than 600,000 Americans who die from heart disease each year and raising awareness about strategies that support heart health. Cardiac rehabilitation (CR) is one of those critical strategies, with the second full week of February each year dedicated to promoting its role in reducing the harmful effects of heart disease. In support of efforts to promote this life-saving program, MVC will host a CR-focused workgroup on Feb. 16, from 2-3 p.m., with MVC Co-Director Mike Thompson, Ph.D., assistant professor in the Department of Cardiac Surgery at Michigan Medicine, as its guest speaker. He will highlight some recent efforts to increase patient enrollment.

This is the third time MVC has hosted a workgroup dedicated to CR utilization; the first took place during last year’s CR week in February 2022 and featured guest presenters Steven Keteyian, Ph.D., Director of Preventive Cardiology at Henry Ford Medical Group, and Greg Merritt, Ph.D., patient advocate, in a discussion about strategies for increasing CR use. The second in November 2022 featured Diane Hamilton, BAA, CEP, of Corewell Health Trenton Hospital, who discussed addressing transportation barriers as an obstacle to CR attendance.

CR is a medically supervised program encompassing exercise, education, peer support, and counseling to help patients recovering from a cardiac event, disease, or procedure. There is high-quality evidence that it saves lives and money. A 2016 meta-analysis estimated that for every 37 coronary heart disease patients who attended CR, one of their lives was saved on average. Additionally, the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2) and the Michigan Value Collaborative (MVC) came together recently to measure the impact attributed to CR for percutaneous coronary intervention (PCI) patients treated between 2015 and 2019, and estimated 86 lives saved, 145 readmissions avoided, and approximately $1.8 million in savings.

Despite the evidence in favor of its clinical impact and cost-effectiveness, CR remains heavily underutilized, with only one in three eligible Michiganders participating. MVC’s hospital-level cardiac rehab reports showcase similar findings (Figure 1). These reports were rebranded recently under the new Michigan Cardiac Rehabilitation Network (MiCR) umbrella in partnership with BMC2. They measure whether and when patients started CR at MVC hospitals and how long they kept going. The collaborative-wide average for PCI patients, for example, was 38.3%, with hospital rates ranging from approximately 10%-60%. Such a wide range in patient participation rates suggests MVC member hospitals would benefit from the insights of top-performing peers.

MVC is pursuing several strategies to address this critical gap in utilization. The upcoming Feb. 16 workgroup will be one of several CR-focused workgroups offered throughout 2023. The Coordinating Center decided to offer workgroups on this topic in part because of its recent incorporation of a CR measure into the MVC Component of the BCBSM Pay-for-Performance (P4P) Program. MVC member hospitals were recently asked to make metric selections for the upcoming Program Year 2024-2025 cycle, and as of February 2023 just over one quarter of hospitals elected to be scored on their CR rates for the new value metric component of the MVC measure. These hospitals will receive more P4P points if their CR utilization rate improves over time or is greater relative to their peers. These hospitals are currently treating the patients who will make up their performance year data for Program Year 2024 of the MVC measure. Therefore, MVC aims to offer tailored workgroups to support those sites being scored on CR utilization, most likely incorporating some unblinded data presentations and highlighting key resources and practices for quality improvement purposes.

The MVC team hopes these efforts to facilitate peer learning within the collaborative will help hospitals across the state improve CR participation. Doing so would save the lives of patients and improve the value of healthcare in Michigan. Sites that selected CR as their value metric component of the MVC P4P measure are encouraged to attend; however, anyone interested in this area of healthcare is welcome. Those interested in attending may register here. Please contact the MVC Coordinating Center with any questions at Michigan-Value-Collaborative@med.umich.edu.

01 Dec 2022

Cardiac Rehab MVC P4P MVC Push Reports P4P preoperative testing

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PY 2024-2025 Selection Reports Sent for MVC Component of BCBSM P4P Program

December 1, 2022 | 0 Comments | Cardiac Rehab, MVC P4P, MVC Push Reports, P4P, preoperative testing

Beginning in 2018, Blue Cross Blue Shield of Michigan (BCBSM) allocated 10% of its Pay-For-Performance (P4P) Program to a metric based on Michigan Value Collaborative (MVC) claims data. In 2022, the BCBSM P4P Quarterly Workgroup approved changes to how hospitals are evaluated in future program cycles. The upcoming two-year cycle including Program Years (PYs) 2024 and 2025 will be the first impacted by these changes, with performance years in 2023 and 2024, respectively (see Figure 1). Hospitals received selection reports for the next cycle this week to aid in their decision-making on metrics within the new program structure.

What is staying the same?

The program will continue to be scored out of 10 points maximum, and hospitals will continue to be evaluated on their risk-adjusted, price-standardized total episode payment, though this will make up a smaller component of the overall program. In addition, most conditions hospitals could select previously for episode payment scoring will still be available for that component of the program. Those include chronic obstructive pulmonary disease (COPD), colectomy (non-cancer), congestive heart failure (CHF), coronary artery bypass grafting (CABG), joint replacement, and pneumonia. Additionally, a hospital’s metric selections will continue to be scored on improvement compared to the hospital’s own past performance and scored on achievement related to an MVC cohort. Each hospital will continue to be awarded the greater of the two scores, either improvement or achievement, which are calculated using Z-scores. Cohort designation is still based on bed size, critical access status, and case mix index.

What is changing?

The PY 2022-2023 program was scored out of 10 points, but 12 points could be earned (10 points from episode spending plus two bonus points). In PYs 2024-2025, the overall program structure (Figure 2) will change so that the maximum score will be 10 points, made up of a maximum of four points from an episode spending metric, a maximum of four points from a value metric (a new component), and a maximum of two points from engagement activities completed in the program year (the calendar year following the performance year). This means that rather than selecting two conditions as in previous program cycles, hospitals will now select one condition for the episode spending metric and select one value metric. In order to be eligible to select a payment condition or value metric, a hospital must be projected to have at least 20 cases in the full baseline year of 2021. No bonus points will be available for PYs 2024-2025.

Brand new in PYs 2024-2025 will be value metrics, which are evidence-based, actionable measures that show variability across the state. Hospitals will be rewarded for high rates of high-value services or low rates of low-value services. Seven value metrics are available for hospitals to choose from: cardiac rehabilitation after CABG, cardiac rehabilitation after percutaneous coronary intervention (PCI), seven-day follow-up after CHF, 14-day follow-up after COPD, seven-day follow-up after pneumonia, preoperative testing, and risk-adjusted readmission after sepsis. The preoperative testing value metric is composed of a group of three low-risk procedures: cholecystectomy, hernia repair, and lumpectomy. Each procedure will be scored separately, and points for this value metric will be awarded based on the highest points achieved for a hospital’s eligible procedures.

Finally, engagement in MVC activities will be built into the program’s scoring structure, rather than being offered as “bonus” points. Hospitals will be eligible to earn up to two points by attending and participating in MVC activities throughout each program year. These points are intended to increase engagement with other hospitals and the MVC Coordinating Center. Hospitals may select their own combination of activities but must include at least one activity from each of the attendance and participation categories to earn any points.

The P4P selection reports distributed this week include tables for the various episode spending and value metrics that identify projected case counts, the hospital’s average payment or rate of utilization, the cohort and MVC All average payments or rates, and the projected changes necessary for the hospital to earn 1 – 4 points. Accompanying the reports was an interpretation guide to walk recipients through a blinded sample report. It includes guidance on how to interpret the tables with suggestions for how this data could be used to inform a hospital’s P4P selections. The guide can be viewed here.

A complete summary of changes to PYs 2024 and 2025 is available here. These changes will not be retroactively applied to PYs 2022-2023. For complete details about PYs 2024-2025, please refer to the P4P Technical Document. Contact the MVC Coordinating Center with any questions. MVC requests that member hospitals complete and submit their PY 2024-2025 selections by December 23, 2022.

27 Oct 2022

BMC2 Cardiac Rehab cardiac rehabilitation Michigan Cardiac Rehabilitation Network

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First Annual MiCR Meeting Draws Cardiac Rehab Stakeholders

October 27, 2022 | 0 Comments | BMC2, Cardiac Rehab, cardiac rehabilitation, Michigan Cardiac Rehabilitation Network

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

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

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

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

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

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

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

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

22 Sep 2022

bariatric surgery Cardiac Rehab conference poster opioid prescribing ROIs

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MVC Showcases Recent Work at Obesity Summit, Poster Session

September 22, 2022 | 0 Comments | bariatric surgery, Cardiac Rehab, conference poster, opioid prescribing, ROIs

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.

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).

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.

05 May 2022

BMC2 Cardiac Rehab MiCR

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MVC, BMC2 Launch Michigan Cardiac Rehab Network & Toolkit

May 5, 2022 | 0 Comments | BMC2, Cardiac Rehab, MiCR

This year in the United States, cardiovascular disease will be responsible for one in every four deaths. Despite its prevalence, few cardiac patients eligible for cardiac rehabilitation utilize this life-changing program. In response, the Michigan Value Collaborative (MVC) and the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2) recently established the new Michigan Cardiac Rehab Network (MiCR) to collaborate on efforts that heighten awareness of these programs and support meaningful improvement in Michigan.

Cardiac rehabilitation (CR) is a comprehensive program encompassing supervised exercise, nutrition education, smoking cessation, mental health resources, skills training for heart-healthy lifestyles, and peer support from others who are experiencing a similar life event. It has a Class IA indication for recent cardiac-related events or procedures, meaning there is high-quality evidence that it is beneficial to patients. In fact, individuals who complete the full program of 36 sessions have a 47% lower risk of death and a 31% lower risk of heart attack than those who attend only one session. The evidence is clear that CR extends life and improves quality of life for patients with a recent cardiac-related event or procedure. Unfortunately, only one in three eligible Michiganders participates—a rate well below the Million Hearts nationwide goal of 70% participation.

Using claims data, MVC can assess both initiation and adherence – whether and when someone starts CR, and how long they keep going. There is wide variability in CR rates between MVC’s member hospitals (see Figure 1 for a sample plot from a recent blinded report). The site with the highest rate of cardiac rehab after coronary artery bypass graft surgery (CABG), for example, succeeds at sending 75% of their CABG patients to CR, while another only sends 28% of their CABG patients. This variation shows that it is possible to reach high CR rates, and hospitals can learn from each other to make improvements that save lives and reduce costs.

MiCR was developed for this reason and will work to equitably increase CR participation for all eligible individuals in Michigan. Serving as Co-Directors of MiCR are Mike Thompson, Co-Director of MVC, and Dr. Devraj Sukul, Associate Director of BMC2 PCI. MiCR will distribute regular CR utilization summaries to relevant providers, convene regular meetings with its stakeholder and advisory groups, create resources that help hospitals and CR facilities optimize CR utilization, and continue to leverage the expertise of both CQIs.

In one of its first coordinated efforts, MiCR worked with CR providers and content experts to create a Cardiac Rehab Best Practices Toolkit, which was launched in April. It outlines initiation, maintenance, and innovation strategies for increasing the utilization of CR (see Figure 2 for a sample page). MVC encourages members to turn to this tool as they work to encourage the enrollment of more patients.

The partner CQIs behind MiCR also released new statewide goals for improved CR utilization. Currently, 30% of patients utilize CR following transcatheter aortic valve replacement (TAVR), surgical aortic valve replacement (SAVR), coronary artery bypass graft surgery (CABG), percutaneous coronary intervention (PCI), and acute myocardial infarction (AMI). The first goal is to reach 40% CR utilization for TAVR, SAVR, CABG, PCI, and AMI patients. In addition, only about 3% of congestive heart failure (CHF) patients currently utilize CR. The second statewide goal is a collaborative-wide utilization rate of 10% for CHF patients. Progress on these goals will be shared by MVC in its CR reports sent every six months.

The two CQIs will also continue with their respective activities in the CR space. MVC supports CR participation in two primary ways. One is providing opportunities for MVC members to collaborate, and the second is the preparation of reports using its unique multi-payer data sources. The MVC team supports collaboration through stakeholder meetings and workgroups, which allow sites and clinicians to share solutions for common challenges. The reports MVC prepares analyze member claims data with time-specific hospital-level information on CR enrollment and completed visits within one year of discharge. This allows hospitals to benchmark their performance against peers and identify areas for improvement. MVC will also share unblinded data on CR rates with members at its May semi-annual meeting in one week, which is meant to drive conversation and encourage best practice sharing across the collaborative. The MVC team hopes that its outreach and resources help members to save lives by providing strong endorsements for CR and addressing barriers that may limit patient participation.

For more information on MVC’s CR efforts, visit MVC’s Value Coalition Campaign webpage. For more information about CR, view this MVC video or visit the Million Hearts website. If you have questions about any of the above activities or resources, reach out to the Coordinating Center at michiganvaluecollaborative@gmail.com.

24 Feb 2022

Cardiac Rehab value coalition campaign

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MVC Draws Attention to Cardiac Rehab in Promotional Week

February 24, 2022 | 0 Comments | Cardiac Rehab, value coalition campaign

Every February while the nation honors American Heart Month, a subset of heart health advocates spend one week paying tribute to the lifesaving value of cardiac rehabilitation. Last week the Michigan Value Collaborative (MVC) Coordinating Center joined in on Cardiac Rehabilitation Week by helping to increase awareness and promote MVC’s efforts to improve utilization. Over the course of the week, MVC distributed press releases, published a daily cadence of social media content on Twitter and LinkedIn, and launched a video about the importance of cardiac rehab – all in service of inspiring collaboration in this area.

Cardiac rehabilitation (CR) has a Class IA indication for recent cardiac-related events or procedures, meaning there is high-quality evidence that it is beneficial to patients. In fact, individuals who complete the full program of 36 sessions have a 25% lower risk of death and a 30% lower risk of heart attack than those who attend only one session. It also reduces hospital readmissions and saves thousands of dollars per patient per year of life saved. Nevertheless, CR is widely underutilized, with national utilization rates of only 25-50%. It is for this reason that MVC wishes to equitably increase CR participation for all eligible individuals in Michigan. Throughout CR week, therefore, MVC endeavored to define the value of CR, what it entails, and how the actions of MVC members impact CR participation.

MVC’s role in the CR space is two-fold. One is the preparation of reports using its unique multi-payer data sources, and the second is providing opportunities for MVC members to collaborate. The reports that MVC prepares for members analyze claims data with time-specific hospital-level information on CR enrollment and completed visits within one year of discharge. This allows hospitals to benchmark their performance against peers and identify areas for improvement. There’s a huge amount of variation in CR rates across many dimensions – hospitals, qualifying events, and payers. For example, the hospital with the highest rate of CR after coronary artery bypass graft surgery (CABG) succeeds at sending 75% of their CABG patients to CR, while another only sends 28% of their CABG patients. This variation shows that it is possible to reach high CR rates, and hospitals can learn from each other to make systemic improvements that get more patients into this life-changing (and cost-saving) program.

To support collaboration among its member base of 100 hospitals and 40 physician organizations, MVC hosted a special, one-time workgroup on CR last week as part of its newly launched “Health in Action” workgroup series. This series is meant to drive discussion and collaboration on special topics that rotate throughout the year. Last week’s session featured the expertise of two special voices in the world of CR: Steven Keteyian, Ph.D., Director of Cardiac Rehabilitation/Preventive Cardiology at Henry Ford Medical Group, and Greg Merritt, Ph.D., patient advocate and founder of Patient is Partner. The workgroup was well attended with over 100 guests, who benefitted from informative and inspiring presentations from both speakers.

Dr. Keteyian presented updates on the clinical effectiveness of CR as well as some of the key barriers facing the field. There is high-quality evidence that CR is beneficial to patients on a variety of physiological measures, including improved exercise tolerance, decreased risk of future hospitalization, and decreased cardiovascular mortality. He also reiterated the value of cardiac rehab relative to other recommended cardiac interventions, with CR demonstrating more lives saved per 1000 patients than ACE inhibitors, statins, and other common medications (see Figure 1).

The current quality measures for CR suggest a patient’s time to enrollment should occur within 21 days of discharge, and that the patient should attend at least 36 sessions to receive the greatest benefit. The current goal for CR participation set by the Million Hearts initiative is 70%. However, Dr. Keteyian found that of the CR-eligible beneficiaries, only 28.6% participated and only 27.6% of those participants completed all 36 sessions. This represents a significant utilization gap. While discussing related challenges, Dr. Keteyian suggested that hospitals implement EMR-driven automatic referrals, overt provider endorsements, and an inpatient liaison to bridge the gap between referral and enrollment. He also recommended the use of hybrid CR programs that leverage telehealth to offer remote options.

Dr. Merritt’s presentation included his own personal story of surviving a cardiac event and his ensuing participation in a CR program. Following his experience, he became a “patient questionologist” dedicated to finding opportunities for patient and provider collaboration. His story ultimately led to the founding of an organization called Patient is Partner, which is dedicated to the principles of patient-partnered care. Inspired by the writings of behavioral scientists as well as Why We Revolt by Victor Montori, Dr. Merritt outlined a vision for healthcare innovation that invites patients and their unique perspectives to help solve healthcare’s greatest challenges. He encouraged attendees to join the movement and invite more patient voices to contribute to their respective committees and teams.

At the conclusion of the week, the MVC team had helped its audiences connect to educational materials, data, specialists, former patients, and successful peers in this space. The Coordinating Center is eager to continue this momentum from CR Week in pursuit of a variety of goals for 2022 and beyond. If your hospital or physician organization is interested in improving CR utilization rates, you can learn more about how MVC supports members to increase CR enrollment or reach out directly at michiganvaluecollaborative@gmail.com. You can also view a recording of the full CR workgroup here.

21 Oct 2021

Cardiac Rehab value coalition campaign

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MVC Efforts to Improve Cardiac Rehab Enrollment in Michigan

October 21, 2021 | 0 Comments | Cardiac Rehab, value coalition campaign

Cardiac rehabilitation (CR) is designed to improve cardiovascular function and mitigate risk factors for future cardiovascular events through monitored exercise, patient education, lifestyle modifications, smoking cessation, and social support (1). For over a decade, CR has been a Class I indication in clinical guidelines for patients who have had a heart attack, chronic stable angina, chronic heart failure, or have undergone a percutaneous coronary intervention (PCI), surgical (SAVR) or transcatheter aortic valve replacement (TAVR), or coronary artery bypass grafting (CABG). The evidence supporting CR as a high-value therapy for patients is clear: better long-term survival, fewer secondary cardiovascular events, fewer readmissions, improved quality of life, and lower healthcare utilization (2–6).

Unfortunately, only a fraction of Michigan residents eligible for CR attend a single session following hospitalization for a qualifying condition, with rates as high as 59% for patients undergoing CABG and as low as 4% for patients with congestive heart failure (CHF) (see Figure 1). These data highlight that we as a state are well short of the national goal set by the Million Hearts Initiative of 70% enrollment for all eligible patients. Data from Michigan also suggests wide variation in CR enrollment across hospitals that are not fully explained by differences in patient case-mix (7).

Since 2019 the MVC Coordinating Center sought to equitably increase participation in CR for all eligible individuals in Michigan in partnership with the Blue Cross Blue Shield Cardiovascular Consortium (BMC2) and the Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative (MSTCVS-QC). In an effort to drive improvement in this area across the collaborative’s membership, MVC developed a number of resources and strategies. For example, the MVC Coordinating Center built hospital-level reports that provide members with information on CR enrollment across eligible conditions benchmarked against all MVC hospitals. This week the newest iteration of this CR report was distributed to members. The previous version of the report was sent in March 2021 with a reporting period of 1/1/17 – 12/31/19. The latest version shifted that reporting period by six months (7/1/17 – 6/30/20), included Medicaid episodes for the first time, expanded the time horizon from 90 days to one year, and added information on CHF and acute myocardial infarction (AMI) episodes.

With the addition of CHF and AMI (both “high-volume” MVC conditions), the number of hospitals eligible to receive a CR report doubled from 47 to 95, so many MVC hospitals received this report for the first time this month. The most significant methodological change compared to the previous report was the expansion of the episode window from 90 days to 365 days (one year). Previous reports undercounted the number of CR visits by using the standard MVC episode length of 90 days when a full CR program consists of 36 sessions, which are often not feasible to complete in 90 days. Therefore, it was important to expand the time horizon to achieve a fuller count. The report instead looked one full year beyond the index event (either PCI, TAVR, SAVR, CABG, CHF, or AMI) to calculate CR utilization rates and number of visits.

The MVC team also convened a multidisciplinary stakeholder group of CR practitioners, physicians, and CQI leaders to foster discussion around barriers and facilitators to CR enrollment. Many of the recent changes to the CR reports were a direct result of suggestions from this stakeholder group. Quarterly seminars have also provided opportunities for local facilities to share ongoing quality improvement activities and to learn from national leaders about innovations in the delivery and quality of CR.

More recently, the MVC team conducted virtual site visits with several CR facilities around the state to learn about their programs, the successes and challenges they have encountered, and ways to improve collaboration in Michigan around CR enrollment. Common themes emerged as barriers to CR enrollment, including lack of patient or physician engagement, geographical and/or technological gaps in care between the hospital and CR facility, and insurance coverage and reimbursement. Through collaborative learning and dissemination of best practices, the MVC Coordinating Center believes that its members can begin to address many of these challenges moving forward.

These efforts are all the more important as CR facilities begin to recover from the effects of the COVID-19 pandemic. Many facilities had to reduce capacity and staff as a result of the pandemic, and the number of CR visits declined significantly compared to pre-pandemic months (see Figure 2). While many CR facilities are back to operating at full capacity, continued efforts will be needed to return CR enrollment to pre-pandemic levels. Some sites in Michigan have adopted virtual, home-based, or hybrid versions of CR to continue providing care to patients throughout the pandemic, and its place as a substitute for facility-based CR will require continued exploration that can be supported through collaborative efforts.

Archive

MVC Celebrates Heart Month, Annual Cardiac Rehab Week

Figure 1.

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Michigan Cardiac Rehab Network Hosts In-Person Stakeholder Meeting at Trinity Health

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MVC’s 2023 Cardiac Rehabilitation Reports Shared with Hospitals

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MVC Workgroup Planned to Support Members Focused on Cardiac Rehabilitation Rates

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PY 2024-2025 Selection Reports Sent for MVC Component of BCBSM P4P Program

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First Annual MiCR Meeting Draws Cardiac Rehab Stakeholders

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MVC Showcases Recent Work at Obesity Summit, Poster Session

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MVC, BMC2 Launch Michigan Cardiac Rehab Network & Toolkit

Figure 1. Collaborative-Wide CR Use Following CABG Discharge

Figure 2. Sample Page from MiCR Best Practices Toolkit

MVC Draws Attention to Cardiac Rehab in Promotional Week

Figure 1. Calculating the Value of Cardiac Rehab

MVC Efforts to Improve Cardiac Rehab Enrollment in Michigan

Figure 1. Collaborative-wide CR enrollment rates for qualifying conditions (01/2017-12/2019)

Figure 2. Changes in CR enrollment from 2019 to 2020 over time and by qualifying condition

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