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MVC Service Day Highlights the Impact of Food Bank Partnerships on Healthcare Outcomes

MVC Service Day Highlights the Impact of Food Bank Partnerships on Healthcare Outcomes

MVC staff stepped out of their daily routines recently when they volunteered as a team at a local nonprofit organization. Eager to make this service opportunity as meaningful to their work as possible, MVC staff selected an organization with ties to health and well-being. Last month they were hosted by Food Gatherers, the food bank and food rescue program serving Michigan residents in Washtenaw County. MVC teammates worked together to sort rescued produce in the Food Gatherers warehouse, saving and packing 1,312 pounds of produce for the community.

Though MVC teammates were excited and impressed by that number, it pales in comparison to the amount of food processed by food banks like Food Gatherers, which last year distributed 7.3 million pounds of food — the equivalent of 6 million meals — through its network of partner programs. In order to collect and distribute all those meals, Food Gatherers maintains a working warehouse where an average of nine tons of food are processed each day, and a busy community kitchen prepares and serves hot meals seven days a week. Volunteers play a significant role in these operations.

Produce boxes and other foods that are processed by volunteers eventually find their way into the hands of over 170 community partners, such as food pantries or emergency groceries. In addition to distributing food, Food Gatherers also works to connect beneficiaries to SNAP and other federal food programs and provide innovative food distribution initiatives at area schools and clinics. A new area of focus is the cultivation of partnerships with healthcare providers to further identify and address food insecurity in the community.

Food Gatherers established its Health Care and Food Bank Partnership Initiative to create a connection between local healthcare institutions and Food Gatherers’ network of partner pantries. It was designed to increase access to food for community members in partnership with healthcare providers. Key activities of the initiative include establishing food insecurity screening and referral programs within primary care locations, training medical professionals such as residents and allied health professionals on the role of food security as a key social determinant of health, and drawing attention to the issue of hunger and healthy food access with healthcare providers.

This is a growing area of interest for food banks across the country since food insecurity is closely linked to poor health outcomes and increased risk of chronic disease. According to one study, in fact, the rate of Type 2 diabetes is 25% higher in adults who are food insecure. In addition, as many as one-third of patients with a chronic illness are unable to afford food, medications, or both. A recent publication using MVC data also found strong associations between chronic disease burden and financial outcomes.

Several components of the Food Gatherers Health Care and Food Bank Partnership Initiative were initially supported through a Michigan Medicine grant. Food Gatherers has worked with Michigan Medicine, Trinity Health St. Joseph Mercy Ann Arbor, and IHA as well as with community-based clinics such as the Hope Clinic, Packard Health, and the Corner Health Center. Though the grant ended in 2021, the larger concept of partnership between healthcare providers and community food banks is still an area of interest and opportunity.

"Food Gatherers has been working with our local health care partners to support and encourage the use of food insecurity screening in primary care settings,” said Markell Miller, MPH, Director of Community Food Programs at Food Gatherers. “When providers can identify food insecurity in a patient, they can help connect the individual to resources - specifically SNAP, or if it's an urgent need, a local food pantry. Hunger is a health issue, and when providers talk about food security, they reinforce the connection between nutrition and health, and also destigmatize the experience for individuals facing food insecurity. Our Hunger and Health Training program provides baseline information for physicians on food security as a social determinant of health, and how to support individuals facing food insecurity. We've focused on training medical residents going into careers in primary care, but there is an opportunity to train other providers to increase knowledge and comfort with food insecurity screening and referrals. We look forward to future opportunities to expand our partnership with health care providers, and also continue to seek sustainable funding solutions to support the network of healthy pantries that are available in our community."

Similar programs are also underway at other food banks across Michigan, such as Gleaners Community Food Bank of Southeastern Michigan. In 2015, Gleaners was one of three participating food banks in a two-year randomized controlled research study on the impact of food bank interventions on outcomes for patients with Type 2 diabetes. They have partnerships with the CHASS Center, Covenant Community Care, Henry Ford Health System, the Michigan Health Endowment Fund, the National Kidney Foundation of Michigan, and Trinity Health St. Joseph Mercy Livingston, and have thus far connected more than 500 patients with healthy food.

MVC recently invited Jessica Ramsay, MPH, Director of Wellness and Nutrition Education at Gleaners, to present at MVC’s upcoming chronic disease management workgroup on Thurs., April 20, from 2 - 3 p.m. The presentation will focus on partnerships between healthcare providers and community organizations, highlighting pilot programs and initiatives at Gleaners that improved both patient outcomes and healthcare utilization through reduced food insecurity. Registration for this workgroup presentation is open now.

To learn more about the food banks mentioned, please visit the websites of Food Gatherers and Gleaners Community Food Bank of Southeastern Michigan. Reach out to MVC if your hospital or PO has a similar partnership in place with a community-based organization – MVC would love to highlight this work.

To learn more about the ways in which food insecurity impacts health, check out the video below from Feeding America.

Illuminating Intersections: Hunger and Health (Feeding America)

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

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

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

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

Figure 1.

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

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

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

Figure 2.

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

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

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

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

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

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MVC and MHA Keystone Center Partner to Develop New Statewide Childbirth Outcomes Report

MVC and MHA Keystone Center Partner to Develop New Statewide Childbirth Outcomes Report

The birth of a child is a life-changing experience and a significant clinical event, with those experiencing pregnancy and childbirth hoping for a positive experience and healthy outcome. Yet the maternal mortality rate in the United States was 23.8 per 100,000 live births in 2020, and four in five pregnancy-related deaths were preventable according to the CDC. One in four of these deaths occur on the day of delivery or within one week, with considerable evidence that negative outcomes are more likely for patients of color. These findings are evidence of the need for quality improvement initiatives that ensure all people who are pregnant or postpartum receive the care they need. In light of this, the Michigan Value Collaborative (MVC) recently collaborated with the Michigan Health and Hospital Association (MHA) Keystone Center on the development of a statewide report on birth outcomes.

MVC claims data comprise approximately 84% of Michigan's insured population; these data are processed into 30- and 90-day price-standardized and risk-adjusted episodes of care that allow MVC to identify practice variation and measure the value of care. MVC creates episodes for over 40 medical and surgical conditions, including vaginal and cesarean childbirth delivery. MVC used a subset of claims from its data on Michigan childbirth episodes to create this new statewide report. The goal was to highlight statewide disparities in care and support the MHA Keystone Center and the Michigan Alliance for Innovation on Maternal Health (MI AIM) in their efforts to increase equitable care and decrease preventable severe maternal morbidity and mortality in Michigan.

MVC’s new statewide childbirth episodes report provides information on total episode payments, mode of delivery, patient characteristics, and rates of certain birth-related complications using 90-day episodes of care for vaginal and cesarean delivery. Measures in this report are based exclusively on Blue Cross Blue Shield of Michigan (BCBSM) PPO Commercial episodes for childbirth index admissions that occurred at MVC-participating hospitals between 1/1/19 and 12/31/21. Hospitals in this report were unidentified and each was required to have a minimum of 20 childbirth episodes across the reporting period to be included. Similarly to other MVC reports, several metrics were displayed by the index hospital’s geographic region of Michigan as categorized by MVC (see MVC regions here), with others stratified by race or mode of delivery.

The analysis found an average price-standardized, risk-adjusted 90-day total episode payment of $7,765 for vaginal delivery and $10,264 for cesarean delivery (Figure 1), with average index lengths of stay of 3.1 and 4.0 days, respectively. Additionally, the overall rate of cesarean delivery was 32.3% in July-Dec. of 2021, a slight increase compared to cesarean rates in 2019 and 2020 (Figure 2).

Figure 1. Average Price-Standardized and Risk-Adjusted 90-Day Total Episode Payments by Mode of Delivery, Overall and by Hospital

Figure 2. Rates of Cesarean Delivery, 2019 Through 2021, Overall and by Region of Michigan

Overall, 7.5% of patients had a diagnosis of hemorrhage, 4.2% had a diagnosis of hypertension, and 1.8% had a diagnosis of severe maternal morbidity (SMM) during their index birth hospitalization. A notable finding was the difference in rates of these complications by race (Figure 3). Patients who were identified as Asian or Pacific Islander had higher rates of hemorrhage than other race categories, and patients who were identified as Black had higher rates of hypertension and SMM than the overall population. This is consistent with other research findings related to disparate health outcomes for non-white patients.

Figure 3. Rates of Hypertension, Hemorrhage, and Severe Maternal Morbidity (SMM), Overall and by Race

Health disparities such as these are an area of focus within the MVC Coordinating Center’s broader strategic framework. MVC’s health equity sub-committee meets regularly to strategize how to emphasize equity among its membership and support related quality improvement initiatives. The Coordinating Center’s aim is to use MVC data to help members identify areas of opportunity and support quality improvement through collaboration with peers. To this end, MVC is currently developing a hospital-level adaptation of the new statewide birth outcomes report to share site-specific data with its members later this year.

“Claims data such as those included in MVC’s episodes of care present a great opportunity to use state-wide data to highlight important findings and disparities related to birth outcomes in Michigan,” said Kristen Hassett, the lead MVC analyst for the analysis. “This report represents an important step in MVC’s work to identify areas of health inequality and then support initiatives to reduce those disparities.”

For the MHA Keystone Center, the statewide report provides valuable data to further inform its work.

“We are proud to partner with organizations like the Michigan Value Collaborative to collect and examine critical data related to childbirth within Michigan health systems,” said Sarah Scranton, vice president of safety and quality at MHA and executive director of MHA Keystone Center. “By evaluating hemorrhage, hypertension and severe maternal morbidity rates across several regions of the state, we are able to address the challenges facing Michigan mothers and birthing centers.”

The MVC statewide childbirth episodes report will aid MHA’s field engagement team while they engage with hospitals not yet partnering with MI AIM. Since its adoption in Michigan in 2016, MI AIM has contributed to significant improvement in hemorrhage-related SMM, hypertension-related SMM, and overall SMM through the implementation of hemorrhage, hypertension, and sepsis patient safety bundles with Michigan birthing hospitals.

To view the complete report, visit the MVC website. The Coordinating Center welcomes any additional questions about the report findings or any custom report analyses inspired by its creation. Contact the MVC team at Michigan-Value-Collaborative@med.umich.edu.

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Distressed Community Index Data Supplements MVC Equity Work

Distressed Community Index Data Supplements MVC Equity Work

Emphasizing health equity in Michigan is a key strategic initiative for the Michigan Value Collaborative. MVC kicked off this strategic initiative at its October 2021 semi-annual meeting with the theme of “The Social Risk and Health Equity Dilemma.” Since then, MVC has expanded its access to data sets related to health equity, developed hospital health equity reports, and regularly convened stakeholders from around the state via a health equity workgroup series that launched in January 2022. MVC is eager to find new and exciting ways to utilize data and collaborate with members on health equity topics in Michigan.

One of the more recent enhancements to MVC’s capacity was the addition of more granular data on social determinants of health. MVC secured access to Distressed Community Index (DCI) data, a tool for measuring the comparative economic well-being of US communities. DCI data was first integrated into MVC reporting in August with the distribution of a new push report on emergency department and post-acute care use. It was also incorporated in MVC’s newest physician organization report on chronic obstructive pulmonary disease, which was distributed to PO members last month.

The DCI data are developed by the Economic Innovation Group and derived from the US Census Bureau’s Business Patterns and American Community Survey Five-Year Estimates (2016-2020). The DCI is a composite measure of ZIP-code level socioeconomic distress comprised of seven key indicators, including education, housing, unemployment, poverty, income, employment changes, and business (see Figure 1).

Figure 1.

The resulting DCI composite measure assigns individual five-digit ZIP codes a number from 0 to 100 with 0 representing the least distressed communities and 100 representing the most distressed communities. The DCI is then grouped into five ordered categories for ease of comparison: distressed, at risk, mid-tier, comfortable, and prosperous. The data include details on 874 ZIP codes in Michigan that have at least 500 residents, of which 192 (22%) are prosperous communities and 120 (14%) are distressed communities. The map below (see Figure 2) highlights the distribution of community-level distress categories across the state of Michigan, with the blue areas representing more prosperous communities and the red areas representing more distressed communities.

Figure 2.

The data also reveal staggering racial/ethnic disparities in Michigan. As seen in Figure 3 below, Black/African American Michiganders are far more likely to live in distressed communities relative to non-Hispanic whites. This information is further evidence of the need for broad efforts to reduce disparities according to race/ethnicity and local community distress.

Figure 3.

Incorporating the DCI into MVC data analytics will offer new opportunities to better understand health equity challenges in Michigan. The MVC Coordinating Center looks forward to using these data in collaboration with its members and is eager to discuss how best to leverage such data sets to identify inequity in Michigan healthcare. Please contact MVC to learn more or request custom analytics.

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BCBSM Initiative Incentivizes Data Collection on Social Factors

BCBSM Initiative Incentivizes Data Collection on Social Factors

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

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

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

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

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

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

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

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

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

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

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

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

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Unique Food Assistance Program Bridges Medical and Food Sectors

Unique Food Assistance Program Bridges Medical and Food Sectors

MVC hosted another successful session of its new health equity workgroup last week with a guest presentation by Ariane Donnelly, MPH, RD, Health Promotion Coordinator at the Washtenaw County Health Department. The new health equity workgroup was established in response to a greater strategic focus on health equity within the MVC Coordinating Center as well as widespread interest in this topic within the healthcare field.

The March 16 workgroup focused on the Prescription for Health program, which takes a unique approach to chronic disease management by connecting the medical system with the food sector. It operates by having participating healthcare providers assign “prescriptions” to their patients to eat more fruits and vegetables. These prescriptions can then be “filled” at local participating farmers markets, where patients receive $100 in tokens to spend on fresh fruits and vegetables as well as nutrition education and support. Participants also work with Community Health Workers to set health goals. The program leverages the fact that Michigan is the second most agriculturally diverse state in the country, and its abundant farmers markets can be an asset in supporting healthy lifestyles for patients.

Evaluation of the program’s effectiveness has been fruitful. For every year of the program, the health department found a statistically significant increase in self-reported fruit and vegetable intake, often by one cup or serving per day (see Figure 1).

Figure 1.

The program was first created in 2008 in response to high levels of food insecurity within communities in Washtenaw County combined with generally low consumption of fruits and vegetables, both of which are associated with an increased risk of chronic disease. Ms. Donnelly pointed out that while many clinics provide nutrition advice, patients face multiple barriers to equitably accessing healthy foods and need additional support. Since its first pilot, the program has continued to grow in total enrollees and economic impact, and it maintained its participation levels throughout the pandemic with a modified version of the program.

Similar programs are in operation in other parts of the state and country as well, such as Food Rx in Chicago and Fresh Prescription in Detroit. Washtenaw County’s Prescription for Health program launched an implementation toolkit in 2016 to help others with starting a similar program in their area.

To learn more about the Prescription for Health program’s operations, impact, and lessons learned, watch the full recording of the workgroup here: https://bit.ly/3IyIsnS. You can also visit the program website for more information: www.washtenaw.org/prescriptionforhealth.

MVC will continue to invite guest speakers with valuable insights on a more equitable health system. The next MVC health equity workgroup will take place on Tuesday, May 10, from 1-2 p.m. If you would like to suggest a topic or speaker for a future workgroup, please contact the MVC Coordinating Center at michiganvaluecollaborative@gmail.com.

Prescription for Health is funded by Saint Joseph Mercy Health System with additional financial support from multiple partners.


Health Equity Report Refreshed with New Data and Demographics

With an enhanced strategic focus on health equity, the MVC Coordinating Center was excited to share refreshed versions of its health equity push report this week. The health equity report was first launched in August 2021 in response to growing interest from members as well as widening gaps in health outcomes for patients with a lower socioeconomic status. The purpose of the report is to help members better understand their patient population, and the newest version re-examines some of the original findings. It also adds data to help providers identify the most impacted patients and understand how their care differs from patients with a higher socioeconomic status.

The report distributed this week provided a comparison of Medicaid patients to Blue Cross Blue Shield of Michigan (BCBSM) and Blue Care Network (BCN) patients, whereas the first iteration compared outcomes of dual-eligible versus non-dual-eligible Medicare patients. Therefore, one change from the previous report is that the patients included are much younger on average. This report incorporated index admissions from 1/1/2018 – 9/30/2021 for BCBSM PPO Commercial and BCN HMO Commercial and from 1/1/2018 – 12/31/2020 for Medicaid. Members who received reports will see comparisons between these two groups for total episode payments, length of stay, 30-day readmission rates, 30-day post-discharge emergency department utilization, and 30-day post-discharge office visit rates.

Despite utilizing different payer data, insurance type was still a good predictor of health outcomes in the report. The Coordinating Center continued to see poorer outcomes across the board for those patients who were publicly rather than privately insured – a finding that is consistent in the research literature as well. These disparities were most pronounced among medical conditions than surgical procedures.

This report continued to look at post-acute care trends but narrowed its focus to office visits specifically. This is because there were significant differences in office visit rates by insurance type in the previous report and skilled nursing facility use was much less relevant within this report's younger patient population. When looking at office visit utilization, the rates were significantly different between BCBSM/BCN and Medicaid patients for both medical conditions (see Figure 1) and surgical procedures. However, the disparity was more pronounced in medical conditions. MVC saw a decrease in office visits in early 2020 across the state that is believed to be related to the pandemic, but visits returned to pre-pandemic rates in the latter half of the year. Furthermore, episodes were excluded from this report if they contained a confirmed diagnosis code of COVID-19 in the first three diagnosis code positions of any inpatient facility claim.

Figure 1. Office Visit Trend Graph from Blinded Report

Another key change to the report was the addition of a patient population demographics table (see Figure 2), which provides the hospital with age, race, zip code, and comorbidity information for Medicaid versus BCBSM/BCN patients. Overall, the most common comorbidity across the state was diabetes, and the Medicaid population was younger on average.

Figure 2. Demographics Table from Blinded Report

Like the first version of the report, there was a conscious decision to exclude comparison groups. This is because the socioeconomic factors of a hospital’s patient population cannot be changed, and there is great diversity between hospitals throughout the state and within geographic regions. For those reasons, benchmarking was not the intention of this report. However, it is important to note that across the state, the data analyzed by the MVC Coordinating Center consistently indicates that Medicaid patients have poorer outcomes than privately insured patients, including longer lengths of stay, higher readmission rates, higher post-discharge emergency department utilization, and lower rates of office visits post-discharge.

The MVC Coordinating Center is eager to support members in improving health equity. Please consider sharing feedback on this report with the Coordinating Center, as well as attending MVC’s newest workgroup on health equity to learn and share with peers. If you have any questions, comments, or suggestions, please contact the Coordinating Center at michiganvaluecollabortative@gmail.com.

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New Health Equity Workgroup Has Successful Launch

New Health Equity Workgroup Has Successful Launch

Health equity has captured the attention of healthcare. It was a top trend for healthcare providers in 2021, and surveys indicate it will be one of the main priorities for large healthcare employers in 2022. It is also a key strategic focus of the MVC Coordinating Center in the years ahead. As such, MVC is building out offerings for its members in this space, which began with the launch of its new health equity report and was followed by a semi-annual meeting dedicated to the topic in October 2021. Most recently, MVC launched a new health equity workgroup, which will continue to meet on a bimonthly basis in 2022.

The first health equity workgroup took place this week featuring speakers from the MSHIELD (Michigan Social Health Interventions to Eliminate Disparities) collaborative—one of the newer teams in the Blue Cross Blue Shield of Michigan Collaborative Quality Initiative (CQI) portfolio. MSHIELD Co-Director Dr. John Scott co-presented with MSHIELD Program Manager Carol Gray. They were joined by 72 attendees representing hospital teams, physician organizations, fellow CQIs, and other areas. The presentation focused on the role of MSHIELD in addressing social risk factors in healthcare as well as members’ approaches to health needs screening, referral, and linkage.

The social determinants of health (SDOH) have a tremendous impact on patient health outcomes, resulting in Healthy People 2030 naming it one of its five priorities. With thousands of journal articles confirming the impact of the SDOH, there is now a shared understanding across healthcare providers that this area is a priority. In fact, it affects patient health outcomes significantly more than clinical care (see Figure 1). MSHIELD’s presenters highlighted this fact and used it as an opportunity to define a common language for the discussion. They said health equity is achieved when every person can attain their full health potential and no one is disadvantaged from achieving this because of socially determined circumstances.

Figure 1. Graphic from MSHIELD Presentation

MSHIELD will serve as a link between the healthcare system, the community resources that can reliably serve patients’ social needs, and the communities that are home to those patients. To that end, MSHIELD will help establish partnerships with key healthcare and community entities and promote the exchange of data and services in a way that helps achieve health equity.

Unlike some of the “legacy” CQIs that are clinically focused, MSHIELD will fill a consulting role with other CQIs to help them set and meet goals related to health behaviors and social needs. Since health equity is a multi-faceted issue affecting all areas of health, MSHIELD also has an unlimited population and practice focus. For the time being, however, the speakers identified that MSHIELD is particularly interested in food access, housing instability, and transportation since those are areas with the strongest evidence for impact in a clinical setting.

MSHIELD’s presenters also summarized their findings from an environmental scan of the larger CQI portfolio. Last year they surveyed the other CQIs in the BCBSM Value Partnerships portfolio to identify what types of SDOH data they may collect and how. Of the 16 SDOH domains (see Figure 2), MSHIELD found that almost all CQIs collect data on demographics, insurance status, and health-related behaviors. However, only three CQIs currently collect data related to material hardship (e.g., food insecurity, housing insecurity, transportation, medication affordability, access to technology, childcare, etc.). MSHIELD hopes to help build on what has been collected so far and assist providers and CQIs alike in their pursuit of health equity initiatives.

Figure 2. Domains of the Social Determinants of Health from MSHIELD Presentation

The workgroup concluded with an active discussion about current practices and challenges experienced by providers in identifying, referring, linking, and following up with patients. Representatives from physician organizations and hospitals alike shared examples about how they integrate screening and capture this data, which led to conversations about the technologies used to assist with this process and the value of universal versus targeted screening strategies. Most of the participants who shared their experience expressed that whichever strategy they adopted, there were efforts to make the screening questions accessible for those with language or literacy barriers. Examples of this that were provided by members included translating materials to common languages from their local community and utilizing the professional abilities of social workers on site. There were also discussions about how to best identify resources within a given community for the purposes of referrals, with some thoughtful suggestions about partnering with community health needs assessment teams and social workers from within hospitals.

To hear the full discussion and learn more details about MSHIELD, the full recorded workgroup can be viewed here. MVC looks forward to continuing this health equity conversation on March 16. Register for the next MVC health equity workgroup here. If you would like to receive future MVC workgroup invitations or you have an idea for a future speaker, please contact the Coordinating Center at michiganvaluecollaborative@gmail.com.

Speaker Biographies:

Dr. Scott is an Assistant Professor of Surgery in the Division of Acute Care Surgery at the University of Michigan. His health policy and health services research interests are focused on improving access to timely, affordable, high-quality surgical care for the acutely ill and injured.

Carol Gray leads the overall management, performance, and coordination of the MSHIELD program and team. She has extensive experience managing public health research teams, communicating across and coordinating with multiple partnerships, and linking and engaging with community-based organizations.


Special Consideration Needed for Older Patients Using Telecare

When most people think about healthcare, the images that come to mind include a trip to their local provider’s office, lab, or hospital for services such as physicals, blood tests, and procedures. However, medical professionals and their patients are increasingly transitioning to more remote services that leverage our advances in communication technologies, resulting in the burgeoning “tele” world of healthcare. But are these services reaching everyone?

Telemedicine, telehealth, and telecare are three examples of remote, interactive services that allow patients to receive healthcare from within their own homes. Although these terms are often used interchangeably, they in fact refer to different aspects of healthcare delivery. Telemedicine applies to physicians who use technology to support the delivery of medical, diagnostic, or treatment-related services. Telehealth is like telemedicine but applies to a broader collection of providers, such as nurses or pharmacists. Telecare (see Figure 1) is generally more consumer-oriented by providing the patient with technology to manage their own care safely from home, such as health apps or digital monitoring devices.

Figure 1. Telecare Slide from MVC Workgroup Presentation

The adoption of “tele” services saw incredible growth in 2020 in response to the pandemic. A report found that Medicare telehealth visits increased 63-fold recently, from 840,000 in 2019 to 52.7 million visits in 2020. However, now that adoption of these services (and the platforms needed to host them) are more commonplace, providers are asking whether it benefits their most vulnerable patients and who may be left behind.

These questions drove the discussion of the most recent MVC workgroup on chronic disease management. Over the course of the session, attendees were particularly interested in how telecare improves elderly care, and whether patients over the age of 65 could adequately access such services. For those older adults utilizing telecare, evidence from the ongoing COVID-19 pandemic identified convenience and affordability as telecare’s primary strengths. In addition, research evidence suggests that the two most effective telecare interventions in this population are automated vital sign monitoring and telephone follow-up by nurses.

Some of the challenges often cited for this population include lack of appropriate internet access or devices, limited digital literacy, medical conditions that may impede participation (i.e., hearing or vision impairments, dementia, etc.), and the need to regularly monitor vitals in very high-risk patients. Although the authors compiling these challenges specifically reference older adults, they could just as easily apply to people experiencing poverty, people with disabilities, and people with more limited language and literacy skills.

Some recommended strategies to address common challenges include tablet delivery services, “mobile medical assistants” who perform video set-up for the patient, assistance from an on-site caregiver, practice or “mock” video visits prior to the appointment date, partnerships with community health workers to support or train patients in their homes, and providing self-monitoring devices. Other simple considerations include the size of the text displayed on the page (use larger text to enhance readability), providing adequate instructions in advance and in multiple languages, and engaging experts in user experience design.

In addition to these considerations, some researchers suggest that, in general, the adoption of new technologies can be predicted in part by Everett Rogers’ Diffusion of Innovation Theory. One study incorporating this theory found that the chances of telecare adoption were highest for three types of older adults: those already receiving long-term or nursing care, those living alone, and those who have fixed daily telecare points of contact.

Increased integration of technology in healthcare is inevitable as advancements continue and we shift to a more digital world. Since the number of people in the U.S. who are age 65 or older will more than double over the next 40 years, it is imperative that older adults are not left behind when transitioning to such services. Rather than fear the challenges, researchers and practitioners are seeking ways to find solutions and help all patients benefit from healthcare access within their own homes.

The MVC Coordinating Center encourages its members to collaborative with one another to benefit from peers’ success stories and lessons learned. If your hospital or physician organization has developed an age-friendly telecare protocol, please consider sharing your story with the MVC Coordinating Center at michiganvaluecollaborative@gmail.com. To catch up on the recent MVC workgroup discussion about telecare, watch the chronic disease management workgroup recording here.

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Patient-Reported Outcomes Improve Quality, Equity of Care

Patient-Reported Outcomes Improve Quality, Equity of Care

For several years, patient-reported outcomes (PROs) have been a topic of interest, in part due to increased utilization of electronic data and the integration of delivery systems. PROs are defined by the Food and Drug Administration (FDA) and National Quality Forum as "any report of the status of a patient's health condition that comes directly from the patient, without interpretation of the patient's response by a clinician or anyone else." In short, PRO tools ask patients questions to measure how they feel and what they are experiencing. With patient-reported outcome measures (PROMs), patients provide information about their health, quality of life, and functional status, either in absolute terms (e.g., pain severity rating) or in response to treatment changes (e.g., new nausea onset). The goal of gathering this information from the patient’s perspective without any interpretation from a healthcare provider is to improve both the quality of care being delivered and health outcomes.

The use of PROs has a variety of potential benefits. They can elicit enhanced patient engagement, be used to clarify the patient’s priorities and thus improve shared decision-making between patients and providers, and can bring to light any benefits or harms of interventions. The potential impact of PROs, therefore, is substantial because involving patients in their healthcare is linked to a myriad of positive patient outcomes. For example, based on a review of studies investigating patient participation, some of the benefits to patients include:

  • increased satisfaction and trust,
  • empowerment,
  • greater self-efficacy to manage health,
  • higher quality of life,
  • better understanding of condition and personal requirements,
  • improved adherence to medical treatment plans,
  • improved communication about symptoms with positive and lasting effects on health.

Ever increasing in its availability, the use of PROs is included in clinical investigations, healthcare practice, healthcare management, and various regulatory or reimbursement areas. As the patient continues to become more central to healthcare, they are in the best position to determine if their healthcare objectives have been achieved. PROMs are not the same as measures reported by patients on their experience of the healthcare system, such as being treated with dignity or waiting too long; however, patient-reported outcome-based performance measures (PRO-PMs) are beginning to find their way into healthcare and may integrate such measures. To help understand the relationship between PROs, PROMs, and PRO-PMs, see Figure 1, which was designed by the Centers for Medicare and Medicaid Services (CMS) in their supplemental guide on PROMs.

Figure 1.

To gather PROs, the tools and instruments known as PROMs must measure criteria that are identifiable, valid, and reliable. Most often these are general or disease-specific self-completed questionnaires, scales, or single-item measures that provide a score for any of the following:

  • functional status,
  • health related quality of life,
  • symptom and/or symptom burden,
  • personal experience of care,
  • health-related behaviors.

Generic PROMs often delve into areas covered by a variety of different conditions, allowing for comparisons across multiple medical conditions. These PROMs help with evaluation and implementation of care provision methodology and equality of service delivery. Some may even provide a cost-effectiveness component. Disease-specific PROMs identify the impact of definitive symptoms on the condition. PROMs can be used as either the primary or secondary outcome measure of a study or trial, and most studies use a combination of disease-specific and generic PROMs.

Measurement tools integrate other existing data (biological, genetic, clinical, and physical) to assess how a patient is functioning regarding their overall health, quality of life, mental well-being, or satisfaction with a healthcare process. Using all these data sources provides a more complete picture of the patient’s health journey and allows for patients and their providers to share decision-making and define individualized care. They also provide a unique opportunity to identify inequalities in healthcare access and treatment.

When utilizing PROMs, practitioners must plan for how the information will be collected and utilized. PROMs can be collected in a variety of ways, including face-to-face interviews, online or paper questionnaires, telephone interviews, or diaries. When deciding which PROMs to utilize, it is important to consider the preferences of patients, providers, and any other involved decision-makers. It is also essential to consider the cognitive, physical, demographic, and socioeconomic barriers that may exist for the patient to ensure they have adequate accommodations to participate. The length, schedule, and timeframe of assessments should also be appropriately assessed, along with any permissions needed to use the information. Lastly, the PROMs should be easy to score and interpret, actionable, and able to facilitate clinical decisions.

The use of PROs is here to stay. The hope is that improvements in interoperability, data governance, security, privacy, and ethics will allow greater integration of PROs. In turn, PROs will allow patient preferences, needs, and health outcomes to further drive value-based healthcare.