28 Sep 2023
0
View Post
MVC’s 2023 Chronic Disease Management Follow-Up Reports Coming to Members Soon

MVC’s 2023 Chronic Disease Management Follow-Up Reports Coming to Members Soon

September 28, 2023 | 0 Comments | ,

MVC will soon distribute the 2023 version of its chronic disease management follow-up reports to members. This refreshed version provides summary data on patients eligible for follow-up care after discharge from hospitalizations for congestive heart failure (CHF) or chronic obstructive pulmonary disease (COPD).

MVC defines timely follow-up care as receipt of an in-person or remote outpatient follow-up visit within 30 days of hospital discharge to home or home health care and before any readmission, emergency department (ED) visit, or procedure. Patients admitted to a skilled nursing facility, long-term acute care hospital, or inpatient rehab within the 30-day episode were excluded. MVC’s follow-up analyses was performed using claims-based episodes of care with index hospital admissions between 7/1/2019 and 06/30/2022 for Blue Cross Blue Shield of Michigan (BCBSM) PPO Commercial and Medicare Advantage (MA), Blue Care Network (BCN) HMO Commercial and MA, and Medicare Fee-for-Service insurance plans. For each of the two chronic conditions included in the report, hospitals with at least 11 episodes per year for a given condition received that condition-specific data.

The report offers a comparison of demographic characteristics for CHF and COPD patients who received a follow-up visit within 30 days versus those who did not receive follow-up. Demographic characteristics tabulated for each condition include the percent of patients living in “at-risk” or “distressed” Zip codes as defined by the Economic Innovation Group’s Distressed Community Index, patients’ average number of comorbidities, the mean age of patients, and the distribution of race and ethnicity. MVC recently refined and expanded its reporting of race and ethnicity identities, and these updates were reflected in the report. Patients are grouped as Hispanic if their insurance provider categorized their combined race/ethnicity as Hispanic or their ethnicity as Hispanic. Additionally, MVC no longer combines smaller groups and discontinued its use of the terms “other” and “unknown.”

On the first page provided for each condition, hospital follow-up rates are provided for three windows of time compared to those at other MVC hospitals (Figure 1), as well as trends over time for each follow-up window (Figure 2). For CHF, follow-up rates are provided in 3-day, 7-day, and 14-day time windows. For COPD, follow-up rates are provided in 7-, 14-, and 30-day time windows.

Figure 1.

Figure 2.

The second page of condition-specific feedback includes a summary of average 30-day risk-adjusted, price-standardized total episode payments by follow-up status compared to statewide and regional averages. Among general acute care hospitals included in the analysis, the statewide total average payment for CHF episodes was $17,235 for patients who received follow-up and $20,069 for those who did not; for COPD episodes, the statewide average payments were $13,815 among those with follow-up and $16,056 among those without. In reports generated for Critical Access Hospitals (CAHs), payments were compared to averages across all MVC CAH members. Rates of 30-day follow-up were also compared by payers across the same groups.

The final figure (Figure 3) in the report for each condition is a summary of follow-up method among those who received any follow-up care. Patients who received follow-up were categorized as having received only in-person follow-up visit(s), only remote follow-up, or both in-person and remote follow-up. MVC found that more than 80% of CHF and COPD patients statewide exclusively received in-person follow-up after a hospitalization.

Figure 3.

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

03 Aug 2023
0
View Post
MVC Develops PO Post-Discharge and ED-Based Episode Reports

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

August 3, 2023 | 0 Comments | ,

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

PO ED-Based Episodes Report

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

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

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

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

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

Figure 1.

PO Skilled Nursing Facility & Home Health Report

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

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

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

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

Figure 2.

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

Figure 3.

Figure 4.

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

Figure 5.

Figure 6.

New Report Distribution Process

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

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

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

20 Jul 2023
0
View Post
MVC Calls Attention to Research, Resources During Week-Long Preoperative Testing Campaign

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

July 20, 2023 | 0 Comments | ,

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

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

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

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

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

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

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

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

Figure 1.

Figure 2.

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

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

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

15 Jun 2023
0
View Post
MVC’s SNF and HH Push Report Latest in Post-Discharge Insights

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

June 15, 2023 | 0 Comments | , ,

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

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

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

Figure 1.

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

Figure 2.

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

Figure 3.

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

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

Figure 4.

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

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

07 Jun 2023
0
View Post
MVC Uses New ED-Based Episode Data in Latest Push Report

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

June 7, 2023 | 0 Comments | , ,

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

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

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

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

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

Figure 1.

Figure 2.

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

Figure 3.

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

01 Jun 2023
0
View Post
MVC’s 2023 Cardiac Rehabilitation Reports Shared with Hospitals

MVC’s 2023 Cardiac Rehabilitation Reports Shared with Hospitals

June 1, 2023 | 0 Comments | , ,

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).

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.

27 Apr 2023
0
View Post
Latest MVC Push Reports and Resources Draw Attention to Low-Value Preoperative Testing

Latest MVC Push Reports and Resources Draw Attention to Low-Value Preoperative Testing

April 27, 2023 | 0 Comments | ,

This week MVC distributed its first of two preoperative testing push reports of 2023, providing members with an opportunity to benchmark their testing practices. MVC first introduced its preoperative testing push reports in 2021 to help members reduce the use of unnecessary testing for surgical procedures. Preoperative testing for low-risk surgeries, especially for young and healthy patients, often provides no clinical benefits yet is ordered regularly at hospitals across Michigan.

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

The latest report utilizes claims from Blue Cross Blue Shield of Michigan (BCBSM) and Blue Care Network (BCN) plans exclusively, including both the commercial and Medicare Advantage plans. This allows members to see MVC’s most up-to-date data, which includes episodes with index admissions from 7/1/2020 through 6/30/2022. Members only received reports if they had 11 or more cases in at least one of the three conditions and at least 20 cases across all three conditions.

The reports received by members this week included a patient snapshot table that defined rates for preoperative testing and no preoperative testing in patients of varying races as well as those with zero, one, or two or more comorbidities. Generally speaking, patients with no comorbidities were more likely to have no preoperative testing than patients with one or more comorbidities. There were also observed differences in testing by age; patients who had preoperative testing were older on average than patients who had no preoperative testing.

A key finding in the report is the average testing rate for all three procedures combined for the entire collaborative, which continues to showcase the wide variability across hospitals in Michigan. Some in the collaborative have an average testing rate close to 10% and some nearly 100% (Figure 1). Individual hospitals receiving a report will see on this figure where they fall compared to other hospitals in the collaborative, as well as their average rate for the three separate procedures to help deduce which procedure is driving their average rate.

Figure 1.

Another trend that continued in this April 2023 report is the consistency of average testing rates for combined procedures over time. A trend graph showed members how their overall rate for any preoperative testing compared in 2020, 2021, and the first half of 2022, with data points for their hospital, the MVC average, and their regional comparison group (Figure 2). There continues to be very little change in testing rates over time when looking at aggregated preoperative testing practices. The prevalence of low-value preoperative testing has remained high on average across the collaborative for three years and likely longer.

Figure 2.

A third figure included in this report shows the absolute change in the rate of any preoperative testing for their hospital’s highest volume surgical condition among laparoscopic cholecystectomy, laparoscopic inguinal hernia repair, and lumpectomy (Figure 3). In this figure, positive values represent an increase in annual preoperative testing from 7/1/2020 to 6/30/2022, and negative values represent a decrease. The MVC average for this metric was -2.3%, so there was a small net decrease in the average rate of any testing in that time period. Once again, the variation across the collaborative was notable, with some hospitals seeing greater than 40% swings in either direction – though some sites may see drastic changes to their rates if case counts are smaller.

Figure 3.

The remaining figures in the report provide preoperative testing rates for specific types of tests, with caterpillar plots for each condition to help benchmark performance to other hospitals across the state. The types of tests with the highest average testing rates across conditions are blood tests—which include complete blood count, basic metabolic panel, and coagulation tests—and electrocardiography tests. For a majority of hospitals, their testing rates are highest within the lumpectomy patient population regardless of test type, with the exception of urinalysis testing rates that are heavily driven by the cholecystectomy population.

The last time MVC shared preoperative testing reports was in July 2022, and since then MVC contributed to and launched resources to help healthcare providers implement changes. MVC members now have access to a sample preoperative testing decision aid for low-risk surgeries, developed in partnership with the Michigan Surgical Quality Collaborative (MSQC) and the Michigan Program on Value Enhancement (MPrOVE), and MVC (Figure 4). The decision aid also comes with a supplemental suggested preoperative testing chart that identifies which tests are recommended for patients who are classified by the American Society of Anesthesiologists (ASA) as Class III or above and undergoing low-risk surgery (Figure 5). Both resources are intended as guides and can be downloaded in their original file formats so hospitals may edit and adapt them within their institution. These resources were developed with input from one institution’s surgery, anesthesiology, and preoperative clinic teams, and based on clinical recommendations put forth by a number of professional societies.

Figure 4.

Figure 5.

These resources were added to a new resource website developed in partnership with MPrOVE, MSQC, and MVC. The goal of the site is to help providers safely “waive the workup” by providing the latest research, national recommendations, arguments against common myths, and frequently asked questions.

In addition, the MVC team is holding several workgroups in 2023 dedicated to preoperative testing. The first took place on March 15 and was heavily attended by MSQC and MVC members working to reduce preoperative testing as part of their P4P programs. A full recording of the workgroup is available here. MVC also has a preoperative testing workgroup scheduled for August 1, from 1-2 p.m., featuring guest presenter Nick Berlin, MD, MPH, MS, who has published several papers on patterns and determinants of low-value preoperative testing. A third preoperative testing workgroup is tentatively scheduled for October 26, from 11 a.m. to 12 p.m. Sites are encouraged to attend these events in order to learn best practices and collaborate with peers on common barriers.

For additional analysis or consultation on your hospital’s preoperative testing rates or practices, reach out to the MVC team for assistance at Michigan-Value-Collaborative@med.umich.edu.

12 Jan 2023
0
View Post
Latest PO Joint Replacement Report Adds Outpatient Rehab Rates, Demographics, and More

Latest PO Joint Replacement Report Adds Outpatient Rehab Rates, Demographics, and More

January 12, 2023 | 0 Comments | , , , ,

MVC proudly partners with 40 physician organizations (PO) spanning the state of Michigan and continues to refine and add to the resources tailored to these members. As part of this work, MVC recently refreshed and shared PO joint replacement reports in December. These PO-level reports were first shared in October 2021 with a focus on the shift away from inpatient surgeries as well as post-acute care utilization for combined joint procedures.

The recently refreshed reports carried forward many of the joint episode metrics included previously, but with additional stratification and detail. For instance, whereas the 2021 version presented figures for all joint surgeries combined, many of the figures in the December 2022 version provided data stratified by hip procedure, knee procedure, and all joint procedures. Similarly, some figures are stratified by the location of the procedure (inpatient vs. outpatient). This new differentiation was intended to help POs more easily understand the underlying drivers of their metrics. For example, the blinded hospital below (Figure 1) could observe that its average 30-day price-standardized total episode payment is driven more by hip surgeries ($17,399) than knee surgeries ($16,643). This site could also observe that its overall total episode payment is below both the collaborative-wide PO average and the average in their region, and at the average for other POs of a similar size.

Figure 1.

Additional detail was also added to the patient attribution table, which now identifies the top 10 index facilities (rather than five) where a PO’s attributed patients underwent joint replacement surgery. This table now also includes each index facility’s percent of joint episodes performed in an outpatient setting as well as their average 30-day price-standardized total episode payment for attributed patients. This change was intended to inform quality improvement discussions between POs and partner hospitals or Ambulatory Surgical Centers (ASCs).

Also new to this report were 30-day outpatient rehabilitation rates and a patient population snapshot table to help POs better understand the demographics of patients included in the report. The table included mean age, top two patient Zip codes, the percent of patients living in an “at-risk” or “distressed” Zip code according to the Distressed Communities Index, the proportion of patients belonging to different racial categories, their average length of stay, and their 30-day post-surgery complication rate. Each of these categories was summarized separately by insurance plan.

This report utilized administrative claims from attributed members spanning 1/1/19 – 6/30/21 for Blue Cross Blue Shield of Michigan (BCBSM) PPO Commercial, BCBSM Medicare Advantage, and Medicare Fee-for-Service. Reports were prepared for all POs that participate in MVC and had at least 20 joint replacement episodes in 2019 and 2020, and at least 11 episodes in the first half of 2021.

In general, report findings indicated that utilization of outpatient surgery settings continued to increase in 2021 on average (Figure 2). However, there was still significant variation between MVC’s 40 PO members in their average rate of joint replacement surgeries taking place in outpatient settings (Figure 3). For joint episodes in 2019 through the first half of 2021, outpatient surgery rates ranged from just over 20% to nearly 80%.

Figure 2.

Figure 3.

On average across the collaborative, POs still had low rates of skilled nursing facility (SNF) utilization (6.7%) and higher rates of home health (HH) utilization (55.3%). However, variation in PO member HH utilization rates ranged from approximately 10% to 90%.

If you have feedback on your new PO joint replacement report or would like to request an additional custom analysis to better fit your needs, contact the Coordinating Center at Michigan-Value-Collaborative@med.umich.edu.

01 Dec 2022
0
View Post
PY 2024-2025 Selection Reports Sent for MVC Component of BCBSM P4P Program

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

December 1, 2022 | 0 Comments | , , , ,

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.

Figure 1.

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.

Figure 2.

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.

17 Nov 2022
0
View Post
Latest Sepsis Report Compares Medicare Advantage and Medicare FFS Patient Outcomes

Latest Sepsis Report Compares Medicare Advantage and Medicare FFS Patient Outcomes

November 17, 2022 | 0 Comments | , ,

The Michigan Value Collaborative distributed refreshed push reports this week for its sepsis service line, providing hospital members with updated figures and measures since the last refresh in April.

The version shared with members this week compares MVC hospitals on 90-day risk-adjusted total episode payments, inpatient length of stay, Intensive Care Unit (ICU)/Cardiac Care Unit (CCU) utilization, inpatient mortality and discharge to hospice, 90-day post-acute care utilization, and 90-day readmission rates. Each figure presented reflects 90-day episodes with index admissions from 7/1/18 – 6/30/21 for Medicare Fee-For-Service (FFS), Blue Cross Blue Shield of Michigan (BCBSM) PPO Commercial, Blue Care Network (BCN) Commercial, BCBSM PPO Medicare Advantage (MA), and BCN MA. Most of the measures also include comparison groups for the "MVC All” average across the collaborative as well as the average for each hospital’s assigned geographic region of Michigan.

This week’s reports stratified many measures by BCBSM/BCN Medicare Advantage and traditional Medicare FFS to investigate differences in outcomes and utilization between these two patient groups. MA saw large increases in yearly enrollment over the last decade, resulting in a growing interest in the difference in quality and cost measures compared to traditional Medicare FFS. Recent research suggested that MA patients experience better outcomes and cost less. This held true for some of the measures in MVC’s latest report. Despite the fact that the MA population is older (77 years) than the Medicare FFS population (72 years), the 90-day readmission rate (see Figure 1) among Medicare FFS sepsis patients was higher (33%) than that of MA sepsis patients (27%).

Figure 1.

Other noticeable differences between the patient populations included disease burden and social barriers. The Medicare FFS population had a greater comorbidity burden than the MA population; 57% of MA patients had three or more comorbidities whereas 61% of the Medicare FFS population had three or more comorbidities. The Medicare FFS population was also more likely to reside in an at-risk or distressed Zip code according to the Distressed Communities Index (37% vs. 31%).

Interestingly, the average 90-day risk-adjusted total episode spending payment among sepsis patients was higher for MA ($38,314) than Medicare FFS ($34,434) (see Figure 2). However, the claims data used in MVC’s report were both price standardized and risk adjusted, so dollars are actually a proxy for healthcare utilization. When taking into account patient factors and payer, BCBSM/BCN MA sepsis patients used more resources than Medicare FFS sepsis patients. Without taking patient factors and payer into account, Medicare FFS sepsis patients used more resources than BCBSM/BCN MA sepsis patients.

Figure 2.

Hospitals can learn more about the differing demographics of these two populations and their BCBSM/BCN commercial counterparts in their patient population snapshot table, a figure that was carried forward from the April reports. The latest reports included additional rows for the rate of septic shock and for the percentage of patients living in an “at-risk” or “distressed” Zip code. The latter is determined by the Economic Innovation Group’s Distressed Communities Index (DCI) data set, which incorporates economic indicators such as education, employment, and income to categorize patient Zip codes as prosperous, comfortable, mid-tier, at-risk, or distressed. The population snapshot table was intended to help hospitals better understand their sepsis patient population. The other demographics included were race, mean age, top three patient Zip codes, the most frequent and average number of comorbidities, and the proportion of patients with a confirmed diagnosis of COVID-19.

The inclusion of COVID-positive patient percentages is an important statistic in the patient population snapshot table since the report included COVID patients. Knowing this percentage could help hospitals understand the extent to which their data is driven (or not) by patients with a confirmed COVID-19 diagnosis.

The latest sepsis reports were also distributed to members of the Michigan Hospital Medicine Safety Consortium (HMS), which partnered with MVC on the original development of this service line for MVC’s registry. MVC plans to provide system-level versions of the latest sepsis report in the coming weeks.

If you have suggestions on how these reports can be improved or the data made more actionable, the Coordinating Center would love to hear from you. We are also seeking feedback on how collaborative members are using this information in their quality improvement projects. Please reach out at Michigan-Value-Collaborative@med.umich.edu.