Helping patients and each other choose wisely

Daniel Wolfson, MHSA, executive vice president and chief operating officer of the American Board of Internal Medicine Foundation, hears a lot of stories about over-use and unnecessary care in his travels as head of the ABIM Foundation’s Choosing Wisely campaign. He even has his own example of receiving four EKGs prior to cataract surgery, even though he had no cardiac risk factors.  When he questioned the need for the EKG, the anesthesiologist revealed that he didn’t want to run the risk of being sued for missing an unlikely chance of atrial fibrillation – a heart rhythm disorder.

“We can’t work that way anymore,” said Wolfson.  According to a study published in JAMA in 2012, overtreatment, or care that is duplicative or unnecessary, accounts for 30 percent of health care delivered in the U.S.  Eliminating overtreatment could save $270 billion in health care spending annually.

That’s where the Choosing Wisely campaign comes in.  The campaign began in 2012 as a way to raise awareness among physicians and patients of the harm and expense that occurs when patients receive more treatment than necessary. Choosing Wisely aims to increase conversations among patients and physicians about overuse, and to help patients make smart, effective choices for their care.

Physicians and health professionals from nearly 70 medical and related societies have created lists of the top five things patients and physicians should question.  Consumer Reports helps get the word out to patients. The campaign is physician-led and evidence-based.  And it’s working.  In just two years, market research indicates that 20% of physicians nationally are aware of the Choosing Wisely campaign and its purpose.

Physicians who participate in the Health Care Resource Stewardship Council, a voluntary subgroup of the Physician Group Incentive Program (PGIP), were among those who talked with Wolfson during a special presentation October 23.  Wolfson stressed to the Council that the success of Choosing Wisely lies with the physicians and health providers who put the concepts into practice.

“Physicians and health networks are putting this campaign into action locally,” says Wolfson.  “It’s up to you to make this work.”

The Health Care Resource Stewardship Council is looking at ways the physician organizations that participate in PGIP can support and implement the Choosing Wisely recommendations in their practices.

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Michigan Urological Surgery Improvement Collaborative Nationally Recognized for Improving Prostate Care in Michigan

MUSIC has been nationally recognized with the 2014 Accelerator Award  by Clinical Innovation + Technology for succeeding in improving care coordination, streamlining clinicians’ workflow and using data to address various issues.

Go to the Blues Perspectives blog for more information.

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Patient-Centered care includes behavioral referrals for grief

I received the call from the PCP’s office referring the patient for distress due to the loss of her husband. On the referral form, there was a note regarding a history of alcohol abuse and current severe depression. I made contact with the patient and set an appointment for the following day.

My intake sheet asks if the patient is married, for how long and, if no longer married, why not. I was struck by the patient’s entry, “Husband died, by me”. Why, ‘by me’ I asked? She tearfully said his family blames her for his death because, when he collapsed at home, she did not apply effective CPR. I told her that, even when done well, CPR was likely to succeed only a small fraction of the time. I then went through her husband’s medical status, they were preparing to bring oxygen into the home for him for his emphysema, and reassured her that there was little she, or anyone, could have done. It was not her fault.

Her crying had stopped, but her mood was still very low. “He was my best friend,” she said. “The family took down all the pictures of us, and replaced them with pictures of him with his former wives.” I reflected that she and he had been very close for well over 20 years of marriage. I suggested she could probably imagine what he would do or say in almost any situation. She agreed. I asked her to imagine that he was standing behind her and, as she turned to him, he would tell her what he thought about how his family was behaving. She began laughing before she turned.

Over the course of the hour I spent with her, I could relieve her of her guilt over her husband’s death, I was able to explain the nature and progress of human grief, and show her that she was actually on a normal track. I could suggest that, though he was dead, he was not wholly gone, as she could talk to him any time and even hear his replies. The comfort he always provided, he could continue to provide. She agreed to come back for another session, and left with a distinctly lighter mood.

Being able to spend an entire hour at a time is one of the luxuries of my practice. Being able to sense and respond to the many factors driving the patient is one of the skill sets of my work. Driving toward sustainable outcomes that allow the patient to live more effectively with whatever challenges they face is my overarching goal. I have the time, and the skills, to do this kind of work, and this is what makes the behavioral specialist referral effective for the patient, and the PCP.

It’s another reason why the Michigan Blues’ Patient-Centered Medical Home Program is encouraging physicians to include behavioral health professionals as part of the care team.

Kenneth L Salzman, PhD, is a psychologist in the Lansing, Michigan area

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Using Lean principles to improve patient care

The Lean for Clinical Redesign program, part of the Physician Group Incentive Program, helps practices redesign their processes so they can be more productive and improve patient care.

Katrina Appell discusses Value Stream Mapping as one tool that helps practices stay focused on their goals and purpose in the Lean process.  Read more in her blog, “Cost Reduction, Waste and Purpose.”

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Culture Breeds Collaboration

One of the most important aspects of a successful multi-hospital collaboration is its culture. If the culture is one of competitiveness and distrust nothing good will follow. This type of culture prevents a good idea discovered at one hospital from being disseminated to the hospital across town. Conversely, if the culture is collegial and non-competitive, participants will share important information they have discovered with others, and allow site visits so that the larger group can observe their progress first hand.

Biennial satisfaction surveys of CQI participants have indicated that the Michigan Surgical Quality Collaborative (MSQC) has developed this type of positive culture.

The potential for a productive partnership among anesthesia, surgery and nursing depends on a positive culture. Implementing a team approach to patient care, and its associated new care management pathways, is difficult.  There are both successes and failures along the way. But if participants are willing to share their experiences, good or bad, the rest of us benefit.

Many of the failures will probably involve getting the anesthesia and surgical providers to work together, and it won’t happen unless the group sees a tangible benefit to patient care, and a viable way to get paid as a team in the new health care environment. But a successful care model has to be developed first, so that it can be showcased to the government and other payers as we think more and more about Accountable Care Organizations and bundled payments.

This culture exists in MSQC, which fosters team-based trials and a data collection infrastructure.  This allows for objective evaluation of findings and ideas for areas of focus and improvement.  It fosters attendance by as many as 300 providers at quarterly meetings.  And, it encourages robust discussion, sharing and planning.

In the end, a collaborative platform must foster innovation or it will fail.

None of us want to do the same thing over and over again, with the same result.  Great ideas often come from unlikely places, best unearthed in a collaborative setting, and in a place where the real needs of doctors and nurses who work at the bedside can be recognized.

Darrell “Skip” Campbell, MD, is chief medical officer, chief of Clinical Affairs and professor of the General Surgery section at the University of Michigan Health System and project director of MSQC.

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Patient prep program earns $6.4M health care innovation award

A joint program among the Michigan Surgical Quality Collaborative, Blue Cross Blue Shield of Michigan and the University of Michigan that prepares patients for their inpatient surgeries recently earned $6.4 million from the Centers for Medicare and Medicaid Services.

By helping patients prepare mentally and physically for the procedure and the demands of recovery, the Michigan Surgical and Health Optimization Program (MSHOP) already has reduced patients’ post-surgical time in the hospital by 30 percent, and saved an average of $2,518 per surgical case.

Learn more at the University of Michigan Health System website.

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Chiropractor Involvement: Let’s Engage and Complete the Task

BCBSM has asked and paid provider organizations (POs) to engage chiropractors for some time now.

As of last summer, only 4 percent of nearly 3,500 eligible chiropractors had been recruited into PGIP. While there are legitimate reasons for why this is difficult, some include a lack of understanding of chiropractic care or perhaps even a bit of professional conceit.

This stalls the PGIP vision of collaboration among all who touch a patient.

When they joined PGIP, physician organizations effectively became population organizations rather than provider organizations.The work of PGIP requires physician organizations to recognize and engage with each provider their populations use.This means bringing additional providers into the POs, including chiropractors.

Why? Even if providers don’t interact with chiropractors, their patients do (and thus the PO population does). In fact, nearly 30 percent of BCBSM patients in PGIP populations use chiropractors. How can a PO justify its value proposition to payers if it isn’t measuring, or even engaging with, providers who deliver care to nearly 30 percent of their population?

Reasons for lack of engagement vary, but following are five reasons I commonly hear cited, along with a rethink of them:

I don’t know what they do.
In all honesty, how many of you know what the electrophysiologist in your cardiology group does? Or your neurologist or nephrologist? You get the picture.

I know what they do, and it’s weird stuff.
Physicians do things that don’t necessarily make sense to others too, like prescribing antibiotics for viral URIs, or checking labs without indications.

Their ethics vary.
Physicians’ ethics can be questioned too – enough that the U.S. Government passed the Sunshine Act in 2010.

They might trash my data.
If they’re going to, they already have. For example, current population data incorporates chiropractic low-back imaging rates in addition to enrolled PO providers imaging rates.  The best opportunity to influence the data is through engagement.

I don’t know how to measure them.

A fixation on HEDIS datasets might indicate that we don’t know how to measure primary care physicians either (ever had a relationship with an A1C?). At a minimum, the lack of precedent with chiropractors gives us an opportunity to trial better ways.

So what has worked for the POs that have engaged chiropractors?  The Upper Peninsula Health Plan, the state’s most engaged PO, cites 3 tools that have worked for them, and all of them are simple:

Send them a letter or email and explain what you want to do. Invite them in.


Pick it up and call those that don’t respond to mail. Explain what you’re doing and invite them again.

No enrollment fee.

Remember, chiropractors are mostly self-employed. When you require a fee, you’re asking them to reach directly into their own wallet to pay you for something that you want, not that they want. They’ll be reluctant, so you better have an exceptional pitch.  Better yet, don’t make them reach into that wallet.
The bottom line is chiropractors are licensed, board-certified health care providers recognized and used by patients and payers. Regardless of individual preferences, PO leaders owe it to their organizations to set emotion aside and lead on this engagement. In so doing, they will help PGIP complete the vision of collaboration among all providers.

Dr. Jeff Huotari is a family medicine physician who has never been treated by a chiropractor, but who notes that “it’s irrelevant given that I’m managing patient preferences, not my own.”  He has embedded a chiropractor in his office to learn better ways to collaborate, and discusses patient care regularly with up to 3 other chiropractors in his area.  The ideas expressed in this blogpost are Dr. Huotari’s and are not an endorsement by Blue Cross Blue Shield of Michigan.

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Study uses Value Partnerships initiative data to analyze gender differences in peripheral artery disease

Dr. Michael Grossman, director of the Blue Cross Blue Shield of Michigan Cardiovascular Consortium PVI Registry, authored a study showing that women have more severe symptoms from peripheral artery disease and have more limits on their lifestyle than men with PAD.  The study, using data from the registry, also showed that both men and women benefit equally from procedures such as angioplasty and stent placement to treat the disease.

The study was published in the Journal of the American College of Cardiology. 

Learn more from the online press release on the University of Michigan Health System website.

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Patient input essential in pay for performance progress

I recently attended and spoke at the Integrated Healthcare Association 9th annual Pay for Performance Symposium in San Francisco. I am thankful for IHA and Blue Cross Blue Shield of Michigan for the opportunity to share what my association with the Physician Group Incentive Program has meant to me personally, and what changes we have made in our practice over the last several years because of this association. There was clear admiration of what we are doing in Michigan, specifically how an insurer has developed such a close, collaborative working relationship with physicians. It was evident that this kind of collaboration is not the norm. It was also evident that as far as pay for performance goes, none of us have things figured out yet.

“Pay-for-performance” is an umbrella term for initiatives aimed at improving the quality, efficiency and overall value of health care. Speaker after speaker shared their experiences and their frustration that their initiatives often haven’t resulted in the desired results. Common sense dictates that increasing the amount and frequency of incentives or rewards will result in increases in the desired behaviors and outcomes but alas, often this is not the case. I was impressed by the effort and intensity of the individuals and their initiatives, but I was also struck by the fact that we still are uncertain on the correct path to take.

What I found most interesting is that many of us have come to the same conclusion, often by totally different journeys. Whatever lies ahead of us has to be done with our patients, not in spite of them. Not only do our programs have to be done with the patients’ interests in mind but with their input and participation. Treating our patients with kindness, respect and even love may be the ultimate missing ingredients in health care today. Finally, we need to learn how to tap into the intrinsic motivation of providers and develop incentives that are based less on the volume of care we provide and more on the value of care our patients deserve.

We are in the middle of the great age of health care transformation. It will be like a roller coaster, with many slow ascents and frequent scary dips. What is important is that we all hop on board. What a ride it will continue to be!

Gregg Stefanek, DO, is a family physician with Gratiot Family Practice in Alma, Michigan.

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MUSIC: A Concerted Effort to Improve Urology Care in Michigan

Continuous Improvement is Expected

Several years ago, after becoming board certified in urology, I applied to become a Fellow with the American College of Surgeons. I prepared a list of my surgical cases and complications and arrived for the required interview and interrogation. Being somewhat appropriately nervous during the interview, I can’t recall many of the questions that I was asked. The message that I took away from that experience, however, was very clear. A commitment to continuous surgical improvement was an expected part of membership in the college.

Searching for a Methodology

As I began my career, I first kept notes of my surgical successes and complications on paper. Over time, I moved to a spreadsheet. Not only was the process time consuming, it was difficult to directly compare my surgical experience with that of others. Differences in reporting were readily apparent even in the academic literature. There really didn’t seem to be any universally accepted standard for reporting in Urology. As a result, it was difficult to know exactly where to try to focus my continuous improvement efforts.

 Michigan Urology Surgical Improvement Collaborative

A couple of years ago, a solution started to emerge. The University of Michigan, under the leadership of Dr. David Miller and Dr. James Montie, initiated a statewide collaborative between academic and private practice urologists. This collaborative, financially and administratively supported by the Value Partnerships Program at Blue Cross Blue Shield of Michigan, became known as the Michigan Urological Surgical Improvement Collaborative (MUSIC).

A diverse group of practices from all over the state started participating.

Each participating group chose a physician leader and employed a designated data abstractor. Outcome measurements were defined by physicians and entered into a standard database by the abstractors.

Discussing and Interpreting the Data

Physician leaders and abstractors from around the state then started regularly meeting to look for trends, and to try to identify opportunities for patient care improvement. As the data started to mature, it started to become possible to have real discussions around the best standard of practice, both at the statewide level, and at the individual practice level.

In our own practice, some of these discussions have been intense. Not everyone agrees on the best way to interpret the data. In my experience, however, these discussions have always been respectful and productive.

Creating Value and Building Relationships

These days, quality improvement initiatives are seemingly everywhere. Many of these initiatives are in reality a distraction, taking physician time away from direct patient care. Physician leadership and feedback are often lacking in such activities, thereby limiting the potential to facilitate meaningful change.

MUSIC has turned out to be more than just an exercise in agreeing upon metrics and collecting data. It has been an opportunity for academic and private practice urologists to ask the questions and learn from each other in an effort to continuously improve urological care.

Working together “in concert” also includes patients.

Soliciting and involving the patients fully in decisions, and helping them make better decisions, is something we are all interested in, and working towards quite expeditiously. – Dr. David Miller

A Video About MUSIC

Recently, I had the opportunity to participate in an interview with Dr. Miller and Dr. Montie, along with my partner Dr. Joe Salisz, and future partner Dr. Matt Smith, about the MUSIC program.

The interview starts out with general information about the program but relatively quickly begins to demonstrate the interactions and collegiality made possible by the program. As a private practice urologist in a relatively small community, I am excited and proud to be involved in the MUSIC initiative. I truly appreciate the relationships and improvements in patient care that have become possible as a consequence of this effort.

To think about why this works is there’s some secret sauce to the combination of the relationships, the data, the fact that we are competitive, and we all want to get better … What the collaborative does is it provides us with a “community of coaches” to think about how we provide care, to offer constructive feedback that we can take and improve upon, and then close the loop, to see if we are actually getting better.” – Dr. David Miller

Note:  This blog originally appeared on the Best Doctors Clinical Curbside site.

Brian Stork, MD, is a urologist in practice at West Shore Urology in Muskegon and Grand Haven, MI

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