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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What are the trends in value-based payments? Symposium speakers provide insight.

Recently, more than 300 physicians, nurses, hospital administrators and physician organization leaders gathered to learn about national and local trends in value-based reimbursement and ACO formation, and discuss how these trends are shaping Michigan initiatives.  It was part of Blue Cross Blue Shield of Michigan’s annual symposium on the pay-for-value transformation.

The day’s discussions centered on trends and best practices in accountable care and population management, and the challenges faced by providers in all care settings in transforming to new care models.  Here are some highlights from the event:

Valerie Lewis, PhD, Assistant Professor, Geisel School of Medicine at Dartmouth

In a national survey of Accountable Care Organizations, 81 percent of respondents indicated they are working on reducing waste or creating efficiencies in managing hospital admission and resource use.  There’s a challenge for hospitals because of the revenue loss associated with those efforts.  Many hospitals in turn are focusing on shifting revenue to ambulatory care clinics.

Peter Schonfeld, Senior Vice President, Michigan Health and Hospital Association

In Michigan, hospitals have successfully improved quality and increased value through the collaboration in the MHA Keystone program and Blue Cross Value Partnerships efforts.  The improvements are necessary for the good of the patient and for participation in new insurance products such as narrow networks. 

Edward McEachern, MD, Executive Director, St. Alphonsus Health Alliance

When the Health Alliance was forming, great thought was put into developing appropriate governance and values.  Physician leadership was imperative, and so was developing a culture of respect, self-sufficiency and interdependence.  According to Dr. McEachern, to successfully transform, “the soft stuff is the hard stuff.”  Integration is long-term, implementation is ongoing.

The Alliance also created a new patient care model.  In the old model, the patient bounces around like a pinball trying to find the right doctor.   In the new model, the patient finds a primary care doctor and enters a continuum of care.  They designed Lean processes around the patient experience.  The goal:  Make it so the patient doesn’t have to move.  Bring the health services to the patient.

Meredith Rosenthal, PhD, Professor of Health Economics and Policy, Harvard

A review of various payment models, from bundled payment to performance payment to reference payment, shows that there is nothing new since the managed care focus of the 1990s.  Dr. Rosenthal calls today’s effort “payment reform 2.0.”  What is different now is the momentum, and the alignment between Medicare and private payers.

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Lower costs, better patient outcomes the goals of new Michigan hospital partnership

Imagine you have incapacitating hip pain from degenerative joint disease. You undergo pre-operative testing, a hip replacement surgery, transfer to an inpatient rehabilitation hospital and then get physical therapy services at home. Your cousin went through the same surgery a year ago, and both of you had good outcomes.

But instead of going to the inpatient rehabilitation hospital as part of the care, your cousin went straight home from the hospital and had a visiting nurse and physical therapist help her start her rehabilitation.

The costs for these kinds of “episodes of care” — defined as care received for a particular condition before, during and after hospitalization — are a major contributor to the high costs of health care, and they vary widely among hospitals. For example, experts say there’s a nearly $20,000 difference in costs of performing cardiac bypass surgery among 27 hospitals in Michigan.

These variations are the subject of a new initiative sponsored by Blue Cross and Blue Care Network to help Michigan hospitals understand their utilization patterns and how they relate to costs and patient outcomes.

The Michigan Value Collaborative will be coordinated by the University of Michigan Health System using claims data from the Blues. It will examine costs and utilization patterns across 20 common conditions, including:

  • Heart attacks
  • Congestive heart failure
  • Cardiac surgery
  • Hip replacement
  • Colon surgery

The analysis will include data compiled from all hospitals in Michigan. Individual hospitals will see their own data alongside data from other hospitals that are not identified.

The idea is to help hospitals understand which services they perform add value and which do not so doctors and hospitals can focus on providing high-value care.

“We often don’t know which services and procedures are the most efficient and effective for patients,” said Dr. David Share, senior vice president of Value Partnerships at BCBSM. “By participating in the Michigan Value Collaborative, hospitals can use our claims data to compare themselves to their peers, learn about what works to yield the best outcomes at the lowest cost and accelerate the adoption of practices that yield the highest value.”

Sven Gustafson is a senior communications specialist with Blue Cross Blue Shield of Michigan

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Surgical skill an important measure in clinical outcome, demonstrated in bariatric surgery study

Does it make a difference in the outcome of a procedure when the surgeon performing it has more fluid motions, or sutures without tugging at tissue?  Does the technical skill of the surgeon relate to better outcomes? That’s the assumption.  But has that assumption been tested?  Is there data that examines the link between technical skill and postoperative outcomes?

The Michigan Bariatric Surgery Collaborative (MBSC) conducted a study involving 20 participating bariatric surgeons. Each surgeon submitted a videotape of himself or herself performing a laparoscopic gastric bypass. Each videotape was rated in various domains of technical skill on a scale of 1 to 5 (with higher scores indicating more advanced skill) by at least 10 peer surgeons who were unaware of the operating surgeon’s identity.  The relationship between these skill ratings and risk-adjusted complication rates, using data from the MBSC clinical-outcomes registry, was then assessed.

Results recently published in the New England Journal of Medicine showed that surgical skill is a strong predictor of clinical outcomes.  The bottom quartile of surgical skill was associated with higher complication rates and higher mortality. The lowest quartile of skill also was associated with longer operations and higher rates of reoperation and readmission.  Greater skill was associated with fewer postoperative complications and lower rates of reoperation, readmission, and visits to the emergency department.

Variation in surgical skill and outcomes may never be eliminated – some surgeons may be more skilled than others.  However, coaching and deliberate practice are effective in improving proficiency among surgeons at any skill level. In Michigan, bariatric surgeons now watch each other operate during site visits, and they can watch online video of surgeons with superior skill and outcomes. They will soon be receiving anonymous, constructive feedback from their peers on strategies for refining their technique.  These coaching and practice sessions are another way that the MBSC is helping to improve outcomes and reduce complications for bariatric surgery procedures statewide.

Can you tell the difference between a procedure done by a highly skilled surgeon and a surgeon with a lower skill level?  See for yourself here:

http://mediareview.nejm.org/MSImageReview/13_00625_birkmeyer/test/NEJM_VideoPlayer_layer_single.html

Sarah Lanivich, MBA, is a health care analyst in Value Partnerships at Blue Cross Blue Shield of Michigan.

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Behavioral health is key component of patient-centered care

It’s time we brought behavioral health assistance out of the shadows and into the full complement of primary care services to aid whole patient recovery and quality of life. Engaging a care team is a logical way to do this. 

Med Net One Health Solutions has embedded nurse-led care management teams in 15 practices throughout southeastern Michigan as part of the CMS primary care transformation demonstration project (MiPCT).  One of the project’s missions is to assess PCMH effectiveness. With the addition of the embedded care team, the primary care physicians continue to take the lead role in their patients’ care, but are able to make referrals to behavioral health specialists within the care team to help address the patients’ psychological and social needs.

 For example, in a busy downriver primary care practice with two physicians, two physician extenders and a patient population of 11,000, the practice was alerted through its hospital notification system when “Betty” was released from the hospital following a cerebral vascular accident. The embedded R.N. Care Coordinator reviewed all discharge notifications and promptly contacted Betty to perform a medication reconciliation and assessment before alerting the practice’s multi-disciplinary care team of primary care physician, social worker and registered dietitian.

 In addition to the need for physical therapy and dietary services, it was learned Betty was dealing with her husband’s alcoholism and experiencing feelings of social isolation and depression. Betty was counseled by the social worker through weekly phone calls; the social worker also connected her with local agencies to obtain social interaction and light housekeeping.

 Ultimately, the social worker and care team helped Betty recover physically and emotionally, and she avoided a hospital readmission. Without direct access to an embedded care team and a behavioral health specialist, Betty’s physician may have been unable to fully address her overall health issues. 

 Ewa Matuszewski is CEO of Med Net One, an Oakland County healthcare management organization

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Exploring the Future of Healthcare Delivery System Transformation

Healthcare Delivery System Transformation – how will it help to improve healthcare? 

This past July, I joined representatives from 36 health plans from around the country at a summit to address this question. The summit was hosted by The Advisory Board Company, a global research, technology, and consulting firm based in Washington D.C.

Transforming healthcare delivery requires the collaboration and cooperation of multiple key players, including hospitals, doctors and health plans. Yet, these players are often competitors, which can make collaboration a challenge.  And with new retail and specialty clinics entering the market, it’s even more important for all of the players to cooperate in order to succeed. 

Two key strategies for future success:  payment innovation and population management.

  • Payment innovation looks at how we can pay for healthcare to achieve better quality and cost efficiency. The traditional fee for service (FFS) model means a payment is made for each service rendered. Therefore, more services equates to more payment. Payment innovation strives for a “fee for value” (FFV), which pays providers based on quality and keeping patients healthy. 
  • Population management addresses the entire care “continuum”, from wellness and preventive services to complex care. It uses a team approach to improve coordination across care settings and ensure the population gets the right care at the right time. This team approach is especially critical for managing high-risk, high-cost patients.

The transition is underway.  Many payers, including Blue Cross Blue Shield of Michigan, have begun new contracting models that pay providers for population management and for patient outcomes.  Summit attendees agreed that future success factors must include cultivating relationships, establishing shared goals with providers, and increased data sharing and transparency across partners.

Robin Mitchell is a manager in the Value Partnerships department and manages the Organized Systems of Care program at Blue Cross Blue Shield of Michigan

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Blue Distinction Total Care Brings Value to Other States

Millions of Michigan patients are receiving higher-quality, more cost-efficient care because of the work we do together in the Value Partnerships programs. These innovative care delivery programs are recognized for improving health care quality in Michigan.

Yet historically, these programs have been available only to our members in Michigan, which poses a challenge for customers who have employees in other states.

Now, with the launch of a new national designation program called Blue Distinction Total CareSM, Value Partnerships programs will be integrated into a national network, giving Blue customers access to PCMH and other quality programs from Blue plans across the country.

Blue Distinction Total Care links these various models across the country through a shared platform, so that we can offer our national customers seamless access to local innovations.   Beginning in 2014, programs from 26 states will be available; the program will continue to expand in 2015 and beyond.

While this is a robust national approach, the program is distinctively local and tailored to address the unique needs of members and providers in each community.

PCMH designated practices in Michigan will automatically meet the criteria and receive the national Blue Distinction Total Care designation. Additionally, providers participating in BCBSM’s Organized Systems of Care program will be recognized as Blue Distinction Total Care provider in the future. 

Shaun Raleigh is manager of Health Care Value National Solutions at Blue Cross Blue Shield of Michigan.

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History and results of the PCMH program – A three-part series

Blue Cross Blue Shield of Michigan’s Patient-Centered Medical Home program is noted for being the largest designation program in the U.S.  Thanks to the tremendous collaboration among participating physicians and physician organizations, it has also shown stellar results. 

PCMH physicians, as compared with non-PCMH physicians, have lower rates of primary-care sensitive ER visits for both adult and pediatric patients.  They have lower rates of  ambulatory-care sensitive hospital stays for adult patients.  The program has saved $155 million in the first three years, because patients are staying healthier and have better access to their PCMH doctors, avoiding costly ER and hospital visits.

David Share, MD, MPH, senior vice president, Value Partnerships at BCBSM, talks about the PCMH model of care and the keys to this program’s success in a three-part podcast series.  Listen here:

Part one -http://www.mibluesperspectives.com/2013/07/23/what-is-a-patient-centered-medical-home/

Part two -http://www.mibluesperspectives.com/2013/08/07/collaboration-drives-patient-centered-medical-home-adoption-across-michigan/

Part three -http://www.mibluesperspectives.com/2013/08/15/podcast-13-what-are-the-results-of-the-michigan-blues-pcmh-model-of-care/

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Establishing Context Around BCBSM’s PCMH Savings

The Patient-Centered Medical Home (PCMH) model of care is one approach to transforming primary care currently being tested in the United States.  The recently published May/June supplement in the Annals of Family Medicine shared practice transformation stories and challenges from groups around the country working to establish the PCMH model.  One of the common themes arising from these groups was the recognition that practice transformation is a journey.  It’s important to distinguish between practicing as a PCMH and being recognized as a PCMH, perhaps best embodied by these two statements: 1) “A practice could be a true PCMH without having received recognition, and a practice that has received PCMH recognition may not be a true PCMH,” and 2) “There is no Cinderella moment when a practice suddenly realizes it is a PCMH”.

Here’s why that is important.  Several previous studies have focused on PCMH as an ‘all-or-none’ phenomenon relying on comparing PCMH recognized practices to practices not recognized as PCMH.  Since PCMH is a transformative, evolutionary process, there are many intermediate stages in the spectrum of PCMH.  As a result, these ‘all-or-none’ comparisons that were intended to estimate the effects of the PCMH model may instead reflect differences in the stages of getting to a full PCMH model. 

This framework helps explain the study findings in the recently released Health Services Research Journal article “Partial and Incremental PCMH Practice Transformation: Implications for Quality and Costs” about the effects of PCMH we observed for the BCBSM PCMH program.  The article describes the association between PCMH capabilities and quality and cost measures. It finds that the degree to which the medical home model is implemented is positively associated with better quality of care and lower costs of care.  We found that even when the PCMH model is only partially implemented, there are significant associations with better quality of care and lower cost of care for adults as well as better quality of care for children.  We also found that the incremental improvements made during the course of a year were associated with even better quality of care. 

The advantage of this approach is that it allows us to estimate the full effects of PCMH, as well as the impact of the incremental changes and intermediate steps to becoming a PCMH.  So, even for practices just beginning their PCMH transformation journey, we can estimate the impacts they are having with their patients well before they become a fully transformed medical home.

Michael Paustian, Ph.D., MS, is a health care manager in the Clinical Epidemiology and Biostatistics Department at Blue Cross Blue Shield of Michigan.

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Talk with your doctor about choosing wisely

Advances in imaging and health technology sometimes lead to additional medical tests and procedures that may not be necessary.  This can result in higher health care costs.   

To help patients and physicians be more aware of test and procedure costs and necessity, the American Board of Internal Medicine has launched the Choosing Wisely campaign. 

In the Choosing Wisely campaign, experts from national medical organizations have joined together to identify tests or procedures that may be overused and can even be harmful.  They urge doctors and patients to talk about the pros and cons and the specific value to the patient before getting these tests.  For example, don’t assume you need a cardiac stress test when you go to the doctor for your annual exam; you may not need it.  According to Choosing Wisely, a routine cardiac stress test if you have no heart disease symptoms is unlikely to change how the doctor manages you.  It may even lead to another unnecessary test that could expose you to excess radiation.

The well respected consumer organization, Consumer Reports, is on board with Choosing Wisely.  They are sharing the Choosing Wisely recommendations with the public to encourage patient and doctor discussions about what tests are actually necessary and appropriate. 

BCBSM’s Physician Group Incentive Program supports a collaborative workgroup of physician organization representatives called the Healthcare Resources Stewardship Council (HRSC).  The goal of the HRSC is to guide physicians across Michigan in making the best use of healthcare resources.  The HRSC promotes using Choosing Wisely to guide conversations between doctors and patients about the appropriateness of certain tests and services.

Medical tests and procedures are important, and can even be life saving, but they may expose you to risks and costs that are not necessary.  For consumer friendly information, go to:  http://consumerhealthchoices.org/.

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