Dr. Regenbogen is the MVC Co-Director
Over the last 10-plus years, the Blue Cross Blue Shield of Michigan (BCBSM) Value Partnerships have grown to include, among other programs, 17 Collaborative Quality Initiatives (CQI). The clinical focus of the CQIs ranges from cardiology to spine surgery to radiation and many others. This “Michigan Model” of collaboration, pay-for-participation, and statewide, population-based quality improvement has yielded wide-ranging improvements, as reported several years ago.
Still, the regional collaboratives model has not spread widely beyond Michigan. Last month, at the inaugural summit of the Center of Excellence for Collaborative Quality Improvement, discussion focused on the challenges of securing financial support for regional collaboratives. Several other states—including Tennessee, South Carolina, Illinois, and Pennsylvania—have multi-hospital improvement initiatives around surgical care, but on a smaller scale than in Michigan. Like Michigan’s, all of these CQIs are supported by a regional Blue Cross Blue Shield insurer. In a commentary in this week’s JAMA Surgery, the leaders of the Michigan Surgical Quality Collaborative argue that an all-payer strategy, including investment from the Centers for Medicare and Medicaid Services (CMS), is needed in order to replicate the Michigan approach to care improvement.
To date, BCBSM has been the sole third-party funding source for the CQIs. Yet, the efforts of each collaborative have been payer-naïve—the benefits accrue to all patients regardless of their insurance coverage. In the Michigan Value Collaborative, we analyze payment data for individuals insured by both BSBSM and Medicare, and will soon expand to include Medicaid beneficiaries as well. And even in states like Michigan, where BCBSM handles quite a large portion of the commercial insurance market, CMS still remains the truly dominant payer, once we consider Medicare and Medicaid in all of their various forms.
This week’s JAMA Surgery Viewpoint considers how CMS could partner with private payers in support of regional collaboratives. Such a partnership could allow Michigan to become a model for the rest of the country. Under the new requirements for MACRA, physicians may satisfy reporting requirements through Qualified Clinical Data Registries. But what if active participation in a proactive CQI became a central part of all medical care in this country, and was supported by CMS? If this degree of dissemination could be achieved, CMS could catalyze innovative care delivery improvement on a far greater scale.
Chad Ellimoottil MD, MS is Director of Analytics for MVC and is an Assistant Professor and urologist at the University of Michigan.
Telemedicine use is rapidly growing in the state of Michigan and is increasingly gaining the attention of health system leaders, payers and policymakers as a way to improve value in quality of care for patients. Telemedicine is defined as the delivery of healthcare services and clinical information using telecommunications technology. Telemedicine can be synchronous (real-time) or asynchronous (also called store-and-forward). There are several commonly used telemedicine modalities:
- Video visit: A form of provider-to-patient telemedicine whereby a clinician conducts an office visit with a remotely located patient using live video
- eConsult: A form of provider-to-provider asynchronous telemedicine whereby a primary care physician sends a specialist a brief question to avoid a formal consultation
- eVisit: A form of provider-to-patient asynchronous telemedicine whereby a patient submits a question or photo and a clinician answers it a later time
- Remote patient monitoring: A form of provider-to-patient synchronous telemedicine whereby a patient is monitored by clinical staff at home using a device
- mHealth: All forms of telemedicine that are conducted using mobile applications
The growth of telemedicine in Michigan has been fostered by forward-thinking commercial payers including Blue Cross Shield of Michigan and Blue Care Network who have been telemedicine friendly. For example, in January 2016, Blue Cross Blue Shield of Michigan began reimbursing for telemedicine visits conducted by patients at home. As we move beyond the early adoption phase, it is helpful to think about ways that telemedicine may be able to help reduce episode spending. For more information click here.
Telemedicine interventions such as post-hospitalization video visits and remote patient monitoring may help reduce readmissions for conditions such as congestive heart failure. For example, by engaging the patient one-week after discharge using a video visit, clinicians can ensure that the patient is complying with discharge medications and that he/she understands important dietary recommendations. A video office visit may be more convenient for a patient who has transportation issue. In addition, daily remote monitoring of the weight of patients with congestive heart failure may help clinicians intervene before a hospitalization occurs. While the opportunities are promising, it is important for health system leaders to know that many studies have shown mixed results on the association between telemedicine use and readmissions [1-2].
Reducing emergency rooms visits
Telemedicine is used in two main ways in the ER. First, telemedicine can be used in the ER itself to help connect ER physicians to specialists. Second, telemedicine can be used to prevent patients from arriving in the ER by offering them a faster solution at home. This latter promise of reduced expensive emergency room visits has been driving much of the momentum for telemedicine adoption. Several studies have shown that telemedicine has the potential to reduce unnecessary, low-complexity, ER visits, however, the verdict is still out there [3-4].
Telemedicine offers a number of opportunities to help reduce episode spending. As the technology gains traction with payers and health systems, it will be important to build an evidence base to support its use in an optimal way.
- Feltner C, et al. Transitional care interventions to prevent readmissions for persons with heart failure: a systematic review and meta-analysis. Ann Intern Med. 2014 Jun 3;160(11):774-84.
- Comín-Colet J et al. Impact on clinical events and healthcare costs of adding telemedicine to multidisciplinary disease management programmes for heart failure: Results of a randomized controlled trial. J Telemed Telecare. 2016 Jul;22(5):282-95.
- Ward MM. Systematic review of telemedicine applications in emergency rooms. Int J Med Inform. 2015 Sep;84(9):601-16.
- Uscher-Pines L, Mehrotra A. Analysis of Teladoc use seems to indicate expanded access to care for patients without prior connection to a provider. Health Aff (Millwood). 2014 Feb;33(2):258-64.