Looking forward – May 2016

David B. Hoyt

David B. Hoyt, MD, FACS

In March, I visited the University of Michigan (U-M) Health System, Ann Arbor, at the invitation of Hasan B. Alam, MB, BS, FACS, Norman W. Thompson Professor and section head, general surgery; and Michael Mulholland, MD, PhD, FACS, chair, department of surgery. There I had the opportunity to learn about the impressive work carried out at the U-M Institute for Healthcare Policy & Innovation (IHPI), the Blue Cross Blue Shield of Michigan Collaborative Quality Initiatives (BCBSM CQI) program, and the Michigan Value Collaborative (MVC).

These programs, which all work together, exemplify the type of synergistic efforts that will shape health policy moving forward. As the nation seeks to implement a patient-centered health care system that emphasizes quality, safety, and cost controls, it will become increasingly necessary for surgeons and their institutions to participate in collaborative quality improvement activities.

About the IHPI

The director of the IHPI, John Z. Ayanian, MD, MPP, provided an overview of the institute’s work. Established in 2012, the not-for-profit IHPI builds on the U-M’s accomplished history in health services research in an effort to improve the quality, safety, accessibility, and affordability of patient care. The IHPI evaluates the effect of health care reforms, improves the health of communities, promotes value-based health care, and develops innovations in health information technology and health care delivery. The IHPI strives to achieve its mission through collaboration, research to support evidence-based approaches to care, and public-private partnerships.

More than 460 researchers contribute to the IHPI’s efforts to resolve health policy issues. The IHPI’s 87,000 square-foot headquarters was designed to support multidisciplinary interaction, housing formal and informal spaces for collaboration.

Central to the effectiveness of any modern quality improvement program is a common data registry. The IHPI’s data hub processes records from a private sector health services and innovation company, the Centers for Medicare & Medicaid Services, Veterans Affairs, the state of Michigan, and other sources. The institute devoted $123 million to health services research in fiscal year 2015. One of the IHPI’s most important projects at present focuses on the evaluation of the state’s Medicaid expansion program, known as the Healthy Michigan Plan, which provides coverage to 625,292 Michigan residents.


Major contributors to the work of the IHPI are participants in the BCBSM CQI. The BCBSM CQI comprises 70 Michigan hospitals; 92 percent of eligible hospitals in the state participate in at least one of the program’s 20-plus CQIs, including the Michigan Surgical Quality Collaborative (MSQC). The MSQC is affiliated with the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®) and was established under the leadership of Darrell A. “Skip” Campbell, Jr., MD, FACS, chief medical officer and Henry King Ransom Professor of Surgery, department of surgery, U-M Health System. Many other surgeons in the U-M are vital in the MSQC, including Mark R. Hemmila, MD, FACS, professor of surgery, section of general surgery, Trauma Burn Research Laboratory; Justin B. Dimick, MD, MPH, FACS, George G. Zuidema Professor of Surgery, chief, division of minimally invasive surgery, director, Center for Healthcare Outcomes and Policy, and associate chair, strategy and finance; and Michael J. Englesbe, MD, FACS, associate professor of surgery, section of transplantation surgery.

The participants in the BCBSM CQI are referred to as Value Partners for their efforts to improve the quality/costs of the health care services they provide. According to David A. Share, MD, senior vice-president, and Tom Leyden, MBA, director, BCBSM Value Partnerships, the most common and costly areas are surgical and medical care.

Participating hospitals and providers collect, share, and analyze data through clinical registries, then design and implement changes to improve outcomes and reduce spending for complex, technical areas of care. CQI registries allow for a more robust analysis of the link between processes and outcomes than can be achieved by examining one group or institution alone.

This innovative and highly regarded program helps providers to self-assess and optimize their care by identifying opportunities to develop best practices or more closely align health care procedures with best practices. As a result, participants are experiencing improved quality and lower costs for certain high-cost, high-volume, high-complexity procedures.


David C. Miller, MD, MPH, FACS, director, MVC, and associate professor, urology; and James M. Dupree, MD, MPH, FACS, co-director, MVC, and assistant professor, urology, described the MVC’s efforts. A partnership between Michigan hospitals and the BCBSM/Blue Care Network (BCBSM/BCN), the MVC builds on the MSQC’s legacy and seeks to improve health care quality across the state through rigorous performance feedback, empirical identification of best practices, and collaborative learning. The MVC hosts semi-annual meetings where representatives from participating hospitals discuss performance data, analyses of best practices, and collective strategies for improving quality and efficiency.

At present, the MVC uses BCBSM claims data to assess hospital performance. Measures are based on utilization and payments for different services, as well as Medicare fee-for-service data. Hospitals receive risk-adjusted measures of 30- and/or 90-day episode payments for common conditions and procedures. Episode costs are risk-adjusted to account for differences in case mix across hospitals and are price-adjusted to reflect utilization rates rather than negotiated fees. Hospitals can examine their data to determine their comparative utilization of services, trends over time, and root causes of variation.

Hospitals use this information to help MVC target improvement opportunities; identify and share best practices; and design, implement, and evaluate statewide interventions with the goal of identifying and sharing best practices and benchmarks for quality and cost.

MVC meeting participation is voluntary. In the future, however, BCBSM expects to include MVC-generated measures in its value-based hospital payment incentive models.

The future of health policy

I commend the U-M and the surgeons, researchers, and public and private sector partners that are leading these efforts. Of course, the U-M is not alone in its efforts to provide leadership in health care policy and quality improvement. Many other academic medical centers are working with a range of affiliates and partners to develop meaningful, value-based health care reforms, including the Center for Surgery and Public Health, a joint initiative of Brigham and Women’s Hospital, Harvard Medical School, and Harvard T. H. Chan School of Public Health, Boston, MA; the Institute on Healthcare Systems, Brandeis University, Waltham, MA; the Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill; the University of California, Los Angeles, Health Policy Research Center; and the University of Wisconsin-Madison Population Health Institute, to name a few.

These think tanks, as well as the provider-run quality improvement collaboratives at work in Florida, Tennessee, Washington, and other parts of the country, have the resources and collective intelligence to develop the policies that will lead to higher-quality, more cost-effective patient care. The government will continue to issue rules and develop legislation that will affect health care delivery; however, as these groups develop value-based reforms, legislators and policymakers will turn to them for advice in shaping the health care system of the future.

“These efforts, so well-developed by the Michigan collaboratives, are exemplars of how we can use health policy to improve care,” said Clifford Y. Ko, MD, MS, MSHS, FACS, Director, ACS NSQIP.

To drive the changes that will lead to better quality and higher standards of cost-effective care, all stakeholders—patients, providers, health care professionals, insurers, government payors, and so on—must join together. I want to congratulate Dr. Mulholland and the U-M faculty on their leadership. I encourage you to find out how your institutions and practices can get involved in these types of efforts in your region. Don’t let these opportunities to better serve your patients pass you by.

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