Michigan Pharmacists Transforming Care and Quality: Developing a Statewide Collaborative of Physician Organizations and Pharmacists to Improve Quality of Care and Reduce Costs.

BACKGROUND: Inappropriate drug use, increasing complexity of drug regimens, continued pressure to control costs, and focus on shared accountability for clinical measures drive the need to leverage the medication expertise of pharmacists in direct patient care. A statewide strategy based on the collaboration of pharmacists and physicians regarding patient care was developed to improve disease state management and medication-related outcomes. PROGRAM DESCRIPTION: Blue Cross Blue Shield of Michigan (BCBSM) partnered with Michigan Medicine to develop and implement a statewide provider-payer program called Michigan Pharmacists Transforming Care and Quality (MPTCQ), which integrates pharmacists within physician practices throughout the state of Michigan. As the MPTCQ Coordinating Center, Michigan Medicine established an infrastructure integrating clinical pharmacists into direct patient care within patient-centered medical home (PCMH) practices and provides direction and guidance for quality and process improvement across physician organizations (POs) and their affiliated physician practices. The primary goal of MPTCQ is to improve patient care and outcomes related to Medicare star ratings and HEDIS measures through integration of clinical pharmacists into direct patient care. The short-term goal is to adopt and modify Michigan Medicine's integrated pharmacist practice model at participating POs, with the long-term goal of developing a sustainable model of pharmacist integration at each PO to improve patient care and outcomes. Initially, pharmacists are delivering disease management (diabetes, hypertension, and hyperlipidemia) and comprehensive medication review services with future plans to expand clinical services. OBSERVATIONS: In 2015, 10 POs participated in year 1 of the program. In collaboration with the MPTCQ Coordinating Center, each PO identified 1 "pharmacist transformation champion" (PTC). The PTC implemented the integrated pharmacist model at 2 or 3 practice sites with at least 2 practicing physicians per site. IMPLICATIONS: MPTCQ is a unique collaboration between a large academic institution, physician organizations, a payer, and a statewide coordinating center to improve patient care and address medication-related challenges by integrating pharmacists into a PCMH network. Pharmacists can actively provide their medication expertise to physicians and patients and optimize quality measure performance. DISCLOSURES: This project was funded by Blue Cross Blue Shield of Michigan. Choe and Spahlinger are employees of Michigan Medicine. Tungol Lin, Kobernik, Cohen, Qureshi, Leyden, and Darland are employees of Blue Cross Blue Shield of Michigan. At the time of manuscript preparation, Share and Wesolowicz were employees of Blue Cross Blue Shield of Michigan. Study concept and design were primarily contributed by Choe, along with the other authors. Choe, Tungol Lin, and Kobernik collected data, and data interpretation was performed by Choe, Tungol Lin, Cohen, and Wesolowicz. The manuscript was written primarily by Choe, along with Tungol Lin and assisted by Kobernik, Cohen, Leyden, and Qureshi. The manuscript was revised by Leyden, Spahlinger, Share, and Darland. Material from this manuscript was previously presented as an education session at the 2016 AMCP Managed Care & Specialty Pharmacy Annual Meeting; April 19-22, 2016; San Francisco, California.

Population Health: A New Paradigm for Medicine.

Healthcare delivery system reform has become a dominant topic of conversation throughout the United States. Driven in part by ever-higher national expenditures on health, an increasing number of payers and provider organizations are working to reduce the costs and improve the quality of healthcare. In this article, we demystify the term "Population Health," review some of the larger payer initiatives currently in effect and discuss specific provider group efforts to improve the quality and cost of healthcare for patients.

Excess hospitalization days in an academic medical center: perceptions of hospitalists and discharge planners.

OBJECTIVE: To determine the frequency of and reasons for medically unnecessary hospital days. STUDY DESIGN: Prospective observational cohort study. METHODS: We developed an online survey to prospectively collect data on hospitalists' and discharge planners' perceived delays in treatment or discharge for patients on their general medicine services. Over a 2-month period, hospitalists and discharge planners completed a daily online survey. RESULTS: We collected data on 3574 patient-days from our hospitalists and data on 2502 patient-days from our discharge planners. Among the hospitalists' responses, 395 patient-days (11%) were thought to be unnecessary. Among the discharge planners' responses, only 186 patient-days (7%) were thought to be unnecessary. The hospitalists believed that the most common reason for discharge delay was lack of extended care facility availability (111 patient-days [28%]), followed by patient or family reasons (62 patient-days [15%]), procedure delays (62 patient-days [15%]), and test scheduling delays (52 patient-days [13%]). The discharge planners' data were similar. CONCLUSIONS: More than 10% of hospital days were reported by our hospitalists to be unnecessary at this academic medical center. Major reasons were lack of extended care facility availability, patient or family reasons, procedure delays, and test scheduling delays. A simple survey instrument to assess perceived delays in the hospital may provide real-time information to initiate improvement changes to reduce excess hospitalization days.

Teaching internal medicine residents quality improvement and patient safety: a lean thinking approach.

Patient safety (PS) and quality improvement (QI) are among the highest priorities for all health systems. Resident physicians are often at the front lines of providing care for patients. In many instances, however, QI and PS initiatives exclude trainees. By aligning the goals of the health system with those of the residency program to engage residents in QI and PS projects, there is a unique opportunity to fulfill both a corporate and educational mission to improve patient care. Here, the authors briefly describe one residency program's educational curriculum to provide foundational knowledge in QI and PS to all its trainees and highlight a resident team-based project that applied principles of lean thinking to evaluate the process of responding to an in-hospital cardiopulmonary arrest. This approach provided residents with a practical experience but also presented an opportunity for trainees to align with the health system's approach to improving quality and safety.

Implementation of lean thinking: one health system's journey.

BACKGROUND: Lean Thinking is a management philosophy derived from the manufacturing industry, where Toyota has long been the gold standard. Health care organizations have started to apply this approach to patient care. After initial experimentation, the University of Michigan Health System (UMHS) has adopted Lean Thinking as its uniform approach to quality improvement and is striving to become a complete Lean organization. PROJECTS: In 2005, the senior leadership selected an initial set of projects in areas that traced the patient's journey across different care settings within our health system. Four of the projects were as follows: orthopedic surgery clinic scheduling, radiation oncology therapy, peripherally inserted central catheter (PICC) services, and coordination of care to the outpatient setting. LESSONS FROM LEAN THINKING: Lean Thinking encourages service providers to focus on value as defined by the customer and the relentless elimination of waste that impedes the flow of value. A series of learning projects were conducted to test whether Lean methods would work at UMHS. The following factors were found to be key to LEAN PROJECT SUCCESS: expert guidance for initial efforts, leadership in the form of clinical champions and senior management support of the improvement work, frontline worker engagement in mapping out "current state" processes, identifying waste and designing an improved "future state," using metrics to develop and track interventions, and defining realistic project scope. FINAL REFLECTIONS: As UMHS's experience applying Lean Thinking to our patient care processes has grown, so have support, enthusiasm, and expertise within the organization. UMHS's Lean Thinking system, now known as the Michigan Quality System, has emerged as the core improvement strategy.

Assessing uncertainty in outsourcing clinical services at tertiary health centers.

When tertiary health centers face capacity constraint, one feasible strategy to meet service demand is outsourcing clinical services to qualified community providers. Clinical outsourcing enables tertiary health centers to meet the expectations of service timeliness and provides good opportunities to collaborate with other health care providers. However, outsourcing may result in dependence and loss of control for the tertiary health centers. Other parties involved in clinical outsourcing such as local partners, patients, and payers may also encounter potential risks as well as enjoy benefits in an outsourcing arrangement. Recommendations on selecting potential outsourcing partners are given to minimize the risks associated with an outsourcing contract.

The effect of distance to primary care physician on health care utilization and disease burden.

BACKGROUND: The relationship of distance to care with total health care utilization and disease burden is not well understood among the managed care population. PURPOSES: The aim of this study was to examine the relationship between the distance from a patient's home to his or her primary care physician (PCP) and the patient's health characteristics. METHODOLOGY: This was a population-based study of commercial health maintenance organization (HMO) members enrolled in one medium-sized health plan in Michigan in 2001. This study measured health care utilization from all settings (per member per year [PMPY]). Disease burden measure was based on the Adjusted Clinical Group (ACG) system. Distance was defined as straight-line distance between a member's residency and his or her PCP. Both direct standardization and regression modeling were used to assess the effect of distance on utilization. FINDINGS: Both utilization and disease burden increased as distance increased, especially among members selecting PCPs in an academic health system (AHS). The difference in observed utilization between local (0-10 miles) and distant (>30 miles) members was 973 dollars (PMPY) for the AHS and 193 dollars (PMPY) for the community independent practice associations (IPA). Compared with age-sex adjustment, ACG adjustment reduced local-distant difference within the same practice group to a greater extent (281 dollars and 59 dollars remaining for the academic and community groups, respectively). Distance as a whole exerted a statistically significant positive effect on either disease burden score or utilization in regression modeling. PRACTICE IMPLICATIONS: HMO members consume more health care and had higher disease burden as their distance from their PCPs increased. The distance traveled by the individuals to their PCPs could be incorporated when adjusting managed care financial risk models. Other remedies include negotiating higher capitation rates for distant patients, carving out distant patients from any financial risk model, or excluding such patients from provider performance assessment.

Lean health care: what can hospitals learn from a world-class automaker?

BACKGROUND: With health care costs continuing to rise, a variety of process improvement methodologies have been proposed to address the reported inefficiencies in health care delivery. Lean production is one such method. The management philosophy and tools of lean production come from the manufacturing industry, where they were pioneered by Toyota Motor Corporation, which is viewed as the leader in utilizing these performance improvement methods. Lean has already enjoyed tremendous success in improving quality and efficiency in both the manufacturing and the service sector industries. RESULTS: Health care systems have just begun to utilize lean methods, with reports of improvements just beginning to appear in the literature. We describe some of the basic philosophy and principles of lean production methods and how these concepts can be applied in the health care environment. We describe some of the early success stories and ongoing endeavors of lean production in various health care organizations. We believe the hospital is an ideal setting for use of the lean production method, which could significantly affect how health care is delivered to patients. CONCLUSIONS: We conclude by discussing some of the potential challenges in introducing and implementing lean production methods in the health care environment. Lean production is a novel approach to delivering high-quality and efficient care to patients, and we believe that the health care sector can anticipate the same high level of success that the manufacturing and service industries have achieved using this approach. Hospitalists are primed to take action in delivering care of greater quality with more efficiency by applying these new principles in the hospital setting.

Disease burden in the managed care population at an academic medical center: the effect of adding local partners.

PURPOSE: Academic medical centers (AMCs) have traditionally cared for the most severely ill patients. AMCs' effort to meet the challenges of managed care contracts may be nullified by adverse selection unless payment mechanisms adequately consider the health risk of the AMC's managed care population. The authors compared the disease burden between the University of Michigan Health System (UMHS) and its community competitors and assessed the effect of adding local primary care partners through strategic outsourcing on these differences in disease burden. METHOD: This is a population-based study from one managed care plan in Michigan. The study population was commercial members (n = 127, 892) enrolled in the plan for the entire 12 months of 2001. The authors derived several morbidity measures from age and sex, Adjusted Clinical Groups, and Aggregated Diagnosis Groups using administrative data. RESULTS: Compared to community groups, the UMHS consistently had a higher disease burden, while the nonacademic groups as a whole had more young members with acute conditions. After the UMHS partnered with two local primary care practice groups in their area, this AMC-local partner group had an equal or lower disease burden than the remainder of the community groups that experienced a slightly higher proportion of members with multiple medical conditions. CONCLUSIONS: The higher disease burden borne by AMCs is a complex phenomenon. Without local partners, the UMHS did experience higher disease burden, although the degree depends on the measurement of morbidity. Partnering with carefully selected local primary care groups may ameliorate the AMC's disproportionate disease burden.

Strategic outsourcing of clinical services: a model for volume-stressed academic medical centers.

Many academic medical centers have significant capacity constraints and limited ability to expand services to meet demand. Health care management should employ strategic thinking to deal with service demands. This article uses three organizational models to develop a theoretical framework to guide the selection of clinical services for outsourcing.

New organizational and funds flow models for an academic cancer center.

The clinical impetus to develop cancer centers has been the recognition that many cancer patients require a comprehensive treatment plan coordinated across multiple specialties. Developing an effective organizational and financial structure among the multiple entities that comprise an academic cancer center has, however, been a challenge. The authors describe an effort to realize a sustainable clinical operation at the University of Michigan Comprehensive Cancer Center (UMCCC) by developing an appropriate management structure and financial model. The modified organizational structure established a clear line of administrative authority and held faculty members accountable for their effort in the UMCCC. A unified budget aligned financial incentive among all stakeholders to increase efficiency, revenue, and margin. The authors report preliminary financial evidence of the success of the new managerial structure.