Taking on the Paradigm Shift in Care Delivery: What Does Value-Based Care Mean for Gastroenterologists?
Question: What do you think defines value-based care in gastroenterology?
William Katkov, MD, Providence Saint John's Health Center, Santa Monica, Calif.: In broad terms, value-based care refers to the trend across all medical specialties that links reimbursement to quality metrics. In gastroenterology, in particular, this has been emerging over the past five years or so. This development has been driven primarily by CMS, but is also being embraced by payers across the board. Value-based care will ultimately play a role in physician credentialing, accreditation and certification.
Lawrence Kosinski, MD, MBA, Managing Partner, Illinois Gastroenterology Group, Elgin: The traditional definition of value uses the formula: Value = (Quality + Service) / Cost. Since quality was so difficult to define, value was only increased by improving the service and/or decreasing the cost. The lack of definition of quality moved the definition to Value = (Outcome + Service) / Cost. This made more sense since we could finally have a cost for an outcome, but what is the outcome upon which this formula is focused? Is it the performance of a procedure or the care provided in a hospitalization?
"The market has now defined the outcome based not upon the appropriate management of a disease, but rather upon the maintenance of the health of a population," according to the "Value-Based Cost Sharing In The United States And Elsewhere Can Increase Patients' Use Of High-Value Goods And Services" Health Affairs report. So the most appropriate current value equation is: Healthcare Value = Health of a population/Cost. Our goal is therefore to increase the amount of health we get out of each dollar spent.
Ingram Roberts, MD, Crozer-Keystone Health System, Crozer Gastroenterology Associates, Springfield, Pa.: My definition of "value-based care" would include care that is evidence-based (i.e. supported by data in the GI literature).Value-based care should be delivered efficiently, expeditiously and at reasonable cost to the healthcare system.
Gilbert Simoni, MD, Los Robles Hospital, Thousand Oaks, Calif.: It is defined by improving the following parameters:
• Quality of care
• Patients safety
• Cost reduction
Hardeep Singh, MD, St. Joseph Hospital, Orange, Calif.: Value based care should be defined as care of patients focused on cost of care, quality of care and outcomes of the care provided.
Pankaj Vashi, MD, Lead National Medical Director, National Clinical Director of Gastroenterology/Nutrition, Metabolic Support and Gastroenterology, Midwestern Regional Medical Center, Zion, Ill.: My take on value-based care is very simple. Provide evidence based care with good outcomes and make recommendations on screening, testing, treatment and follow-up as per the guidelines established by the American College of Gastroenterology and American Gastroenterological Association.
The healthcare environment is continually evolving. The future of the healthcare landscape is moving from a fee-for-service to a pay-for-performance model. Whether it's a single practice physician or large healthcare organization, success will be based on performance measures for quality and efficiency. And of course, both the perceived and actual experience the patient encounters before, during and after care plays a major role in defining value-based care.
Q: What do gastroenterologists need to do to transition to this model of care?
WK: Everyone needs to prepare for the transition. Most gastroenterologists are involved in preparation to some degree. It is often a labor intensive undertaking, and there are significant costs involved. The incentives and penalties have not been large thus far, but this will inevitably change.
A positive aspect of this development, for GI, is that most of the quality measures being used are evidence-based. Measures include polyp detection rate, colonoscope withdrawal time, cecal intubation rate and quality of bowel preparation. This is just the beginning. Patient satisfaction will also begin to play a significant role.
LK: To provide value, gastroenterologists need to find their place in the healthcare value chain. To do this we need to embrace accountable care entities, redesign our practices to run more efficiently and engage our patients through the use of portals and apps.
IR: Transitioning to such a model would require a reevaluation of conventional E and M coding, which is a "bullet point" framework for doctor-patient encounters that often truly does not represent how and why both physicians and patients think.
GS: Most of us are doing that, using quality measures to improve those parameters.
HS: In order to transition to this type of care we will need to assess how we are approaching patients with specific problems and diagnoses, and analyze how we can improve our methods of delivery and outcomes. Specifically in gastroenterology we need to assess how we can maintain quality of care while decreasing costs.
For example, we need to look at how quickly we see patients in the hospital presenting with GI bleeding, how quickly those patients undergo an endoscopy if indicated, and how quickly the patients are discharged. Most importantly, we need to assess the outcomes of those patients presenting with the diagnosis of GI bleeding when treated by us.
PV: The field of gastroenterology is unique since it involves invasive procedures used for screening purposes. Standard documentation of processes, procedures, quality measures and outcomes are the most important shifts that are needed. Gone are the days when physicians are paid for service irrespective of outcomes. The care provided to the patient needs to always be front and center. There needs to be an integrated approach to care, where physicians across the disciplines are collaborating with one another and working towards what is best for the patient as one cohesive entity.
Q: How do you think reimbursement will be affected by value-based care?
WK: I think the insurance industry will follow the lead of CMS. Currently, CMS mandates that gastroenterologists record these quality measures. The reward or penalty is financial. There will be an increasing demand to record these measures. Penalties will increase for not participating in quality programs and eventually eligibility to participate in Medicare could be affected.
LK: Unfortunately, we are just beginning to see the effects of the exchanges. The future will be influenced by them greatly. Insurance products will be narrow networked and markedly discounted. Those who embrace risk will enjoy a risk premium, but those who either choose not to or are unable due to their practice structures will realize a markedly decreased fee for service payment as a result. ACOs will result in a similar effect on reimbursements.
IR: As I mentioned above, we are already seeing more examples of "globalization" (e.g., office visits before screening colonoscopies which are no longer reimbursed) which many of our surgical colleagues are quite familiar with already. An example in another medical specialty where we may see changes coming might be that oncologists often see many of their cancer patients in remission for numerous chronological follow ups. These types of office visits might not be reimbursed in the future. A similar scenario may occur with inflammatory bowel patients in remission who are frequently seen in the gastroenterologist's office when no change in medical management is required. I can think of any number of other examples.
GS: Most likely reimbursements will decrease in many cases. The reason is not because many gastroenterologists do not provide quality care, but because certain physicians tend to get the "sicker" and "older" patients or may see tougher cases, especially if you are subspecialist (for example having a high number of chronic disease patients). Therefore, they may not be able to fulfill the cost reduction parameter.
HS: Ultimately, our outcomes and costs of care will be compared to our peers. Based on this, insures will likely pay us based on whether or not we can maintain good outcomes. They could even give us bonuses based on good outcomes, shorter length of stay, lower complication rate, etc. Another model would be for them to give the hospital a bundle payment per diagnosis — the hospital or HMO/IPA would then divide the payment to the physician and adjust the payment based on performance.
Q: What tools can gastroenterologists use for the reporting requirements that accompany value-based care?
WK: The major GI societies, the ASGE, AGA and ACG, offer instruments for recording and measuring these quality metrics. Most of the measures at this point relate to colonoscopy, and are implemented in ambulatory endoscopy centers. Many centers have developed their own tools.
Q: What benefits can gastroenterologists expect from value-based care?
WK: The immediate benefits of value-based care are financial. But, this trend will also elevate the quality of care across specialties and practices. A good example is withdrawal time in colonoscopy. The relationship between withdrawal time and neoplasm detection rates is based on good clinical research and confers clear benefits for patients. Therefore, the reward for meeting that standard is not only financial, but also improved patient care.
LK: As healthcare "money ball" is rolled out, there will be a larger focus on outcomes and the metrics that measure them. This will result in more uniform provision of care with less variability in outcome. This is good for all.
IR: The benefits will be cost savings primarily to the overall system. The literature clearly has shown that endoscopic procedures are clearly over-utilized for certain patient populations (Medicare beneficiaries) and for certain diagnoses (GERD). Hopefully, gastroenterologists will benefit from delivering higher quality care without utilizing large amounts of resources. Physicians should be incentivized and rewarded for these clinical practices in contrast to the traditional "fee-for-service" that rewards resource over usage.
GS: There may be some financial benefits for a select group of gastroenterologists who tend to see younger and healthier patients. Patients can expect to see a trend toward improvement in quality of care and reduction in cost of healthcare.
HS: A benefit may be that it would encourage us to see how we can improve the ways that we are providing care to patients. It will likely force us to become more efficient in our delivery of care.
PV: Over time, I can see great impact on patient care by the implementation of value-based care. Everyone will benefit. Not only will there be financial incentives for the gastroenterologist based on good outcomes, but also patients will benefit by receiving better care and being empowered to take control of their health and wellness. Cancer Treatment Centers of America at Midwestern Regional Medical Center was recently awarded the 2014 Healthgrades Outstanding Patient Experience Award. I believe this award is a direct reflection of where the world of healthcare is heading. The questions asked to patients from all across the nation address issues such as cleanliness, pain management, responsiveness to patients’ needs and more. In all disciplines, including gastroenterology, the patient experience is something that will need to remain at the top of all provider strategies.
Q: How do you think value-based care will evolve over the next few years?
WK: The value-based approach is not going to be restricted to procedures. It will be extended into other areas. In the practice setting, CMS has already provided an incentive to meet very basic quality measures for specific diagnoses such as hepatitis C screening. This type of approach will continue to expand.
As the use of quality measures grows, the transparency of this data will increase and physicians need to be prepared for that. This is all facilitated by electronic medical records.
As quality becomes more clearly linked to reimbursement, value-based care may play a role at the health system level. Health systems participating in population management will be evaluating their own physician members based on quality measures.
IR: We are already seeing changes occurring and I expect more will come. The caveat is that gastroenterologists will be "told" exactly what to do for each diagnosis and what is "not allowed"; medicine is often inexact and the best practicing physicians know what is appropriate and what managements are not. Society must decide what physicians overall (and gastroenterologists) are "worth." Increasing patient loads, decreasing reimbursements and loss of autonomy may drive physicians into "burnout"—which is a loss to our patients and to our profession.
GS: There is a lot to learn. There may be different value-based care parameters for different groups of gastroenterologists based on the population they see, or the types of conditions they treat. Currently there are VBCs for: inflammatory bowel disease, viral hepatitis, malnutrition, GERD, Barrett's esophagus, obesity, colorectal cancer screening/surveillance and prevention and GI motility disorder. There may be many more conditions added to this list.
HS: I think it will be a big adjustment for us in private practice especially because it is a drastic change compared to how we've done things in the past. There will undoubtedly be some growing pains and it will take some time for all of us to adjust to this new approach to providing medical care.
PV: Over the next five years, the transition to value-based care will be challenging, but necessary. There needs to be an evolution to change from volume of service delivered to value of service delivered. On top of delivering better care to patients, the hope is that the financial incentives to physicians and providers for practicing value-based care will help play a role in the evolution. However, I truly believe that the patient is going to play a more prominent role in value-based care. Woven into and throughout everything discussed here is the need for communication. The patient of the future will be more informed and demand to be communicated with on multiple levels. It will be important for us as providers and healthcare professionals to create environments to foster that communication. Closing the communication gap between patient and provider and provider to provider can be critical to ensuring positive outcomes.
More Articles on Gastroenterology:
ASCs vs. HOPDs: 21 Statistics on 2013 Medicare Reimbursement for Colonoscopy
Fine-Tune Patient Communication in Gastroenterology: The Role of EHR, Value of Face-to-Face Interaction & More
4 Recent GI-Driven Center Openings & Technology Acquisitions
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