- Email: [email protected]
How Does a Gastroenterologist Demonstrate Value?
Gastroenterology 2014;147:927–929
AGA BOARD STRATEGIC UPDATE How Does a Gastroenterologist Demonstrate Value? Lawrence Kosinski Illinois Gastroenterology Group, Elgin, Illinois
The AGA is committed long-term to the issue of quality and to demonstrating how gastroenterologists can enhance their value via improved outcomes and increased efficiency and cost-effectiveness. We’ve asked Dr Larry Kosinski, an innovative thinker in this area, to share his thoughts on the value equation and what it means for gastroenterologists.
B
efore we can answer this question, we must define value.
Definition of Value Some would define value using the formula: Value ¼ Quality = Cost: Unfortunately, this definition resulted in the development of process measures directed at how services were being provided rather than a focus on health outcomes. The next refinement of the Value Equation therefore became: Value ¼ Outcome = Cost: However, this equation begs the question of the definition of “outcome.” For example, is “outcome” 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 the health of a population.1 So the most appropriate current Value Equation is: Healthcare Value ¼ Health of a population=Cost: Health would be defined as stated in the preamble of the World Health Organization—Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity. AGA has spent the last 7 years developing measures that focus on outcomes and population management. They are available at http://www.gastro.org/practice/ quality-initiatives/performance-measures. Our goal is therefore to maximize the health of a population while providing cost-efficient care. If a patient in that population is healthy, our goal is to maintain their health through preventive health maintenance measures (CRC Screening and Surveillance). Value is driven by the quality of
the colonoscopy and the appropriate use of surveillance intervals. If the patient has an acute illness the goal is to restore that patient to health (Acute GI Bleed). Value here is driven by rapid control of bleeding and appropriate triage. Finally, if the patient has a chronic illness such as inflammatory bowel disease (IBD), the goal is to manage the care of that illness so as to bring that patient as close to normal health as possible. Value in patients with chronic disease like IBD is augmented by appropriate adherence to evidence based guidelines and close engagement with the patient. Population Health is the aggregate management of that population and its respective components.
What Is Our True Competitive Advantage? How do Gastroenterologists as specialists find their place or niche in this changing marketplace? Where does our competitive advantage exist and where are our strongest barriers to entry? Gastroenterologists are the most knowledgeable healthcare professionals for digestive diseases. This is an unarguable point. Our knowledge of disease, pathophysiology and outcomes is our most significant competitive advantage and represents the strongest barrier to entry for less trained professionals like primary care providers and mid-level providers. Unfortunately, the last 3 decades have denigrated this aspect of our professional services. We have become too dependent upon procedural revenue which has risen to unsustainable levels and is vulnerable to technologic replacement. We need to recapture our knowledge-based competitive advantage and exploit it. In order to re-establish our competitive advantage, we need to pursue risk-based structures designed to compensate us for what we know rather than what we do. There is always a risk premium for those who can manage it and it’s time for us to get our share.
Why Is This Happening Now? Changes are being driven by demographic, financial, and political realities. The US spends 20% of the revenue it takes in on healthcare and that is breaking the back of the tax payer.2 Add to this the demographic reality that the baby Abbreviations used in this paper: CRC, colorectal cancer; IBD, inflammatory bowel disease. © 2014 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2014.08.001
AGA SECTION
Podcast interview: www.gastro.org/ gastropodcast. Also available on iTunes.
928
Lawrence Kosinski
Key Items for AGA Members to Know The current value equation is: Healthcare Value ¼ Health of a population/Cost. 10,000 new beneficiaries join Medicare every day and will continue to do so for the next 10 years, until all 75 million have signed up. This necessitates new structures that will encourage value over volume and reorient the focus of all healthcare professionals on the maintenance of health rather than the treatment of disease. Gastroenterologists are positioned well to succeed in a future system that is based on value as defined as cost to maintain the health of a population. You can find all the tools discussed in this article by doing a quick search on AGA’s website www.gastro. org.
boom has hit Medicare age and you can see why value must be our focus. We are adding 10,000 new Medicare beneficiaries every day and will continue to do so for the next 10 years until all 75 million have signed up. This has become a political battle that we have all seen played out in the U.S. Congress. Clearly new structures are necessary that will encourage value over volume and reorient the focus of all healthcare professionals on the maintenance of health rather than the treatment of disease.
How Do Gastroenterologists Find Their Place in the Health Care Value Chain? Figure 1 demonstrates a simplified health care value chain.3 Through the Roadmap to the Future of GI Practice, AGA is helping gastroenterologists understand how to demonstrate value.4 There are 3 components to our approach:
(1) Alternative Payment Models
AGA SECTION
The current reimbursement structure is changing so that interests are aligned and incentives promote the preservation of health rather than the treatment of disease. This will require the acceptance of risk- bearing contracts where providers are compensated for maintaining health in an accountable structure. This can and will take multiple forms including bundled payment with warranties, episode-based payments, condition-based payments, and intensive medical homes for specific diseases like IBD.
Gastroenterology Vol. 147, No. 4
(2) Practice Redesign Financial pressures will intensify over time which will compress margins. Each member of the value chain must examine their specific costs of doing business and seek ways to provide more cost-efficient care. All professionals must be working to the capacity of their licensure and privileging. This will mean increased use of mid-level providers and nurse specialists instead of physicians. It may also mean that nonphysicians will be performing some select procedures.
(3) Patient Engagement We cannot succeed without the cooperation and participation of the patient. Patient engagement is the new elephant in the room. No longer do we have the freedom to wait for patients to call us with a problem. Because we will be at risk for their care, we must proactively seek them out and maintain a high level of engagement. This will require the use of all forms of communication from apps to portals. Fortunately, technology is providing us with some cutting edge tools for this including cloud-based solutions.
How Is AGA Helping GIs Succeed in This New Environment? The practice goal of the AGA Strategic Plan of 20135 states: AGA will provide its members with resources, tools and skills to enhance practice and provide quality patient care. To accomplish this goal, the AGA has developed its Roadmap to the Future of GI designed to provide tools for each of the previously mentioned 3 components, which are clearly delineated in the Objectives of the Roadmap. Educational programs are being developed to address these needs. Here are some examples:
Move to Alternative Payment Models The AGA Quality improvement timeline outlines the reimbursement impact of changing policies like Physician Quality Reporting System, meaningful use and the valuebased payment modifier. http://www.gastro.org/practice/ aga-quality-improvement-timeline The AGA Digestive Health Recognition Program helps you demonstrate to payers that you provide high-value care. Read our emails, newspaper, and journals for frequent articles on what you need to know about accountable care arrangements (such as narrow networks, shared savings models) AGA has developed a bundled payment model for colonoscopy that can inform practice negotiations with local and regional payors.6
Figure 1. Health care value chain. Reprinted with permission from Lawton R. Burns, Wharton School Colleagues, The Health Care Value Chain: Producers, Purchasers, and Providers. Copyright © 2002 by John Wiley & Sons, Inc.
October 2014
AGA has worked with the American College of Physicians to develop a High Value Care Coordination Toolkit to provide guidance to primary care physicians about the type of preparation needed to enable a more effective referral to GIs. It covers GERD, chronic diarrhea, rectal bleeding, abdominal pain, hepatitis C and abnormal liver function tests.
The AGA has positioned itself to lead the way through the implementation of its Roadmap for the Future of GI. It is designing the tools that will enable its members to succeed in the new environment of healthcare. I’m excited to be part of it.
References 1.
AGA has developed a suite of clinical decision tools and corresponding care pathways for members in a variety of practice settings. AGA has developed an ICD-10 Resource Center to help practices transition from ICD-9 to ICD-10.
2.
Patient Engagement AGA is exploring new ways to measure and improve patient experience and engagement via online applications and interactive patient education materials.
3.
Conclusion The current changing healthcare environment will place significant stress on each of us and our respective practices. Our industry is not unlike others though and change is inevitable and in fact creates opportunity. It’s time to recapture our place in the health care value chain. We are the most knowledgeable in our space and are positioned well to succeed in a future system that is based in value that is defined by cost to maintain the health of a population. To accomplish this we must embrace risk and use our knowledge to succeed in accountable structures. Concurrently, we must look within our practices and not fear to redesign older models in favor of those that will be positioned for the new environment. Lastly, but probably most importantly, we must engage our patients beyond disease management and embrace the use of technologies that will facilitate this engagement; they are the Holy Grail.
929
4.
5. 6.
Thomson S, Schang L, Chernew ME. Value-based cost sharing in the United States and elsewhere can increase patients’ use of high-value goods and services. Health Aff 2013;32:704–712. Centers for Medicare and Medicaid Services, National Health Expenditures Projections 2011-2021. Available: www.cms.gov/Research-Statistics-data-and-Systems/ Statistics-Trends-and-Reports/NationalHealthExpend Data/Downloads/Proj2011PDF.pdf. Accessed March 2014. Burns LR, Wharton School Colleagues. The health care value chain: producers, purchasers, and providers. 1st ed. San Francisco, CA: Jossey Bass Wiley, 2002. Available: ftp://ftp.unicauca.edu.co/Facultades/FIET/Materias/ Gestion_tecnologica/2005/Clase%203/healt%20chain% 20value.pdf. Accessed March 2014. Miller HD. Win-win-win approaches to healthcare cost control through physician-led payment reform. Clin Gastroenterol Hepatol 2014;12:355–358. AGA 2013 Strategic Plan. September 2013. Brill JV, Jain R, Margolis PS, et al. A bundled payment framework for colonoscopy performed for colorectal cancer screening or surveillance. Gastroenterology 2014; 146:849–853.
Reprint requests Address requests for reprints to: Lawrence Kosinski, MD, MBA, AGAF, Illinois Gastroenterology Group, 745 Fletcher Drive, Elgin, Illinois 60123. e-mail: [email protected]. Conflicts of interest The author discloses no conflicts.
AGA SECTION
Practice Redesign
How Does a Gastroenterologist Demonstrate Value?
AGA BOARD STRATEGIC UPDATE How Does a Gastroenterologist Demonstrate Value? Lawrence Kosinski Illinois Gastroenterology Group, Elgin, Illinois
The AGA is committed long-term to the issue of quality and to demonstrating how gastroenterologists can enhance their value via improved outcomes and increased efficiency and cost-effectiveness. We’ve asked Dr Larry Kosinski, an innovative thinker in this area, to share his thoughts on the value equation and what it means for gastroenterologists.
B
efore we can answer this question, we must define value.
Definition of Value Some would define value using the formula: Value ¼ Quality = Cost: Unfortunately, this definition resulted in the development of process measures directed at how services were being provided rather than a focus on health outcomes. The next refinement of the Value Equation therefore became: Value ¼ Outcome = Cost: However, this equation begs the question of the definition of “outcome.” For example, is “outcome” 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 the health of a population.1 So the most appropriate current Value Equation is: Healthcare Value ¼ Health of a population=Cost: Health would be defined as stated in the preamble of the World Health Organization—Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity. AGA has spent the last 7 years developing measures that focus on outcomes and population management. They are available at http://www.gastro.org/practice/ quality-initiatives/performance-measures. Our goal is therefore to maximize the health of a population while providing cost-efficient care. If a patient in that population is healthy, our goal is to maintain their health through preventive health maintenance measures (CRC Screening and Surveillance). Value is driven by the quality of
the colonoscopy and the appropriate use of surveillance intervals. If the patient has an acute illness the goal is to restore that patient to health (Acute GI Bleed). Value here is driven by rapid control of bleeding and appropriate triage. Finally, if the patient has a chronic illness such as inflammatory bowel disease (IBD), the goal is to manage the care of that illness so as to bring that patient as close to normal health as possible. Value in patients with chronic disease like IBD is augmented by appropriate adherence to evidence based guidelines and close engagement with the patient. Population Health is the aggregate management of that population and its respective components.
What Is Our True Competitive Advantage? How do Gastroenterologists as specialists find their place or niche in this changing marketplace? Where does our competitive advantage exist and where are our strongest barriers to entry? Gastroenterologists are the most knowledgeable healthcare professionals for digestive diseases. This is an unarguable point. Our knowledge of disease, pathophysiology and outcomes is our most significant competitive advantage and represents the strongest barrier to entry for less trained professionals like primary care providers and mid-level providers. Unfortunately, the last 3 decades have denigrated this aspect of our professional services. We have become too dependent upon procedural revenue which has risen to unsustainable levels and is vulnerable to technologic replacement. We need to recapture our knowledge-based competitive advantage and exploit it. In order to re-establish our competitive advantage, we need to pursue risk-based structures designed to compensate us for what we know rather than what we do. There is always a risk premium for those who can manage it and it’s time for us to get our share.
Why Is This Happening Now? Changes are being driven by demographic, financial, and political realities. The US spends 20% of the revenue it takes in on healthcare and that is breaking the back of the tax payer.2 Add to this the demographic reality that the baby Abbreviations used in this paper: CRC, colorectal cancer; IBD, inflammatory bowel disease. © 2014 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2014.08.001
AGA SECTION
Podcast interview: www.gastro.org/ gastropodcast. Also available on iTunes.
928
Lawrence Kosinski
Key Items for AGA Members to Know The current value equation is: Healthcare Value ¼ Health of a population/Cost. 10,000 new beneficiaries join Medicare every day and will continue to do so for the next 10 years, until all 75 million have signed up. This necessitates new structures that will encourage value over volume and reorient the focus of all healthcare professionals on the maintenance of health rather than the treatment of disease. Gastroenterologists are positioned well to succeed in a future system that is based on value as defined as cost to maintain the health of a population. You can find all the tools discussed in this article by doing a quick search on AGA’s website www.gastro. org.
boom has hit Medicare age and you can see why value must be our focus. We are adding 10,000 new Medicare beneficiaries every day and will continue to do so for the next 10 years until all 75 million have signed up. This has become a political battle that we have all seen played out in the U.S. Congress. Clearly new structures are necessary that will encourage value over volume and reorient the focus of all healthcare professionals on the maintenance of health rather than the treatment of disease.
How Do Gastroenterologists Find Their Place in the Health Care Value Chain? Figure 1 demonstrates a simplified health care value chain.3 Through the Roadmap to the Future of GI Practice, AGA is helping gastroenterologists understand how to demonstrate value.4 There are 3 components to our approach:
(1) Alternative Payment Models
AGA SECTION
The current reimbursement structure is changing so that interests are aligned and incentives promote the preservation of health rather than the treatment of disease. This will require the acceptance of risk- bearing contracts where providers are compensated for maintaining health in an accountable structure. This can and will take multiple forms including bundled payment with warranties, episode-based payments, condition-based payments, and intensive medical homes for specific diseases like IBD.
Gastroenterology Vol. 147, No. 4
(2) Practice Redesign Financial pressures will intensify over time which will compress margins. Each member of the value chain must examine their specific costs of doing business and seek ways to provide more cost-efficient care. All professionals must be working to the capacity of their licensure and privileging. This will mean increased use of mid-level providers and nurse specialists instead of physicians. It may also mean that nonphysicians will be performing some select procedures.
(3) Patient Engagement We cannot succeed without the cooperation and participation of the patient. Patient engagement is the new elephant in the room. No longer do we have the freedom to wait for patients to call us with a problem. Because we will be at risk for their care, we must proactively seek them out and maintain a high level of engagement. This will require the use of all forms of communication from apps to portals. Fortunately, technology is providing us with some cutting edge tools for this including cloud-based solutions.
How Is AGA Helping GIs Succeed in This New Environment? The practice goal of the AGA Strategic Plan of 20135 states: AGA will provide its members with resources, tools and skills to enhance practice and provide quality patient care. To accomplish this goal, the AGA has developed its Roadmap to the Future of GI designed to provide tools for each of the previously mentioned 3 components, which are clearly delineated in the Objectives of the Roadmap. Educational programs are being developed to address these needs. Here are some examples:
Move to Alternative Payment Models The AGA Quality improvement timeline outlines the reimbursement impact of changing policies like Physician Quality Reporting System, meaningful use and the valuebased payment modifier. http://www.gastro.org/practice/ aga-quality-improvement-timeline The AGA Digestive Health Recognition Program helps you demonstrate to payers that you provide high-value care. Read our emails, newspaper, and journals for frequent articles on what you need to know about accountable care arrangements (such as narrow networks, shared savings models) AGA has developed a bundled payment model for colonoscopy that can inform practice negotiations with local and regional payors.6
Figure 1. Health care value chain. Reprinted with permission from Lawton R. Burns, Wharton School Colleagues, The Health Care Value Chain: Producers, Purchasers, and Providers. Copyright © 2002 by John Wiley & Sons, Inc.
October 2014
AGA has worked with the American College of Physicians to develop a High Value Care Coordination Toolkit to provide guidance to primary care physicians about the type of preparation needed to enable a more effective referral to GIs. It covers GERD, chronic diarrhea, rectal bleeding, abdominal pain, hepatitis C and abnormal liver function tests.
The AGA has positioned itself to lead the way through the implementation of its Roadmap for the Future of GI. It is designing the tools that will enable its members to succeed in the new environment of healthcare. I’m excited to be part of it.
References 1.
AGA has developed a suite of clinical decision tools and corresponding care pathways for members in a variety of practice settings. AGA has developed an ICD-10 Resource Center to help practices transition from ICD-9 to ICD-10.
2.
Patient Engagement AGA is exploring new ways to measure and improve patient experience and engagement via online applications and interactive patient education materials.
3.
Conclusion The current changing healthcare environment will place significant stress on each of us and our respective practices. Our industry is not unlike others though and change is inevitable and in fact creates opportunity. It’s time to recapture our place in the health care value chain. We are the most knowledgeable in our space and are positioned well to succeed in a future system that is based in value that is defined by cost to maintain the health of a population. To accomplish this we must embrace risk and use our knowledge to succeed in accountable structures. Concurrently, we must look within our practices and not fear to redesign older models in favor of those that will be positioned for the new environment. Lastly, but probably most importantly, we must engage our patients beyond disease management and embrace the use of technologies that will facilitate this engagement; they are the Holy Grail.
929
4.
5. 6.
Thomson S, Schang L, Chernew ME. Value-based cost sharing in the United States and elsewhere can increase patients’ use of high-value goods and services. Health Aff 2013;32:704–712. Centers for Medicare and Medicaid Services, National Health Expenditures Projections 2011-2021. Available: www.cms.gov/Research-Statistics-data-and-Systems/ Statistics-Trends-and-Reports/NationalHealthExpend Data/Downloads/Proj2011PDF.pdf. Accessed March 2014. Burns LR, Wharton School Colleagues. The health care value chain: producers, purchasers, and providers. 1st ed. San Francisco, CA: Jossey Bass Wiley, 2002. Available: ftp://ftp.unicauca.edu.co/Facultades/FIET/Materias/ Gestion_tecnologica/2005/Clase%203/healt%20chain% 20value.pdf. Accessed March 2014. Miller HD. Win-win-win approaches to healthcare cost control through physician-led payment reform. Clin Gastroenterol Hepatol 2014;12:355–358. AGA 2013 Strategic Plan. September 2013. Brill JV, Jain R, Margolis PS, et al. A bundled payment framework for colonoscopy performed for colorectal cancer screening or surveillance. Gastroenterology 2014; 146:849–853.
Reprint requests Address requests for reprints to: Lawrence Kosinski, MD, MBA, AGAF, Illinois Gastroenterology Group, 745 Fletcher Drive, Elgin, Illinois 60123. e-mail: [email protected]. Conflicts of interest The author discloses no conflicts.
AGA SECTION
Practice Redesign
How Does a Gastroenterologist Demonstrate Value?