US medicine is fragmented and economically unsustainable and has vast opportunities for quality improvement. A current solution is to create large accountable care organizations. Fragmentation should be reduced and clinical coordination be improved, which means that gastroenterologists and other specialists will be challenged to change practices from traditional reactive and consultative care to a principal care model in which they manage appropriate clinical service lines. The pay-off in improved patient care and financial stability can be substantial. This article discusses a proposed evolution toward clinical service line management that might be achieved by an independent single specialty practice.
Whether or not accountable care organizations (ACOs) become a reality during the evolution of health care in the United States, they will force changes in the care of patients with complex or chronic diseases toward a more organized, coordinated model. Providers will be held accountable for outcomes, and reimbursement will move from a volume-driven model to one based more on demonstrable improvement in health value. If physicians want to avoid being marginalized during this transition, they must present viable models of care that are evidence based and meet the needs of major stakeholders. Physicians must demonstrate that they are responsible stewards of health care resources who can achieve excellent patient health outcomes. Berwick and colleagues have defined this overarching goal of US medicine as the triple aim, which is to improve care of the individual, maximize health of a population, and reduce overall costs.
Gastroenterologists have an opportunity to assume a central role as managers of both medical care and health care resources for populations of patients with several chronic digestive diseases, including inflammatory bowel disease (IBD), gastroesophageal reflux disease (GERD), chronic liver disease, colorectal cancer prevention, and nutritional disorders among others. When specialists manage a population, this is termed principal care in contradistinction to primary care. As primary care providers (PCPs) are evolving their practices into patient-centered medical homes (PCMHs), specialists can become patient-centered medical home neighbors (PCMH-N). Here, patients with certain chronic conditions are comanaged by the PCMH and the specialty practice, but the responsibilities and communication expectations are clearly defined to maintain PCP-specialty coordination. At times, some patients will identify the specialist as their principal point of contact with the medical system. Examples of PCMH-N can be found in oncology. As an example, when a cancer becomes the key health issue for patients, then the management of their health care would be transitioned to an oncologist. Although this is uncommon in gastrointestine (GI), in a formal sense, the concept of principal caregiver is apparent in many current clinical practices and even can be introduced in a staged manner for those in traditional practices of any size.
As pointed out by other authors in this monograph, evolving practice into a principal care model will enhance patient outcomes and will allow to advance up the food chain of reimbursement (see articles 4 and 9 elsewhere in this issue). Achieving success will require physicians to focus on high-cost patients, coordinate care across multiple service sites, build practice infrastructure to support a chronic care model, increase office visit opportunities, reduce fragmentation, respond to the acute needs of patients, manage medicines more proactively, and provide appropriate preventive care.
This article outlines a stepwise approach to managing a clinical service line. Minnesota Gastroenterology PA has implemented the initial steps of such a program. Minnesota Gastroenterology is a large, integrated, single-specialty practice in the upper Midwest. Several subspecialty areas of focus have been developed over the last 5 to 8 years, including IBD, esophageal disorders, and chronic liver disease. This monograph discusses the IBD program as it stands now and outlines future plans as we move aggressively into an advanced chronic care practice model. The author draws illustrations from other two other service lines to explain the hypothesis that an independent practice can provide a must-have clinical service that a regional ACO or health care system would find difficult to replicate within an employment model. Independent gastroenterology practices are decreasing in number, and many specialty practices are being purchased by hospital systems. Although some high-profile physician-hospital organizations (PHOs), such as Mayo Clinic, Cleveland Clinic, Geisinger Health System, or Intermountain Health Care, can develop robust GI service lines, most PHOs do not have sufficient depth in their GI departments to provide the same level of expertise, geographic coverage, or coordination that can be achieved using the model described here. Practices that can embrace current imperatives to integrate care of complex patients and develop PCMH-N will become indispensable (and irreplaceable) for regional health care systems. Practices that remain focused factories of endoscopic procedures risk becoming simply a discounted commodity. Of importance, this model is scalable, that is, it does not require practices to be large and highly capitalized. What is needed is a patient-centered focus, a coordinated team of providers who can deliver the needed services in a timely manner, and a sufficient health information technology (HIT) to manage patients at a population level and extract clinical outcome data.
Essential underlying practice infrastructure
Today, US health care is preoccupied with competition for market share, cost shifting, and cost reduction, all played out within a zero-sum game. As articulated by Porter and Teisberg, the right kind of competition will improve outcomes by incorporating 3 guiding principles: (1) emphasis on value for patients, (2) organization around medical conditions and care cycles, and (3) measurement of risk-adjusted outcomes and costs. Building an infrastructure within a GI practice to accomplish such a transition requires the following 7 steps (usually in this order):
- 1.
Development of a strong physician-led governance in which the primary focus is on everyone together building a patient-centered practice.
- 2.
Alignment of compensation and partners’ philosophy with the mission and vision of the practice (usually meaning that production-based compensation must be modified to support program building and team-based care).
- 3.
Building a robust HIT system that is capable of easy data entry, population identification (eg, all patients with IBD), registry function, action alerts, standard order sets, clinical decision support (CDS) tools, and other advanced information methodology.
- 4.
Support of dedicated subspecialists with recognized disease-specific expertise (and ongoing continuing medical education).
- 5.
Clinical care algorithms that define points of care transfer (PCP to specialist, general specialist to the IBD Care Team), evidence-based guidelines (with the capability of assessing compliance), and validated outcome measures.
- 6.
Capability of resource identification (what is spent on the population) and Lean analytic capability.
- 7.
Development of the care team and infrastructure to provide acute care, urgent care, and chronic care.
Although these steps seem daunting and will take time, small practices can accomplish most, if not all, aspects of a PCMH-N and examples have been published. Large specialty practices have advantages with economies of scale, enhanced capital, the ability to cross-subsidize (many partners still performing colonoscopy, whereas others managing complex cognitive care), and other factors not found in small offices. The relative ease of information transfer, proximity of the needed services, and culture of cooperation advantage the multispecialty practices. Although current reimbursement does not favor a PCMH-N model, changes that will emanate from the Patient Protection and Affordable Care Act (PPACA) will change medical payments in a manner that will support this transformation. Other chapters in this monograph have outlined the key components of the PPACA as they relate to value-based payments and accountability (eg, chapters 1 and 9).
Governance structure, partner commitment, and compensation
The current governance structure of this practice includes participation in leadership roles and committees by a wide variety of physicians who understand that their contributions help support the larger practice goals and are not provided to further personal agendas. Most positions are volunteer, although leadership positions are compensated enough so that partners do not feel compromised economically when they assume leadership of this large corporation (more than 500 employees). Compensation demonstrates the practice commitment to physician leadership and the importance of these positions. Secondly, widespread participation in committees or Clinical Focus Groups assures of the depth of expertise needed to design robust programs.
Key committees determine how the practice delivers care, including the Operations Management Group and Clinical Focus Groups (eg, IBD), each of which reports to the Clinical Practice Committee. The Quality Committee provides improvement goals and performance measures. The Finance Committee defines financial expectations and implements production analysis using a monthly Dashboard as described in a previous publication. The HIT Department performs internal data extraction, builds population registries, and has worked with Featherstone Informatics Group (FigMD) to develop an electronic interface with the American Gastroenterological Association (AGA) Digestive Health Outcomes Registry (DHOR). For details, see http://www.gastro.org/practice/digestive-health-outcomes-registry .
The cooperative philosophy of the partnership developed over the decade after the initial integration in 1998 (3 practices merged and then the practice grew by recruitment). Various compensation systems are debated, and finally (for the moment), a 50:50 split in professional income in which 50% is shared and 50% is based on production is agreed on. The shared portion is diluted by an even split of facility income from the practice-owned ambulatory surgery centers as regulated by the Stark laws, which means that only 18% of income is based on productivity, a percentage that encourages high production but narrows the margin between the highest and lowest earners. An internal quality incentive (1% of total income) is enough to focus attention on annual quality goals (mostly because of the competitive nature of the partners). As of now, there is substantial support for partners who want to develop Centers of Excellence and team-based care as long as the plans are vetted through all appropriate committees and the partnership is educated through a fair process of presentation and feedback.
Governance structure, partner commitment, and compensation
The current governance structure of this practice includes participation in leadership roles and committees by a wide variety of physicians who understand that their contributions help support the larger practice goals and are not provided to further personal agendas. Most positions are volunteer, although leadership positions are compensated enough so that partners do not feel compromised economically when they assume leadership of this large corporation (more than 500 employees). Compensation demonstrates the practice commitment to physician leadership and the importance of these positions. Secondly, widespread participation in committees or Clinical Focus Groups assures of the depth of expertise needed to design robust programs.
Key committees determine how the practice delivers care, including the Operations Management Group and Clinical Focus Groups (eg, IBD), each of which reports to the Clinical Practice Committee. The Quality Committee provides improvement goals and performance measures. The Finance Committee defines financial expectations and implements production analysis using a monthly Dashboard as described in a previous publication. The HIT Department performs internal data extraction, builds population registries, and has worked with Featherstone Informatics Group (FigMD) to develop an electronic interface with the American Gastroenterological Association (AGA) Digestive Health Outcomes Registry (DHOR). For details, see http://www.gastro.org/practice/digestive-health-outcomes-registry .
The cooperative philosophy of the partnership developed over the decade after the initial integration in 1998 (3 practices merged and then the practice grew by recruitment). Various compensation systems are debated, and finally (for the moment), a 50:50 split in professional income in which 50% is shared and 50% is based on production is agreed on. The shared portion is diluted by an even split of facility income from the practice-owned ambulatory surgery centers as regulated by the Stark laws, which means that only 18% of income is based on productivity, a percentage that encourages high production but narrows the margin between the highest and lowest earners. An internal quality incentive (1% of total income) is enough to focus attention on annual quality goals (mostly because of the competitive nature of the partners). As of now, there is substantial support for partners who want to develop Centers of Excellence and team-based care as long as the plans are vetted through all appropriate committees and the partnership is educated through a fair process of presentation and feedback.
HIT infrastructure
HIT within the practice is based on NextGen Electronic Medical Record and NextGen Enterprise Practice Management System, 2 components of a fully integrated, network-wide electronic system that records all practice functions. An internal HIT team used NextGen templates to develop an endoscopic reporting system, a pathology result reporting system (fully searchable and linked to endoscopy), registries (hepatitis C and IBD), a recall system, and templates for cognitive clinic functions (with voice recognition). The pathology database is designed using the Systematized Nomenclature of Medicine-Clinical Terms (SNOMED CT) terminology. Finally, the authors use the reporting functions of the electronic health record (EHR) to generate report cards and the monthly performance dashboard described previously.
The key difference between many current gastroenterology EHRs is the need for interfacing with external databases (both regional EHRs and registries), and the capabilities needed for clinical service line management include the capability of identifying specific populations, recording in a standardized (template) fashion, and implementing alerts (both proactive and retroactive). Both issues are being resolved rapidly as EHRs mature and cloud technology becomes available as a tool to integrate information from disparate data sources.
For the IBD-focused care team to succeed, standardized clinical data input should be developed and then patients who qualified for the team’s care should be identified. The format suggested here is but an example of how one might construct data entry and is only partially based on what is currently present in the system. The initial screenshot of the IBD template series (for patients with Crohn’s disease) is presented in Fig. 1 .
Related posts:
Impact of Health Care Reform on the Independent GI Practice
Electronic Medical Records and the Gastroenterologist
A Letter to Fellows: Transitioning From Training into Practice in Uncertain Times
Medical Practice Integration: Going Big in Private Practice
Demonstrating Value: Registries and Beyond
Gastroenterologists and Accountable Care Organizations
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