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53 Gastroenterology Taking on the Paradigm Shift in Care Delivery: What Does Value-Based Care Mean for Gastroenterologists? By Carrie Pallardy V alue-based care is changing healthcare delivery and moving toward reshaping the way physicians are compensated. Here six gastroen- terologists share how they define value-based care and what they think it means for their field. Question: What do you think defines value-based care in gastro- enterology? 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 reimburse- ment to quality metrics. In gastroenterology, in particular, this has been emerging over the past five years or so. This devel- opment 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 defini- tion 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 appropri- ate 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, expeditious- ly 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 • Patient safety • Cost reduction Hardeep Singh, MD, St. Joseph Hospital, Orange, Calif.: Value-based care should be defined as care of patients fo- cused 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, Meta- bolic 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 health- care landscape is moving from a fee-for-service to a pay-for-performance model. Whether it's a single practice physician or large healthcare organiza- tion, 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 un- dertaking, and there are significant costs involved. The incentives and penal- ties 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 enti- ties, 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 en- counters 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 pa- rameters. HS: In order to transition to this type of care we will need to assess how we are ap- proaching 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 pro- cedures 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 ir- respective 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.