Issue link: https://beckershealthcare.uberflip.com/i/332156
54 Gastroenterology 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 pro- grams 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 nar- row 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 "globaliza- tion" (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 gas- troenterologist'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 be- cause certain physicians tend to get the "sicker" and "older" patients or may see tougher cases, especially if you are a 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 re- quirements 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 with- drawal 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 liter- ature clearly has shown that endoscopic procedures are clearly over-utilized for certain patient populations (Medicare beneficiaries) and for certain di- agnoses (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 be- come more efficient in our delivery of care. PV: Over time, I can see great impact on patient care by the implementa- tion of value-based care. Everyone will benefit. Not only will there be finan- cial 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 Health- grades 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 diag- noses 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 in- crease 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 gastroenterolo- gists) 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 disor- der. 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 challeng- ing, 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 de- mand 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 pro- vider and provider to provider can be critical to ensuring positive outcomes. n