Specialists are Testing the Value-based Care Waters

MHE Publication, MHE July 2021, Volume 31, Issue 7

After having thrived in a fee-for-service healthcare system, can chronic disease specialists be enticed to switch?

Specialists are key partners for delivering value-based care, particularly for patients with chronic diseases. This involves the appropriate diagnosis of conditions, including rare diseases, stewardship of diagnostics and value-based prescribing for specialty medications.

Lawrence Kosinski, M.D., MBA, founder and chief medical officer of SonarMD, a tech-enabled care coordination solution for digestive health, notes the great majority of high per-capita cost of care comes from specialists’ orders.

“Right now, most specialty value-based care programs focus on procedure episodes like hip or knee surgery,” he says. “But specialists also care for patients with complex, chronic medical conditions, and this care accounts for $220 billion in healthcare spending annually — not including the fast-growing specialty pharma expense.”

A large proportion of that cost is variable. For example, among gastrointestinal (GI) diseases, inflammatory bowel disease (IBD) drives more than half the total variable cost. That’s an indicator that there’s an opportunity to better manage those patients with IBD through value-based care arrangements.

“If clinical and financial incentives are aligned, specialists would be further incentivized to keep patients out of acute-care settings, lowering the overall cost of care and improving quality of life for patients with chronic disease,” Kosinski says.

A major challenge is that many chronic conditions do not have current published clinical pathways. “The care is provided in a reactive fashion, as it is dependent upon a patient recognizing symptom deterioration,” observes Kosinski. “Unfortunately, they often don’t detect this deterioration until a hospital visit is necessary.”

Additionally, specialists typically do not have a financial incentive to proactively manage complex care or specialty formulary costs. Many specialists have thrived in a healthcare system geared toward fee for service, which rewards doing procedures and sometimes writing a prescription. The stakes are higher now with specialty drugs making up an increasing proportion of total drug expenditures. Kosinski ticks off some ways to infuse more value into healthcare: aligning payer and provider incentives with the best outcomes for the lowest possible costs, deploying technology to make efficient use of whatever resources are at hand and getting patients vested in their healthcare.

Keith Boell, D.O., chief quality officer for population initiatives at Geisinger, a healthcare system and health plan headquartered in Danville, Pennsylvania, says the industry has been slow to get specialists involved in value-based care.

“Specialists can help influence the care of patients across a large geographic footprint, including patients they may not see in their clinics,” he says. “When the majority of reimbursement is fee for service, specialists are incentivized to focus on patients in their clinics and may not become as engaged in the broader population health discussion.”

Distance can be a major barrier for some patients. Many specialists practice in large, multispecialty practices, frequently at academic medical centers, requiring patients to travel from their local communities. Many people in and out of healthcare see telehealth solving that problem.

Getting tech involved

Good patient outcomes have served as the most convincing argument for physicians to accept value-based care strategies. In addition, creating a transparent and representative physician leadership that the medical staff has confidence in is of critical importance. It is essential to have a forum to allow rapid dissemination of information and to exchange feedback. Technology can play a critical role in encouraging this coordination.

Daniel Hommes, M.D., a gastroenterologist who has worked and published extensively in value-based care, notes specialists offer a higher chance of achieving better clinical outcomes and patient experiences at lower cost. An example would be if their clinical network is delivering on Healthcare Effectiveness Data and Information Set quality measures tied to financial incentives and bonus structures. “The biggest challenge is getting a technology infrastructure in place that can facilitate providers (with offering) value-based care since traditional EMR systems do not offer this,” he says.

SonarMD’s IBD solution can leverage technology to facilitate patient engagement and care coordination while driving financial and clinical alignment with payers. “This was especially helpful during the pandemic to ensure patients were proactively engaged and the care team could catch flare-ups before hospitalization was required,” Kosinski says. “Our work with these practices is contracted through Horizon Blue Cross Blue Shield of New Jersey, so physicians are paid to proactively manage IBD, and Horizon Blue Cross can share in savings from the program.”

A value-based care strategy

At Geisinger, specialists are involved in several value-based care initiatives. One is a program called “Lower GI Flag,” a collaboration between Geisinger and Medial EarlySign that uses machine learning to identify patients at the highest risk for colorectal cancer who are overdue for screenings.

“We can do targeted outreach to get those patients scheduled for a colonoscopy,” Boell says. “Additionally, advanced endoscopy services can help patients avoid higher cost settings, including the operating room.”

Because gastroenterologists spend the majority of their time doing colonoscopies for screening and surveillance of colon polyps, which have little variation in cost, these procedures should be bundled into 14-day episodes, which would bring gastroenterologists into the value chain, Kosinski says.

“But gastroenterologists must also think beyond colonoscopies and endoscopies to consider more integrated care management for patients with chronic conditions,” he continues. “This is an opportunity to broaden their financial model and keep patients in their practices instead of in acute care settings.”

Tonny M. Lee, M.D., medical director of the GI laboratory and chair of the Gastroenterology Division at Providence Little Company of Mary Medical Center in Torrance, California, says as healthcare delivery continues to evolve on both regional and national levels, health systems must also strive to meet new and expected standards.

With that in mind, great efforts have been implemented to achieve the goals of value-based care, including enhancing patient experiences, elevating providers’ clinical experience and serving unique needs of various communities. To meet these demands, the hospital has created clinical institutes across eight specialties. “The clinical institute model differentiates Providence from other health systems by pulling on the expertise across our 11-hospital region to share latest findings, treatment options and any advances through research,” says Lee.

For example, physician leaders have met on a routine basis to share clinical concerns and establish consensus guidelines for acute GI hemorrhage management, colorectal cancer prevention and approaches to treating patients with irritable bowel syndrome and IBD, he says. “The clinical institute model has facilitated a free exchange of ideas among surgeons, radiologists, oncologists and gastroenterologists, fostering a stronger bond and camaraderie on a personal level," observes Lee. Patients are less likely to seek care academic medical centers as a result. Ultimately, the efforts lead to better access and outcomes and improved patient satisfaction.

Physician engagement continues to be an issue, though, as the system’s goals and those of independent specialists often do not completely align, Lee continues. Educating clinicians to recognize the value of quality over quantity remains a top priority. The disruption of healthcare caused by the COVID-19 pandemic and a renewed interest in preventive care may help push them along.

Many health systems are banking on value-based care, now and in the future, Lee says. It’s an opportune time for specialists to get involved and join the trend, he says: “By adopting value-based care, specialists not only can achieve the Holy Grail of improved patient care but also can potentially enhance financial rewards by shared savings and other revenue enhancements.”

Keith Loria is a freelance writer in the Washington, D.C., area.