Key elements of consumer-oriented care—patient engagement and care integration—also are core components in ongoing efforts to enhance the value that patients get from specialists.
In an ideal world, people with volatile chronic conditions could identify specialists whose patients are more likely to avoid emergency department (ED) visits, inpatient admissions, and the debilitating health crises that prompt them.
A handful of gastroenterology practices are paving the way for that to happen. In response to the value movement in health care, leading gastroenterologists in Chicago and Pittsburgh are adapting the patient-centered medical home model to treat patients with inflammatory bowel disease (IBD)—and the benefits to the patients have surprised even the physicians.
Their care models are somewhat different, but here’s what they have in common: Each has reduced ED visits and hospitalizations for patients with IBD by more than 50 percent.
Most gastroenterology practices are not set up to provide the patient engagement and integrated care that are essential to the medical home model. But as the implications of this new approach to chronic care management become clear, patients with IBD and other chronic conditions can be expected to seek out the providers who can keep them healthy.
The same goes for health plans and employers. For example, Blue Cross and Blue Shield of Illinois is so happy with the medical home care delivery model for IBD care used by Illinois Gastroenterology Group (IGG), Chicago’s largest gastroenterology practice, that it has expanded the concept to three other practices around the state. The health plan contracted with SonarMD, which provides technology that supports IGG’s patient engagement strategy, so that the other practices can deliver the same proactive care for high-cost patients.
“We’ve replicated our original approach with IGG and hope to replicate the same results for our members,” Donna Levigne, divisional senior vice president of healthcare delivery for Blue Cross and Blue Shield of Illinois, says in emailed comments.
Miguel Regueiro, MD, a gastroenterologist and co-director of the Total Care-IBD specialty medical home at UPMC, foresees a day when integrated, high-touch care for patients diagnosed with IBD becomes standard. Providers thus need to get prepared.
“If they are not doing something like this in the future, the payer is going to demand it,” he says. “Trying to figure this out in their own region is going to be important.”
Why Health Plans Have a Stake
IBD is an umbrella term for two autoimmune digestive disorders—Crohn’s disease and ulcerative colitis—that affect about 1.6 million Americans. Although the conditions can go into remission for long periods, both have painful and serious symptoms that can wreak havoc on patients’ lives. More than half of people with Crohn’s disease will require surgery to address damage to their colon. Some patients with ulcerative colitis, the more common condition, must have their colon removed.
Because of surgeries and hospitalizations—and, in some cases, the use of expensive biologics—patients with IBD have high healthcare costs. Annual direct costs are estimated at $12,000 to $20,000 per patient.
In recent years, specialists have come to recognize that patients with IBD often have mental health and psychosocial comorbidities that exacerbate symptoms and complicate treatment. In a white paper published by the American Gastroenterology Association earlier this year, Regueiro and coauthors write that “whole person care”—medical care plus psychosocial, environmental, and behavioral interventions—may “result in achieving highest health value.” a
Some health plans are stepping up to support the new approach to care. Through its “intensive medical home” contract, Blue Cross and Blue and Shield of Illinois pays IGG a per member, per month fee to support the labor-intensive care delivery model. After a successful pilot, the insurer started encouraging gastroenterology practices across the state to follow the example.
“This specialty intensive medical home model—which is aimed at improving patient care while reducing avoidable complications and associated treatment costs—has enormous potential for making the healthcare system work in a sustainable way,” Levigne says.
Meanwhile, in Pittsburgh, UPMC Health Plan uses the term specialty medical home to describe the Total Care-IBD program developed by Regueiro and his colleagues. Total Care-IBD is in the third year of a pilot in which the gastroenterology care team serves as the principal provider for patients with IBD, responsible for coordinating and managing all their healthcare needs, including behavioral health and psychosocial support.
UPMC Health Plan is supporting the work with funding for additional staff. With the pilot ending next year, the plan and associated providers are working on the details of a novel alternative payment model.
‘Hovering’ Over Chronically Sick Patients
The idea of adapting the patient-centered medical home approach to IBD care began when IGG’s Lawrence Kosinski, MD, MBA, analyzed Blue Cross and Blue Shield of Illinois claims data on the Crohn’s disease patients in his practice to understand why the care of those patients is so expensive. He found that ED visits and hospitalizations were the big cost drivers—and that, in the majority of cases, patients had not visited their gastroenterologist in the month before excruciating pain or severe dehydration from diarrhea required emergency treatment.
“We’ve uncovered something that I myself didn’t have any idea we would encounter: Patients with chronic disease flirt with the edge all the time,” he says.
Patients may get so used to feeling ill that they don’t recognize when their status is deteriorating until they are in a crisis. In response, Kosinski and his colleagues developed a whole new way of interacting with patients who have Crohn’s and ulcerative colitis. Nurse care managers—aided by a smartphone app that asks patients to answer a few questions about their health status on the first day of each month—constantly monitor patients. At the first sign of deterioration, patients are urged to visit the gastroenterologist’s office to head off a serious problem.
“People who have serious chronic diseases like IBD need a little hovering,” Kosinski says. “You need to be there for them not only when they perceive they need intervention, but when we perceive they need intervention.”
In the first two years of IGG’s intensive medical home contract, inpatient costs for patients with Crohn’s and ulcerative colitis dropped by about 60 percent. Overall costs for these patients are about 10 percent lower than they were before implementation of the new care delivery model, Kosinski says, and significantly lower than the costs for patients in a control group.
Integrating Behavioral Health
When Regueiro and his colleagues were developing their specialty medical home for high-utilizer IBD patients, they hoped to decrease both ED visits and hospitalizations for those patients by 2 percent from the previous year. In fact, ED visits fell by 52 percent and hospitalizations by 53 percent during the first year of the pilot, Regueiro says.
He co-directs the specialty medical home with psychiatrist Eva Szigethy, MD, PhD, an expert in behavioral health services for patients with chronic illnesses. They supervise a large care team—nurse practitioners, nurse coordinators, social workers, and dietitians—that provides a wide range of services not typically offered by gastroenterology practices. Many Total Care-IBD patients also work with UPMC Health Plan health coaches on lifestyle modifications. b
Based on the pilot’s early results, Regueiro is “cautiously optimistic” that the specialty medical home care model will point the way to a better standard of care for patients with IBD. He believes integrated psychosocial support, including easy-to-access telepsychiatry, is one key to success. Other vital elements are team-based care, enhanced access for outpatient visits, and care coordination.
“Whether it will be called a medical home going forward, I don’t know,” he says. “But as the disease becomes more complex, with the need to provide psychosocial care and help with pain management, specialty centers are going to get more referrals and a new care model will evolve.”
Lola Butcher writes about healthcare business and policy topics for several HFMA publications.
Interviewed for this article: Lawrence Kosinski, MD, MBA, partner, Illinois Gastroenterology Group, Chicago; Donna Levigne, divisional senior vice president-healthcare delivery, Blue Cross and Blue Shield of Illinois; Miguel Regueiro, MD, co-director, Total Care-IBD, University of Pittsburgh Medical Center, Pittsburgh.
a. Szigethy, E.M. Allen, J.I., Reiss, M., et al., “White Paper AGA: The Impact of Mental and Psychosocial Factors on the Care of Patients With Inflammatory Bowel Disease,” Clinical Gastroenterology and Hepatology, July 2017.
b. Regueiro, M., Click, B., Holder, D., et al., “Constructing an Inflammatory Bowel Disease Patient-Centered Medical Home,” Clinical Gastroenterology and Hepatology, August 2017.