Payment Models

Developing a Specialty Medical Home Contract

February 16, 2018 11:40 am

Health plan and UPMC physicians worked together to identify the top one-third of high-utilization patients and enrolled them into a specialized medical home.

UPMC Health Plan and gastroenterologists at the University of Pittsburgh Medical Center (UPMC) are in the final stage of a three-year pilot of a new model of care—called a specialty medical home—for high-cost patients with inflammatory bowel disease (IBD). 

The health plan is providing a wide range of support—including funding for key staff positions needed in the new care model—and the UPMC Gastroenterology Division is assuming responsibility for coordinating and managing all the healthcare services needed by patients enrolled in the specialty medical home.  

“We are working to make certain that not only is the care of the inflammatory bowel disease occurring, but each individual member is being taken care of from a preventive services standpoint and receiving behavioral health services or anything else they need,” says Stephen Perkins, MD, chief medical officer, Commercial and Medicare Services, UPMC Health Plan. When the pilot ends, the two entities will analyze the results to determine a payment method that rewards clinicians appropriately while saving money for the health plan. 

The first two years of the specialty medical home pilot have already provided several important lessons: 

  • Hospital and emergency department (ED) use is dramatically reduced under this care model. 

  • Patients like the specialty home care. 

  • Patients’ quality of life has improved. 

  • The total cost of care is reduced. 

See related toolProgress Measures for IBD Specialty Medical Home 

IBD in Context

About 1.6 million Americans are affected with Crohn’s disease and ulcerative colitis—described collectively as IBD. Both are autoimmune disorders that are increasing in prevalence globally. 

For payers, patients with IBD have some of the highest per-member per-month costs of any patient group. Annual direct healthcare costs average $12,000 to $20,000 per patient, although the range of cost varies much more widely than that, depending on the disease severity and how well the patient’s symptoms are managed (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, Vol. 15, pp. 986-997). Some patients with IBD experience remission for long periods of time; others are treated successfully with expensive biologics; still others suffer from poorly controlled symptoms that trigger ED visits, hospitalizations, and surgery. 

The high healthcare costs for patients with IBD have not always been well understood. Many patients receive ED and inpatient care to address pain that is not directly related to an IBD flare up, and their gastroenterologists might not even be aware of the hospitalizations. 

In recent years, gastrointestinal (GI) specialists have come to recognize that mental health conditions, such as depression and anxiety, and psychosocial challenges—illness perception, difficulty with coping, unhealthy behaviors, and stress—contribute significantly to the poor health status of some IBD patients.   

Most GI practices, however, are not equipped to help patients address those issues, prompting trips to the ED and pain management providers in search of relief. The goal of Total Care IBD—UPMC’s specialty medical home—is to take a “whole person” approach that improves the quality of care patients receive while lowering the overall costs. 

Getting Started

It was a subset of high-cost patients with IBD that first attracted UPMC Health Plan’s attention. “Not only did they have high levels of service utilization, including the treatment of their bowel disease, but they also had problems with unplanned care services such as emergency department presentations and admissions to the hospital, and they were just very difficult to manage,” Perkins says. 

In early 2015, health plan leaders started discussions with Miguel Reguiero, MD, head of UPMC’s Clinical Inflammatory Bowel Disease Center, who was developing an interdisciplinary approach to IBD care. The IBD Center had seen a 30 percent increase in patients in the previous three years, and the health plan had experienced a 27 percent increase in members with IBD during that time. “The health plan said, ‘If you could add additional staff and really look at this from a holistic, whole patient view, what would you need?’” Reguiero says. 

He pointed to Eva Szigethy, MD, a UPMC psychiatrist who specializes in patients with chronic diseases like Crohn’s and ulcerative colitis. He believed that a team approach to IBD care, with a focus on care coordination and addressing patients’ psychosocial needs, could help patients better manage their symptoms, improving the quality of life while reducing healthcare utilization.   

The health plan’s data analysis showed that 16 percent of IBD members accounted for 48 percent of its per-member per-month costs for IBD care, and 29 percent of patients accounted for almost 80 percent of total annual costs (Reguiero, M., Click, B., Holder D, et al., “ Constructing an Inflammatory Bowel Disease Patient-Centered Medical Home,” Clinical Gastroenterology and Hepatology, August 2017, vol. 15, pp. 1148-1153). Working with Reguiero, they determined that they needed at least 300 high-cost, high-utilizing patients to justify the expense associated with a specialized medical home. Considering that about 30 percent of IBD patients fall into the “high-utilizing” category, they set the goal of enrolling at least 1,000 patients into the specialized medical home by the end of the pilot. 

New Approach to Patient Care

In UPMC’s old model of IBD care—which is still standard medical practice across the country—Reguiero served as a specialist who made or confirmed an IBD diagnosis and prescribed a treatment plan. “If there wasn’t active inflammation driving their pain or if they had depression or anxiety that was probably linked indirectly to their disease, these people would go home and then end up going to the ED because we weren’t really addressing their care needs,” he says. 

In the Total Care-IBD model, he co-leads a team with Szigethy as the psychiatrist and includes nurse practitioners, nurse coordinators, a social worker, a dietitian, and health coaches. Team members use a “complexity grid” to identify and measure patients’ health risks and health needs. This allows the team to quantify patient status in four domains—biological, psychological, social, and health system utilization—to understand the level of complexity and apply the appropriate interventions. 

Several technologies—including telepsychiatry visits, health coach virtual visits, remote monitoring, and behavioral interventions via smart phone—are used to support patients outside of face-to-face visits with their care team. 

Collaboration in Action

During the specialized medical home pilot, the health plan and medical center are collaborating in ways that are highly unusual in health care today. Indeed, Reguiero said the Total Care-IBD collaboration is possible largely because of UPMC’s integrated delivery and finance system.

Reguiero and his colleagues have redesigned their IBD care protocols to provide and coordinate a large array of services, and the health plan has provided essential supports, including: 

  • Utilization data on its IBD population so the highest-utilizing patients can be targeted for enrollment into the specialized medical home. 

  • Funding for Reguiero to hire nurse coordinators, certified nurse practitioners, a dietitian, a social worker, and a psychiatrist to build the specialized medical home team. 

  • Support from the health plan’s staff, including nurses and a social worker who make house calls to certain high-utilizing patients. 

  • Operational support, including data analytics, publicizing the IBD socialized medical home to its members, and facilitating approval of IBD medications. 

Beyond that, the health plan’s health coaches and case managers are available to help identify and address patient needs. “When the patient is outside of the office and needs some additional assistance, education, or just encouragement with regards to the treatment regimen, we can help reinforce the treatment plan,” says Amy Helwig, MD, vice president for quality improvement and performance, UPMC Health Plan. 

Similarly, health plan coaches and case managers identify barriers to care, such as lack of transportation or caregiver support at home, that can adversely affect patient health status. 

Results to Date

Full results of the pilot to date have not been published, but Reguiero and co-authors shared some preliminary results in a recent paper (Reguiero, M., Click, B., Holder D, et al., “ Constructing an Inflammatory Bowel Disease Patient-Centered Medical Home,” Clinical Gastroenterology and Hepatology, August 2017, vol. 15, pp. 1148-1153): 

  • Of the more than 325 patients enrolled in the first year, 90 percent were retained in the second year. 

  • Quality-of-life measures for enrolled patients significantly improved. 

  • Patient satisfaction with physician communication was in the 99th percentile. 

  • Most enrolled patients were assigned a health plan coach and used UPMC’s electronic medical record portal to communicate with clinicians 

  • Emergency department visits and hospitalizations were reduced by 50 percent in the pilot’s first year. 

That big reduction in ED and hospital use took the specialized medical home creators by surprise; their goal had been a 2 percent drop in emergency and inpatient utilization in the first year. Reguiero says he is “cautiously optimistic” that the new model of care will continue to keep patients out of the hospital in the long run, but he is waiting for results from the entire three years of the pilot before he is sure.  

That’s because Reguiero attributes the reduced ED and hospital utilization, in part, to the psychosocial services that specialized medical home patients receive. It is common for patients with chronic disease to grow weary of therapy sessions, so he wonders if they will become less engaged over time and require more acute care because of it.    

“However, we are doing a lot of remote telepsychiatry with these patients, so we are not asking them to come into the office frequently and that seems to be engaging them longer-term,” he says. 

Care Model of the Future?

Reguiero and his health plan colleagues think they are helping create the future of IBD care in America, but they cannot yet forecast the payment and care-delivery model that will replace what’s currently in place. 

As the treatment of IBD becomes more complex, with the need for closely monitored biological drugs and psychosocial support, patients are increasingly being referred to specialty centers, Reguiero says. And, as the cost effectiveness of whole patient care becomes clearer, payers should be motivated to support highly coordinated, team-based care. 

But not all patients will have access to programs like Total Care-IBD, so community-based gastroenterologists will need to find a way to improve the value of their care as well. Thus, GI practices need to start assessing their options for providing whole-person care.  

“They may want to consider who are the different team members I need, such as those with a social work skill set, to meet the needs of my patients?” Helwig says. “Maybe it’s not having those individuals in the [physician] group but having established relationships” for patient referrals. 

In their jointly authored paper, health plan and medical center leaders said the optimal payment model for specialized medical home care has not yet been determined “but probably will include either a shared savings or global cap approach, with an emphasis on the total cost of care reduction.” 

That will require the GI practice to be aware of all the care the patient receives, know the cost of that care, and be able to take financial risk for delivery of that care, the authors said. 

Lola Butcher is a freelance writer and editor based in Missouri. 

Interviewed for this article: 

Amy Helwig, MD, MS, is vice president, quality improvement and performance, UPMC Health Plan, Pittsburgh.  

Stephen Perkins, MD, is chief medical officer, Commercial and Medicare Services, UPMC Health Plan, Pittsburgh.  

Miguel D. Regueiro, MD, is IBD clinical medical director and co-director, Total Care-IBD, University of Pittsburgh Medical Center, Pittsburgh.


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