Growth and Efficiency in Gastroenterology

It may be time for GI practices to step out of the procedure-heavy comfort zone to prepare for value-based reimbursement and an aging population.

This article first appeared in the June 2015 issue of HealthLeaders magazine.

When Katie Couric underwent a colonoscopy on live television in 2000 as host of the Today show, she not only heightened awareness of the important role colonoscopies play in detecting colon cancer, but she actually boosted the rate of colonoscopies among men and women. Jay Monahan, Couric's husband, died from colon cancer at age 42, and the experience led to Couric's efforts to raise awareness about screening for the disease. The strategy worked and subsequently ushered in a boon to GI practices.

While there are other less-invasive screening tests available for colon cancer, such as the fecal occult blood test (FOBT) or fecal immunochemical test (FIT), which can be done at home annually, colonoscopies are regarded as the gold standard and are the most commonly used screening test to detect polyps that can turn into colon cancer.

"Gastroenterology started gaining traction because of the volumes from the 'Couric effect,' " says Yousif A-Rahim, MD, PhD, chief medical officer for Nashville-based Covenant Surgical Partners, owner and operator of 28 ambulatory surgical centers, most of which are GI-focused, across the country. "We've enjoyed a relatively sanguine era since 2000."

Insurance coverage for colonoscopies, from private payers and Medicare, also helped improve colonoscopy volumes at GI practices. A-Rahim says that at the GI ASCs that Covenant runs, colonoscopies and endoscopies are the "bread and butter" of its revenue streams. Still, technological advances, a mature market—after all, Couric's TV colonoscopy was 15 years ago—and reimbursement reductions are pressures that all GI practices are
facing today.

Some providers, such as Covenant, remain focused on the procedural mainstays of their specialty, but other gastroenterology providers are preparing for a fee-for-value transition by partnering with insurance companies and focusing on specific populations to improve readmission rates.

Success key No. 1: Optimize efficiency
As CMO at Covenant Surgical Partners, A-Rahim has a broad view of the landscape that GI practices are operating in today. He is part of the executive team that is involved in acquiring new practices, but it was only seven years ago that he was on the other side of the negotiating table with Covenant. In 2013, A-Rahim sold the majority of shares of his GI practice, Pacific Endoscopy in Oahu, Hawaii, to the firm.

Specialists, such as GI physicians, have not been immune to the economic realities of running a private practice. There has been a greater focus on primary care physicians leaving private practice for hospital-based employment, but specialists are also looking for some economic cover, which corporate partners such as Covenant and Nashville-based AMSURG can provide.

"With Covenant coming on board, we were able to expand," says A-Rahim. "Pacific Endoscopy now is three different entities, with a fourth center that is under agreement."

Among the primary benefits of becoming a Covenant partner, says A-Rahim, is the standardization of back-end office tasks that take a physician away from seeing patients. HR, payroll, collections, dealing with insurance companies, and recruiting new physicians are all tasks taken over by Covenant's professional arm.

"The majority of doctors are not entrepreneurs," says A-Rahim. "I was a clinician, and the CEO and cofounder of Pacific Endoscopy, and I took on the business development, but suddenly, I don't have to do that anymore. I have someone who is highly specialized and that's all they do."

Each practice that's acquired sells a majority share to Covenant and it, in addition to the practical matters it offloads from physician and staff, also provides pathology laboratory management and anesthesia services.

But prior to partnering with Covenant, Pacific Endoscopy was already optimizing its efficiency to keep patient visits under two hours, which is "tremendous," according to A-Rahim.

"There is a lot of work that goes into it," he says. "We are completely paperless, and before a patient is admitted, we have their history, insurance is verified, and they are registered."

A-Rahim says risk stratifying patients is another way Pacific Endoscopy optimizes its throughput. If a patient is advanced in age, then that person will likely be scheduled for a colonoscopy in the morning so he or she isn't fasting through the afternoon. He estimates that of the 13,000 patients Pacific Endoscopy sees annually, 70% are there for colonoscopies and 30% for endoscopies.

"It's also based on their comorbidities," says A-Rahim. "Before a patient is admitted, we have their history and we can tell if the procedure is likely to be complicated, so we can set aside the amount of time a physician would need with that patient."

Covenant's anesthesia services are the real "magic" that improved efficiency at Pacific Endoscopy, according to A-Rahim. That's because Covenant uses propofol for moderate or conscious sedation of patients who are getting a colonoscopy or endoscopy. A-Rahim says patients are easily arousable because propofol leaves their system quicker, impacting their recovery time.

"Traditionally, we could only do two procedures an hour; now we can actually do three, sometimes four," says A-Rahim, who estimates that the use of propofol has also improved Pacific Endoscopy's overall practice efficiency by 30% because it eliminated the use of nurses who were in the exam room to monitor patients under conscious sedation.

"At Pacific Endoscopy, we had two RNs in the room who were paid between $85,000 and $90,000 a year, and those RNs are used somewhere else; they're not in the room anymore," he says.

The two RNs have been replaced with one certified registered nurse anesthetist, who administers propofol and monitors the patient. The CRNA's salary is about $200,000. A-Rahim says there is partial reimbursement for the CRNA's services, which helps offset the cost, though it's the increase in volume that makes up for the increased expense of using propofol. He also says patients prefer it.

"Our patients love it," says A-Rahim. "You feel great, you're not nauseous, you're not throwing up. When we used conscious sedation, it took 30 minutes to two hours for patients to be semi-recovered to walk; with propofol it's 15 minutes. That's huge because we can take more patients."

Success key No. 2: Value-based care
While the outlook for colonoscopies remains stable, some GI practices are looking to other nonprocedural endeavors that will prepare them for a future under value-based care.

For example, Illinois Gastroenterology Group, an independent group with 45 GI physicians, 16 offices, and seven ASCs serving the Chicago suburbs, recently partnered with BlueCross BlueShield of Illinois to pilot a care model for patients with inflammatory bowel disease, which includes Crohn's disease and ulcerative colitis.

"It was clear to me that we needed to move our gastroenterological community away from a fee-for-service type [of] arrangement … and begin a value-based initiative," says Lawrence Kosinski, MD, MBA, FACG, AGAF managing partner at IGG. "Over half the money that GI physicians receive and live off of emanates from the performance of colonoscopies for colorectal cancer screening and surveillance, so we looked to the next big category of care provided by GI physicians, and that is patients that have inflammatory bowel disease."

BCBSIL announced that it was piloting its specialty intensive medical home with IGG in October 2014. The name of the care model sounds similar to the NCQA's patient-centered medical home initiative but is not part of NCQA, though Walter Hollinger, MD, medical director of strategic operations at BCBSIL, says the aim is similar—to coordinate care for patients, but at a specialty group practice.

"We realized that for Crohn's patients, they, for the most part, have a primary care-like relationship with their gastroenterologist, so it seemed reasonable to take what we had developed for the intensive medical home and apply it."

"The reason we call it intensive is that patients enrolled in the program have had a significant level of medical complexity, severity of illness, and likelihood of having a significant medical event in the near future," says Hollinger.

BCBSIL has three years of experience with its intensive medical home model. It was first rolled out to large primary care groups across Illinois. The partnership with IGG is the insurer's first foray into seeing if it will work for specialists, too.

"We realized that for Crohn's patients, they, for the most part, have a primary care-like relationship with their gastroenterologist, so it seemed reasonable to take what we had developed for the intensive medical home and apply it," Hollinger says.

The partnership between IGG and BCBSIL was a natural fit, according to Kosinski, who says 70% of IGG's patients either have Medicare or BCBSIL.

"It made absolutely the best sense to me that BCBSIL was the best place to go."

"[Payers] are not the evil empire. They never were the evil empire; it's just that we didn't have any communication with them. But I see a lot of positives moving forward."

The two sides acknowledge the inherent tension that exists between providers and payers, but the economic climate in healthcare has changed the dynamic.

"They are not the evil empire," quips Kosinski, referring to the historically frosty relationship that doctors and insurance companies have. "They never were the evil empire; it's just that we didn't have any communication with them. But I see a lot of positives moving forward."

For BCBSIL, the strategy to partner with specialists, particularly large groups that are key providers, keeps the risk environment competitive. Some hospitals and health systems are considering developing their own health plans in order to capitalize on the move toward value-based care. If patients are insured by the hospital they're staying in, then controlling costs, or at least knowing the cost of care, becomes, theoretically, easier.

Traditional payer-developed care models tailored for its providers could be a win-win situation, explains Hollinger.

"These arrangements would allow primary care physicians and specialists who don't want to be affiliated with a very large local hospital system to maintain their independence and provide the care in the way they feel is most appropriate for their patients," says Hollinger.

The reason that BCBSIL decided to experiment with gastroenterology first has more to do with Kosinski's goal of reducing the cost of care and improving patient outcomes. He is the one who approached BCBSIL back in 2012. He says he was looking for data on the total cost of care for his patients with Crohn's disease.

"It was mind-blowing to me," says Kosinski. "Over half the money the payer spent was going to the treatment of complications of this illness. GI physicians were only receiving three-and-one-half cents on the dollar of what the payer was spending, yet we are the experts that are supposed to be managing this illness."

Crohn's disease complications are serious and often require hospitalization. Patients often become so used to dealing with the illness that they don't realize they are deteriorating, and so try to fix the issue on their own. "The complications are fistulas, bowel obstructions, abscesses, serious infections—and there is no easy way to handle those once they occur," says Kosinski.

By combing through the patient data IGG received from BCBSIL, he says he found that only one-third of the Crohn's disease patients who went to the hospital for complications had seen a provider 30 days prior to that admission. It pointed to a lack of patient engagement, says Kosinski, who then developed a Web-based app that pings Crohn's disease patients in between visits. In his initial study group of 50 patients, their hospitalizations went from 17% to 5%. The data convinced BCBSIL that Kosinski was onto something, and now there are 185 Crohn's disease patients enrolled in the specialty intensive medical home. The goal is to enroll 500.

Hollinger says based on the experience BCBSIL has had with its primary care intensive medical homes, he expects the cost of care to also decrease.

"We were able to demonstrate fairly consistently that for our initial very large primary care practices, we did see an improvement in the per member per month in overall medical costs with a reduction of about 7%," says Hollinger.

In real dollars, Hollinger says BCBSIL was able to reduce the total per member per month cost by $95.

BCBSIL contracts with and pays nurse care managers, who are key players in its specialty intensive medical home model. At a practice as large as IGG's, with multiple locations, Kosinski says BCBSIL's financial contribution to support a nurse care manager doesn't cover all the patients, but he believes it's a first step to getting "boats rowing in the same direction."

"We have six part-time nurse care managers and a chief nurse care manager," says Kosinski. So even though we are being paid for one full-time nurse care manager from BCBSIL, we are incurring significant expense, but that's okay. We appreciate the fact that we have our major payer to help us build the appropriate infrastructure for value-based care."

Success key No. 3: Prepare for population health
Other GI practices are focusing on nonprocedural services, too, but instead of looking at patient populations with a common disease they are looking at an age demographic. At the University of Michigan Health System, an integrated academic health system with three hospitals, 40 outpatient locations, more than 120 clinics, and a $3.3 billion operating budget, that population is seniors.

The Geriatrics Center is a multi-specialty geriatric facility that is designed to be a one-stop shop, of sorts, for seniors. Gastroenterology was added to the roster of specialties, which include rheumatology, neurology, endocrinology, nephrology, hepatology, palliative care, and psychiatry.

"Going to a regular GI clinic, the physicians just looked at swallowing without noticing social issues or geriatric syndromes. We were trying to get those patients in to balance GI treatment with other comorbidities."

"If you talk to an 80- or 85-year-old patient, they often have more than one health problem, and they're seeing many different specialists," says Jeffrey Halter, MD, director of the Geriatrics Center at UMHS. "As we developed the clinic, it seemed we could make it easier on patients and families to have a more coordinated approach to care."

The GI clinic is provided twice a week, on Monday and Thursday afternoons. Karen Hall, MD, PhD, who started the GI clinic but has since moved on to serve as director for the Acute Care for Elders unit, a joint operation between UMHS and St. Joseph Mercy Ann Arbor, says the clinic helped identify underlying issues that are inherent in older patients, but that traditional GI doctors may miss.

"Going to a regular GI clinic, the physicians just looked at swallowing without noticing social issues or geriatric syndromes," says Hall. "We were trying to get those patients in to balance GI treatment with other comorbidities."

Demand for the GI clinic grew, says Hall. The clinic started out as just a half day with one provider, but within a year, there was enough need to expand the clinic to an additional half day and grow by two providers.

Jocelyn Wiggins, BM, BCh, associate division chief for the division of geriatric and palliative medicine at UMHS, and medical director for the Geriatrics Center Clinics, says the current three-month wait for an appointment at the center's GI clinic shows how much need exists in the geriatric population.

"There are a lot of things about gastroenterology disease that becomes common with age," says Wiggins, "for example, chronic constipation, diverticulitis, impaction—and managing these early prevents complications later."

Though Hall is no longer seeing patients at the half-day GI clinic, she still does the follow-up appointments for patients discharged from the hospital, and Wiggins says the rate of 30-day readmission for the population is remarkably lower.

"The national readmission rate is 20%, our institution is 19%, [and] for people who get seen in our clinic, it is 11%. Care coordination is key."

Reprint HLR0615-9