Dr. Charles Accurso was recently interviewed by AISHealth regarding the true value of bundled payment programs for colonoscopies and other life-saving procedures, as well as the roadblocks involved with making them possible.
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Colonoscopy Bundles Offer Opportunity for GI Physicians
Digestive HealthCare Center in Hillsborough, N.J., is seeing benefits from two bundled payment contracts for colonoscopy, but major barriers still stand in the way of gastroenterologists who want to ink value-based contracts with payers.
That’s the word from Charles Accurso, M.D., medical director of the Digestive HealthCare Center and Central Jersey Ambulatory Surgery Center. Accurso spoke at the recent National Value-Based Payment and Pay for Performance Summit in San Francisco, sponsored by Global Health Care, LLC.
The medical group is an independent gastrointestinal (GI) group with seven physicians, and it owns a two-room ambulatory surgery center that performs colonoscopies and other procedures. The center employs anesthesiologists and pathologists and can perform virtual colonoscopy and CT scans on site. It also features a pathology lab and an infusion center, Accurso said.
In the Hillsborough, N.J., medical care market, there are three competing hospital systems and two competing accountable care organizations (ACOs), with the physician referral base splintered between the different hospital systems, Accurso said. His vision is to have an independent center, not one affiliated with any of the other health care entities in the market.
“We’re able to control and bundle the vast majority of GI care in an outpatient setting,” Accurso said. The center can improve quality and patient satisfaction by monitoring and reporting data and implementing quality improvement measures. It also can lower costs by following evidence-based guidelines for appropriate screening time frames and follow-up intervals, and by managing and controlling potentially avoidable costs during the bundle episode time frame, he said.
Colonoscopy usually represents more than half of a GI practice’s revenue. It’s “a relatively easy procedure to bundle” for several reasons, Accurso said:
- The time frame around the colonoscopy procedure is easy to define,
- It’s a very common procedure for colorectal cancer screening and polyp removal, and
- It’s both diagnostic and therapeutic, since it can diagnose disease and remove polyps at the same time.
In addition, how the procedure is performed affects the quality of care, he said. If a gastroenterologist is unable to look at the entire colon as part of the colonoscopy procedure (measured by what’s called the cecal intubation rate), then the quality rating is lower. This is fairly easy to measure, and the cecal intubation rate should be greater than 95%, he said.
Quality also is increased by monitoring and reporting the number of premalignant polyps found — the average adenoma detection rate is 25% for women and 30% for men, he said. “The higher the adenoma detection rate, the better quality the procedure,” Accurso said. “Ask your favorite gastroenterologist what their adenoma detection rate is — mine is 36%.”
There are rare complications associated with colonoscopy, Accurso said. Bleeding will occur in one out of 1,000 cases, and bowel perforation will occur in one out of every 2,000 cases, he said. These usually occur with polyp removal, and can be minimized by appropriate training and board certification in gastroenterology, he said.
Obviously, where colonoscopy is performed affects costs, Accurso said. Inpatient hospital settings are the most expensive, and outpatient hospital settings also are costly. Ambulatory surgery center settings are the least expensive options, he added.
So far, Digestive HealthCare Center has signed two value-based contracts for colonoscopy, Accurso said, including a contract with Horizon Blue Cross Blue Shield of New Jersey as part of its Episodes of Care bundled payment program, and a second contract with a regional third party administrator.
The two have somewhat different terms, but both feature evidence-based quality measures, including adenoma detection rate, cecal intubation rate and patient satisfaction, Accurso said. The physicians share savings only if there’s high patient satisfaction, as measured by the payer.
The Horizon agreement is a retrospective episode of care contract. The budget for each episode is set based on retrospective practice costs in the last two years, Accurso said, and fee-for-service payments are used as a baseline going forward.
Financial reconciliation and sharing of savings occur quarterly, he said. If costs drop below the budget, the physician group shares those savings with the payer, provided the quality and patient satisfaction goals were met.
Meanwhile, the contract with the third-party administrator (TPA) is prospective; the group receives one set price that includes:
- Initial consultation and 30 days of follow-up.
- Ambulatory surgery center.
- A guarantee to redo the procedure “at our cost” if unable to complete due to poor colon preparation. (Accurso said that 10% to 20% of colonoscopies are incomplete.)
- Virtual colonoscopy for failed optical colonoscopy.
Under the TPA contract, quality measures are reported to a certified clinical registry — in this case, the American Academy of Gastroenterology’s GIQulC. Quality measures also are shared with patients on Digestive HealthCare Center’s website, and are disclosed to payers, Accurso said.
The contracts achieve savings by providing the service in the most cost-efficient location — in this case, an ambulatory surgery center — and by standardizing care to decrease variation across all contracts, Accurso said. The gastroenterologists also focus on minimizing potentially avoidable complications of colonoscopy, including bad preparations and post-procedure emergency room visits, and coordinate care among all providers, he said.
“Clinical and financial alignment leads to increased coordination of care, including with risk-bearing primary care physicians, patient-centered medical homes and ACOs,” he said. “It’s a work in progress — there are new lessons learned every quarter.”
The first three years of the Horizon colonoscopy program have yielded strong results, Accurso said. The program has achieved a 97% patient satisfaction rate, and overall, Horizon Episode of Care partners across New Jersey are trending better in terms of quality and cost.
Digestive HealthCare Center has achieved shared savings every quarter since the start of the program, which accounts for “around 10% or 15% of our book of business,” Accurso said.
In the prospective bundled payment agreement with the TPA, the price per colonoscopy is negotiated up front, he said, adding, “the payment is appropriate for the services we provide.” The payer had to make a major infrastructure investment to administer this type of contract, he said.
For a specialty group like Digestive HealthCare Center to pursue bundled payments, “you need a willing payer partner,” Accurso said. The group has cultivated new working relationships with payers, and the financial incentives are working to change the behavior of everyone involved, he said. However, “you need physician leaders, particularly specialists, to implement these value-based programs,” he added.
IBS, GERD Are Other Targets
Colonoscopies may represent the most obvious opportunity for gastroenterologists in bundled payment, but there are others, Accurso said.
For example, gastroenterologists are well suited to manage care (and costs) in inflammatory bowel disease (IBS), he said. In fact, the Illinois Gastroenterology Group is doing just that in partnership with Blue Cross Blue Shield of Illinois, and initial results are promising: the medical group lowered the cost of care by 10% over the first 10 months of the program, and showed a 57% reduction in hospitalization payments and a 53% reduction in emergency room payments (VBC 3/16, p. 5).
There also are opportunities for value-based agreements in managing chronic liver disease and gastroesophageal reflux disease (GERD), Accurso said.
Primary care physicians who refer patients to a bundled payment program may see financial advantages as well, if they’re also involved in a value-based program, since the bundled payment program may reduce the cost of care and improve quality of care for their patients, he said.
However, there are barriers to these types of arrangements, and it’s challenging to start a program when all of the pieces aren’t in place, Accurso said.
Implementation costs “are significant,” he said, but can be reduced by negotiating an upfront “management fee” for the specialists that can be credited from shared savings and therefore will not increase the cost of the program.
For colonoscopies, Digestive HealthCare Center has an advantage when negotiating a prospective bundled payment agreement: it employs its own pathologists and anesthesiologists, Accurso said. Many practices “don’t necessarily own all pieces of the bundle,” and therefore can’t negotiate them with payers, he said.
In addition, “some GIs do not have full ownership of the ambulatory surgery center to be able to negotiate the costs into the bundle,” he added. Providers need relief from anti-kickback regulations in order to cooperate in developing these new programs, he said. In addition, the programs require a “general contractor” to organize and pay for the downstream services — that general contractor could receive the bundled payment and distribute it downstream, he said.
Additional challenges to bundled payments and other types of specialist-driven value-based arrangements include the lack of access to actionable information to coordinate care in real time, limited interoperability of practice management systems and electronic medical records, practice management systems that aren’t designed to administer value-based contracts, and reluctance among payers to start a program, he said.
Also, primary care physicians need to learn about the benefits of referring into a bundled payment specialist program, Accurso said. Payers need to identify participating specialist practices as preferred providers and educate their primary care physicians on the programs. Meanwhile, participating specialists need to reach out to other providers, particularly other specialists, to collaborate on implementing the programs, he said.
Retrospective Model Is Easier
Specialists need to ensure they have outlier protection clause limits against catastrophic cases, and to include in the bundle only costs that the participating physicians can actually control, he said.
Finally, a retrospective model with fee-for-service and shared savings is easier to implement, and represents an opportunity to collaborate with payers in a low-risk environment, since there’s no downside risk initially, he said. The prospective model is difficult to implement unless all the services are controlled by the GI practice, he added.
Payers shouldn’t assume that working with hospital systems and ACOs is the only way to go, Accurso said. Instead, they should strive to develop a medical neighborhood of philosophically and economically aligned physicians and other providers, share cost and quality data with their customers, and develop financial incentives for patients to use these programs, he said.
“Meaningful payment models for care delivery by specialists is possible,” Accurso said. “Specialty physicians are willing and able to help redesign care, and financial alignment of specialty physicians can lead to lower cost and better quality for patients.