Value-based care is a term heard across all specialties in healthcare, but value is an abstract term. Physicians, payers and patients each have a stake in defining value-based care and what it means for the future of healthcare. Caroll Koscheski, MD, FACG, Chairman of the National Affairs Committee for the American College of Gastroenterology and ACG Governor for North Carolina, tackles the idea and how value-based care will affect the field of gastroenterology. A board-certified gastroenterologist, Dr. Koscheski is in private practice with a seven-physician group in Hickory, N.C. The physician group owns a three-room endoscopy center and handles all of its contracting with payers.
Cost vs. quality
Value is a key priority in nearly every industry and this is not the first time healthcare has attempted to put the idea into practice. "Work in past years was pretty much limited to cost management in medicine without any strong efforts on the quality side of the equation," says Dr. Koscheski. "This resulted in the restrictive practice by HMOs and the old gatekeeper models of healthcare delivery that everyone grew to hate." To avoid repeating the past, the elements of cost management and quality need to be given equal weight.
"Costs initially seem quite easy to measure, since as physicians we look at this as strictly a fee schedule," says Dr. Koscheski. Professional fees vary slightly from practice to practice, more so from market to market. The challenge will be to create the measures that evaluate clinical quality.
Quality parameters are constantly evolving and quality, like value, can be a difficult concept to define. "Fortunately in gastroenterology, we have had a number of leaders who have taken this task to heart over the past two decades and beyond," says Dr. Koscheski. There are well-established practice guidelines and metrics for several GI-related illnesses. Proven quality metrics in GI/endoscopy include:
• Adenoma detection rate
• Scope withdrawal time
• Quality of preparation
Useful quality parameters, such as these frequently used ones, will cover a large volume of cases performed. "This is especially important since it will typically encompass a large amount of dollars spent," he says. However, defining proven quality metrics is a large step forward in marrying the concepts of cost and quality.
Quality reporting: burden vs. boon
Value, regardless of definition, means little without demonstration. "Most physicians strive to do quality work for their patients, but we need to show it," says Dr. Koscheski. The Centers for Medicare and Medicaid Services ASC Quality Reporting Program has begun adopting measurement parameters specific to GI. Gastroenterologists also have registries, such as the GI Quality Improvement Consortium and an AGA registry, which gather nationwide quality measures data.
Quality reporting, much of which is now necessary, takes both time and money. "While there are costs involved, there are no financial rewards for far for participation. It is a very one-sided project," says Dr. Koscheski.
However, there are benefits. CMS now recognizes participation in these registries as a Physician Quality Reporting System measure. Additionally, the commitment of involved physicians provides data that serves as a valuable resource in the GI field through utilization of the various GI registries.
Quality data is also becoming a resource for patients. "I have had patients ask me about adenoma detection rates and complications rates," says Dr. Koscheski. Tracking rates such as these at a national and individual level will aid gastroenterologists in identifying areas for quality improvement and demonstrating valuable care.
Whether physicians view quality reporting as an undue burden or useful tool, it is now a vital element of practicing medicine. "There is no question that there will be work in this, but you have to just realize this transformation healthcare is going through will be a lasting change," says Dr. Koscheski.
Shift in reimbursement models
The drive for value-based care has caused widespread discussion of a shift away from a fee-for-service reimbursement model to a value-based reimbursement model. Despite discussion, little has been done to make this move. "It will most likely start in the hospital setting in large systems," says Dr. Koscheski. "It will take vigorous input from all parties involved: doctors, hospitals, pharmacies, ancillary services, etc."
If payers intend to link reimbursement to quality, they will begin to develop quality measures. "I would hope that insurance companies will see that if they are going to succeed, they need to partner with physicians," says Dr. Koscheski. "They need to ask for physician input on developing pure quality measures."
Despite the potential for physicians to save payers money through meeting these standards, there remains resistance to a large pay-for-performance model. "In a successful model, one would hope for some form of bonus pay for meeting certain quality and cost goals," he says.This, in fact, is one of the target goals of the new ACO models.
Industry support
Healthcare continues to change and physicians must work to remain on top of the latest requirements. "My main advice for the practicing gastroenterologists is to get connected with their GI societies and read everything that comes across their desk," says Dr. Koscheski. "We are fortunate to have three excellent GI societies that are very reliable resources for this, as well as many other topics in the changing realm of healthcare delivery."
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