Transcript advancesinibd.com

The patient centered IBD medical
home: Will this be the future of
IBD healthcare delivery?
Miguel Regueiro, M.D.
Professor of Medicine
Associate Chief for Education
Clinical Head and Co-Director, IBD Center
University of Pittsburgh School of Medicine
Building the IBD Home
of Tomorrow
A New Model for 360o Subspecialty
Patient Centered Care
Miguel Regueiro, M.D.
Professor of Medicine
What is a patient centered medical home? The History
• Primary Care Model the last decade (initial PCMH)
– Prominent Component of Health Care Reform Law
– Endorsed by the ACP, AAFP, AAP, AMA
• Combines primary care with systematic improvement of a
patient population
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Personal physician providing first contact and continuous care
Use of chronic disease registries
Implementation of information technology
New operations for communication between physicians and pts
What about subspecialty medical homes? (Casalino, NEJM 2010)
• The ACP Council of Subspecialty Societies has produced a
detailed statement:
– “…certain specialist practices provide long-term “principal
care” for chronic conditions and should be eligible to serve as
medical homes.” (http://www.acponline.org/advocacy/where_we_stand/medical _home/clarification.pdf).
• Recent endorsement by ACCardiology, ACChest, AANeuro
• BUT, most subspecialists do not provide primary care
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Developing an IBD Medical Home: The
Pittsburgh experience
Collaborating with the UPMC Health Plan
(Insurance Company)
Purpose: The IBD Medical Home will provide high-quality,
comprehensive, cost-effective, patient-centered health care
for patients with Crohn’s disease and ulcerative colitis.
Initial Health Plan Meeting: “Tell us more about your IBD
Center. Your IBD Home must cut costs!”
• Top 10 costs for IBD pts - #1 and 2 (mostly biologic), #3 surgery
What Types of Service do these Members Utilize?
Rank
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2
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4
5
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10
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% of Members in
% of Total Claim
Unique Members
Financial Service Type Total PMPM
Units/ 1,000
population with at 1 least
Expenditure
with at least 1 Claim
1 claim
Pharmacy
$616.13
31.6%
32,591
2,190
92.2%
Injectable Drugs
$370.18
19.5%
4,549
1,126
47.4%
IP Medical Surgical
$306.48
16.2%
408
523
22.0%
Specialist
$130.21
6.9%
10,553
2,226
93.7%
Outpatient Surgery
$71.08
3.8%
924
1,238
52.1%
Emergency Room
$67.94
3.6%
1,389
1,119
47.1%
Lab Services
$58.84
3.1%
5,785
2,197
92.5%
PCP
$40.26
2.1%
5,577
2,013
84.7%
Observations
$35.04
1.8%
200
292
12.3%
High Tech Radiology
$34.25
1.8%
478
975
41.0%
2014 UPMC IBD Center Executive Summary – Pt #s
UPMC IBD Center – Increasing Numbers of IBD Patients
7,000
6,319
5,878
6,000
5,202
5,000
4,000
New
3,000
2,000
1,283
1,491
1,829
1,000
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FY11
7
FY12
FY13
Total
16 IBD Quality Parameters (incorporated 2011 in EMR)
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Physicians are enrolled in the Physician Quality Reporting System (PQRS)
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Documentation of IBD activity and severity at each visit (PQRS)
Documentation of quality of life at each visit
Documentation of vitamin D measurement and repletion
Documentation of vitamin B12 measurement and repletion
Documentation of folic acid measurement and repletion
Documentation of iron measurement and repletion if anemic
Documentation of steroid-sparing therapy (PQRS)
Documentation of assessment of bone health (PQRS)
Documentation of status of influenza vaccine yearly (PQRS)
Documentation of status of pneumococcal vaccine at baseline, 1 yr later (if immunosuppressed)
and then every 5 yrs (PQRS)
Documentation of cessation of smoking assistance (PQRS)
Documentation of C. difficile testing (outpatients increased sx’s and all inpatients)
Documentation of pre-anti-TNF testing for Hepatitis B (PQRS)
Documentation of pre-anti-TNF testing for Tuberculosis (PQRS)
Documentation of surveillance colonoscopy every 1-3 years for patients with extensive ulcerative
colitis or Crohn’s disease for more than 8 years
Documentation of thromboembolism prevention (inpatients)
2014 UPMC IBD Center Executive Summary – Press Ganey
Physician Communication CGCHAPS Score-CY13
for the 6 IBD MD’s (avg. 97%)
100
95
DOM
GI
90
85
80
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9
2
3
4
5
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Why would a patient want to enter an IBD Home?
• Patient Centered Expert Care from board certified
gastroenterologists specializing in IBD as well as other health care providers
experienced in caring for patients with Crohn’s disease and ulcerative colitis.
IBD schedulers
Personal Nurse Coordinator
assigned to each patient
entering medical home.
Coordination across entire
health system to meet
individual needs of the patient
VIP Center
Rapid Access <72
hour new and return
visits
IBD surgeons
IBD Connect
Dietitian
Prevention
Quality
24/7 IBD
physician on call
with access to
EMR
all patients entered
in Patient Portal
Inpatient Consult Service 365 day inpatient IBD physician care
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Telemedicine
Patient visits
IBD LIVE (MDs)
Second Phase of Meetings with Health Plan: “We want the
IBD medical home, let’s start with High Utilizer patients”
• Improving Quality with a patient centered approach
Identifying and targeting high utilizer patients
• “Tell us how you will optimize care and reduce cost in”
• Mental Health
• Surgery
• Biologics
To start: Who are the High Utilizers and
how do we identify them?
Crohn’s disease “hotspotting”: Analysis of regional patterns of admission to
identify clinical factors associated with “superutilizer” patient behavior (UPMC DDW
2014, Binion, Regueiro et al. from PHC4 PA administrative database)
Super-utilizers 1) tertiary centers 2) surgery/mental health interventions 3) most costly
$24.3 million of total
$36.9 million from
UPMC PUH-SHY
> 150 admissions/ year
50- 150 admissions/ year
<50 admissions/ year
UPMC PUH-SHY
34 pts account for $10.2
million inpatient charges
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The Nurse identifies high risk and high
utilizer patients
A minority of patients lead to the highest cost
UPMC Study: Frequent Telephone Encounters of Patients
with IBD (C Ramos-Rivers, M Regueiro …D Binion Clin Gastoenterol Hepatol 2013)
• All ingoing/outgoing calls to IBD RNs from 2009-2010
– 2009: 21,979 calls for 2,475 patients (~9 calls/patient)
– 2010: 32,667 calls for 3,118 patients (~11 calls/patient)
• ~125 calls per day!
– 15% of patients accounted for more than ½ of calls
• Increased telephone calls associated with:
– poor QOL, increased clinic visits, increased ER visits (36% vs.
6%), increased hospitalizations (40% vs. 4%)
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The Number of Phone Calls predicted ED visits
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15% of UPMC IBD Pts account for 48% of Expenditures
Novel Patient-Centered care for the “Super-Utilizers”
Concluding statement from the
2/26/14 JAMA editorial Schwenk
et al. regarding the Patient
Centered Medical Home (PCMH):
“The next critical phase
of PCMH development
should focus on its
strategic deployment for
the care of highutilization patients with
chronic conditions,
frequently with
concomitant mental
illness, pain, and often
poor social support.”
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UPMC IBD HOME: The BESST Approach for IBD
(BESST = Behavioral (skills), Social (support), Stress (reduction) Training)
• > 50% of IBD patients have pain, stress, coping
difficulties, anxiety/depression, and fatigue that lead to
worsening inflammation and increased healthcare
utilization.
Behavioral Health
•Psychiatrists
•Psychologists
•Social Workers
Brain
Shared Decision Making
•Co-design treatment
•Telemedicine
•24/7 access
Gut
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Results:
•Better Coping
•Individualized
•Empowering
•Reduced Stress
Leads to:
•Better Quality of Life
•Improved Adherence
•Trust in Healthcare
team
Example of BESST approach – Ann’s story
• Ann is a 45-year-old woman with a 12-year history of IBD. Although she
does not have signs of active Crohn’s, she has had constant severe
pain, is depressed, and having a difficult time working.
• IBD Connect visits the patient in the hospital: “I hate the pain and the
emergency room, people are awful. They treat me like a drug
addict.”
• She had 23 hospital admissions/emergency room visits, 19 CT
scans, and 7 endoscopic procedures in the past year for her
intractable pain.
• She chooses to complete all of her 8 behavioral sessions face-toface, learns relaxation techniques, utilizes web based sessions, and is
able to call behavioral health specialist after hours.
• “My favorite imagery when I have pain is to imagine I am holding a
balloon: I transfer my pain to the balloon and release it, and as I do, I
feel so relaxed and free.”
• “I am off of narcotics. I have not needed any tests or hospitalizations in
over one year.”
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Impact of BESST on Clinical Outcomes and Medical Utilization
Variable
Phone Calls (n=46)
PCP Visits (n=14)
IBD Visits (n=53)
Total Clinic Visits (n=54)
ED Visits (n=23)
Hospitalizations (n=16)
Hospital Days (n=17)
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Pre VIP
Mean (sd)
8.8 (9.8)
2.9 (1.5)
3.5 (2.7)
6.2 (5.6)
3.6 (3.4)
1.7 (1.1)
10.4 (8.3)
Post VIP
Mean (sd)
8.2 (10.3)
1.6 (1.5)
2.8 (3.4)
5.9 (6.8)
2.3 (2.6)
1.5 (1.9)
6.2 (11.7)
p-value
0.131
0.015
0.013
0.142
0.034
0.388
0.061
Optimizing Surgery for Crohn’s and Colitis Patients
• The UPMC IBD Home will decrease surgery by targeting
surgery for those IBD pts who need an operation, but will
avoid surgery for those who would benefit from medications.
• The UPMC Med-Surg Approach to IBD: all cases are
discussed by gastroenterologists and surgeons to determine
appropriateness of surgery-decisions are made collectively.
• Twice weekly IBD management meetings –
Surgeons/Gastroenterologists
– Each Monday at noon – “break” in IBD clinic to discuss cases on M2
– IBD LIVE every Thursday at 7am – UPMC and non-UPMC sites
• Clinical Care Pathways – optimizing the timing or need for
surgery
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Biologics have revolutionized IBD Care, but are expensive –
the Health Plan’s approach, “Cut costs, use biosimilars”
• Biosimilars (or follow-on biologics) are terms used to
describe officially approved subsequent versions of
innovator biopharmaceutical products made by a different
sponsor following patent and exclusivity expiry on the
innovator product. (Nick, C (2012).
– "The US Biosimilars Act: Challenges Facing Regulatory Approval".
Pharm Med 26 (3): 145–152.
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Biologics have revolutionized IBD Care, but are expensive: through
evidence-based care pathways the IBD Home would avoid improper use,
optimize biologic use, and keep an “eye” on the biosimilars
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Telemedicine and The IBD LIVE
conference – Innovative Technology for
the Medical Home
1) Keep the patient at home and at school/work
2) Collaborate with IBD colleagues virtually
Telemedicine in the IBD Medical Home (courtesy of Ray Cross MD,
U of Maryland)
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UPMC Center for Connected Medicine (Dr Andrew Watson)
and IBD Medical Home
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IBD LIVE – last Thursday of the month at 7am
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The Inflammatory Bowel Disease Live Interinstitutional and
Interdisciplinary Videoconference Education (IBD LIVE) Series
Inflamm Bowel Dis 2014;20:1687 - 1695
Miguel D. Regueiro, MD,1 Julia B. Greer, MD, MPH,1 David G. Binion, MD,1 Wolfgang H. Schraut, MD,2
Alka Goyal, MD,3 David J. Keljo, MD,3 Raymond K. Cross, MD, MS,4 Emmanuelle D. Williams, MD,5 Hans
H. Herfarth, MD, PhD,6 Corey A. Siegel, MD,7 Ioannis Oikonomou, MD,8 Myron H. Brand, MD,8,9 Douglas
J. Hartman, MD,10 Mitchell E. Tublin, MD,11 Peter L. Davis, MD,11 Leonard Baidoo, MD,1 Eva Szigethy,
MD, PhD,12,13,14 and Andrew R. Watson, MD, MLitt15 on behalf of the IBD LIVE Physician Group
Moving toward the UPMC IBD Medical
Home – Health Plan IBD Database Tool
Start Date January 2015 – Identifying the Population
Summarized Target Population by County
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UPMC Medical Home – Health Plan Members
~5,000 IBD Members – initial request: “we want
all members in the IBD Home”
IBD Patients Filtered By Line of Business, Age,
% IBD Spend
722 Members
Per Member Per Month IBD Spend – Target IBD
Rank
Condition
Prevalence
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INFLAMMATORY BOWEL DISEASE
2
PMPM
Total Spend
554
77%
$
733
$
5,386,494
NEOPLASM MALIGNANT
7
1%
$
36
$
264,188
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CENTRAL NERV SYS DISEASE
2
0%
$
1
$
7,678
4
MIGRAINE
34
5%
$
1
$
7,316
5
HYPERTENSION
50
7%
$
1
$
5,156
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DM
14
2%
$
0
$
3,066
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HYPERLIPIDEMIA
38
5%
$
0
$
2,740
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LIVER DISEASE
13
2%
$
0
$
2,728
Key Chronic Conditions Prevalence and PMPM
Chronic Condition Prevalence %
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
$-
$100
$200
$300
$400
$500
Chronic Condition PMPM
$600
$700
$800
$900
IBD Medical Home Starts in January by targeting 722 (of ~5,000)
UPMC HP High Utilizer patients
Total Members:
722
Average Age:
32.2
% Female:
50.7%
% Allegheny:
34.1%
Members In:
Total Medical Paid
$
7,813,907
Medical
PMPM
Total Rx Paid
$
$
1,063
5,745,724
Rx PMPM Total PMPM Total PMPY
$ 782
$ 1,845
$ 22,144
Shared Savings
PCMH
GIM
IBD Stratification
UPP Gastro.
251
215
10
41
189
Age Distribution of Target Population
80
70
Number of Members
60
50
40
30
20
10
0
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59 61 63 65 67 69 71 73 75 77 79 81 83 85 87 89 91 93 95 97
Age as of December 31, 2013
IBD Medical Home – Adding Value/Quality and Reducing
Cost
• The BESST Approach (BESST = Behavioral (skills), Social (support),
Stress (reduction) Training) – psychiatry/psychology/Social Workers
• Incorporating the 8 PQRS IBD parameters
• Preventative Health – vaccines, bone health, smoking cessation, etc…
• Clinical Pathways – include in EMR
• IBD LIVE Conference and Bi-weekly Med-Surg-Peds-Path-Radiology
(Multidisciplinary clinics and conferences)
• Telemedicine and Virtual technology
• Shared Decision Making
• Evaluating pharmaceutical costs and biosimilars
• Patient Satisfaction – Press Ganey and CGCHAPS Score
• IBD Connect – inpatient volunteer service (peer to peer)
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The 3 “Pillars” necessary in creating an IBD Home– to start, a
strong IBD center with pts and multidisciplinary care
IBD Home
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Moving from IBD Centers to IBD Homes and what is the
difference?
• IBD Center – collaboration with hospital/medical center
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Often the center is built around the healthcare team
Gastroenterologists as consultants and referred pts by providers
RVU based, volume proposition for payment
Institutional support from downstream revenue (surgery, pathology,
radiology, infusions)
• IBD Patient Centered Medical Home –collaboration with
insurance company
– Put the patient at the center of the care model
– Gastroenterologists as principal care providers and “referred” pts by
payer – population based approach
– Value based – quality, preventative medicine, telemedicine, point of
contact mental health care, etc..
– Insurance/Payer support to improve value and reduce cost – shared
savings or global payment models
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The Patient Centered IBD Medical Home
The question remains: Will this be the future of IBD
healthcare delivery????????