Measuring, Improving, and Reimbursing for Quality in IBD Management

At a session during Digestive Disease Week 2017, held in Chicago from May 6-9, speakers discussed the ongoing efforts to define, measure, and improve the quality of care for patients with inflammatory bowel disease (IBD).

Gil Melmed, MD, director of Cedars-Sinai’s Clinical IBD division, kicked off the lecture with a story about how his grandmother told him her new doctor was good because he was “such a nice guy.” But the real meaning of quality, Melmed said, is about the care that is actually delivered and whether it meets basic standards of value. As the healthcare landscape changes, reimbursement will be increasingly determined by quality, and there are significant opportunities for improvement, such as preventable complications, waste, and variation across practices.

The traditional framework of measuring quality is based on structure, process, and outcome metrics, but more recent quality indicators have begun to include accountability and patient-derived outcomes. After all, Melmed said, patients want to feel their clinician is addressing their concerns during a visit, not just checking a series of boxes. He listed just a few of the quality measure sets currently used in IBD management, from the process- and accountability-focused metrics used by the American Gastroenterological Association (AGA) to the QUOTE-IBD measures created with feedback from patients in 7 countries.

For practices just starting to experiment with quality indicators, Melmed suggested picking a single measure and seeing if their system is even set up to capture that measure, or by evaluating the “denominator,” or the number of IBD patients that would be impacted by a potential quality measurement initiative. Still, he emphasized that measurement is not equal to improvement. “Customers don’t measure you on how hard you tried. They measure you on what you deliver,” Melmed said, paraphrasing Steve Jobs.

Another entity measuring clinicians on what they deliver is CMS, according to the next presenter, Joel Brill, MD, chief medical officer at Predictive Health, LLC. He outlined the role of advanced payment models (APMs) in IBD and their risks and benefits to practices. Under the Medicare Access and CHIP Reauthorization Act (MACRA), practices will have to choose between entering 3 doors, Brill explained.

Behind Door 1 is the Merit-based Incentive Payment System (MIPS), the pay-for-performance option that includes quality reporting requirements. Entering Door 2 means joining an alternative payment model (APM), which rewards practices for managing population health and “being on the right side of change.” Door 3 leads into physician-focused payment models, which involve monetary risk and shared savings without the MIPS requirements, which Brill said let practices be “exempted from being MIPSed to death.”

Regardless of which door a practice chooses, Brill said it was clear that “the shift to value-based care is here to stay, and sticking your head in the sand is no longer an option.” He pointed to bundled payment models, which have been embraced by the AGA, as a good step to take while waiting for more APMs to develop, but emphasized that these models must be consistent and replicable.

The next speaker, Lawrence Kosinski, MD, MBA, managing partner of the Illinois Gastroenterology Group, presented his work on Project Sonar as an example of how to succeed in a physician-focused payment model. The project’s name comes from the analogy that patients with Crohn’s disease are like submarines, “running silent and deep” and only surfacing when they’re in trouble. Instead, this model aims to engage patients and intervene before they develop serious problems. It does so by “pinging” patients monthly and asking them to complete an online questionnaire that produces a “sonar score” indicating their Crohn’s disease activity level.

Kosinski’s data demonstrated that as patients’ sonar scores declined, so did the cost of care; in fact, the insurer that funded Project Sonar saw a 650% return on its $840 per member annual investment in the program. Inpatient costs for the study population have been cut in half, and the total cost of care decreased by 9.8%. Patient satisfaction also increased, as hospitalizations dropped and their quality of life improved. These successes helped Project Sonar gain a positive recommendation from HHS’ Physician-Focused Payment Model Technical Advisory Committee.

When asked about the take-aways from the Project Sonar experience, Kosinski said the key was patient engagement, which providers “will have to focus much more on if we want to succeed.” He also stressed the importance of a long-term vision that focuses on improving infrastructure and population health. “We shouldn’t focus on our own revenue streams when trying to build value,” he said.

Finally, presenter Corey Siegel, MD, MS, director of the IBD Center at the Dartmouth-Hitchcock Medical Center, spoke about quality collaboratives in IBD care, specifically the IBD Qorus initiative launched by the Crohn’s and Colitis Foundation of America. The program has been implemented in 30 states, and all of the participating sites collaborate to share which ideas have been successful in improving clinical outcomes and lowering costs.

In this system, the care team feeds clinical data and the patient feeds patient-reported outcome data onto a shared data platform used during visits. This “coproduction” platform has “transformed patient visits,” as it incorporates patient concerns, clinical measurements, symptom trackers, and treatment history onto an easy-to-use dashboard that allows clinicians to spend more time talking about what’s important to the patient.

It also facilitates population management efforts, as it lets practices sort patients by salient characteristics and create interventions for specific high-risk patient groups. According to Siegel, this “incredibly powerful tool” not only lets clinicians manage their own patient populations, but also helps each practice learn from and guide one another, as they “push each other towards success.”

The presentation was evidently persuasive, as an audience member asked Siegel how his own practice could join the IBD Qorus initiative.

Corrected May 11 to clarify AGA position on bundled payment models.