2014 Advances in Inflammatory Bowel Diseases

Orlando, FloridaDecember 4, 2014

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How Recently Federally Mandated Changes are Altering

the Care of our IBD PatientsRobert Burakoff, MD MPHClinical Chief, Division of

GastroenterologyDirector, Center for Digestive Health

Associate Professor of Medicine Harvard Medical School

Brigham and Women’s Hospital

Richard Johannes, MD MSInstructor of Medicine

Harvard Medical School

Agenda

• Background

• Goals of federal healthcare policy– Broaden coverage (ACA)– Modify payment incentives– Delivery system redesign

• The transition from Volume to Value

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A growing portion of annual GDP

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The number of uninsured Americans is down

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What is the proper target of resource allocation of the healthcare system?

1. Should we only provide care that avoids errors of harm but doesn’t provide care that could produce improved health (value)? OR

2. Should we target a level where the increased health benefits are balanced by the increased costs? OR

3. Should we target a level where we provide all care that is potentially beneficial regardless of cost?

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Graphical Depiction

#1Resources put into HealthcareResources put into Healthcare

#3

Maximum Impact

#2

Economic Optimum

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What is the proper target of resource allocation of the healthcare system?

• Choice 1 is unrealistic• What about choice 2? Many policy makers and

business leaders would suggest this choice.• However, practicing physicians, healthcare

professionals, patients, state and federal agencies (Medicaid, Medicare, FDA) and laws require or behave as though choice 3 was the best target.

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Graphical Depiction

#1Resources put into HealthcareResources put into Healthcare

#3

Maximum Impact

#2

Economic Optimum

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#4

Harm

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Some Surprises in US healthcare

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5 Trends that will Impact Our Practices

• Cost containment• Consolidation at all

levels of health care• Accountability• Performance

measurement• Population

managementClinical Gastroenterology and Hepatology

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Cost ContainmentMerit based incentive payment system

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2018 2019 2020 2021 2022 2023 2024

(+/-) 4% (+/-) 5% (+/-) 7% (+/-) 9%

PQRSEHR

Meaningful Use

Value Based Payment Modifier*

Resource Use

Resource Use

Clinical Practice

Improvement Activities

Clinical Practice

Improvement Activities

Lower cost and fairness

• Hospital Acquired Infections for example

• Perhaps as many as 2 million, with costs between $17-$29 billion

• They are already on the CMS Hospital Acquired Conditions list

• There have been some great successes (esp. central line bloodstream infections)

• But without a cost sharing models nearly all of the economic benefits accrue to insurers despite all of the work being done by hospitals and providers

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Consolidation

• Potential for enhanced efficiency • Recent JAMA paper by Robinson & Miller at least

suggests consolidation has the potential to actually increase costs through larger overhead.

• After adjustment for severity and local factors between 2009-2012:– Hospital owned organizations incurred costs of 10.3% higher than

physician owned organizations

– Multi-hospital owned organizations incurred cost increases of 19.8% higher than physician owned organizations.

13Source: Robinson JC, Miller K. JAMA. 2014 Oct 22-29;312(16):1663-9.

Will GI become an employed specialty?

Specialty2009 %

Employed

Family Medicine 56%

Internal Medicine 46%

Neurosurgery 41%

Neurology 41%

OB/GYN 39%

General Surgery 37%

Oncology 29%

Cardiology 26%

Otolaryngology 25%

Orthopedic Surgery 21%

Gastroenterology 19%

Urology 16%

Source: MGMA 2009 | Advisory Board 2009

Hospital Reasons for Employment

% Net Revenue from Employed Physicians

16%

2000 2004 2008 2012

18%

25%

35%

Gain LeverageFor GrowthStrategy

Stabilize Market /Secure Access

Transform Care Delivery

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Accountability

• ACOs and alternative delivery strategies• In September 2014 CMS reported their results• Encouraging but there are only 19 “pioneer”

ACOs • Experimental Payment models

1. Base payment

2. Quality component (Performance)

3. Warranty component?

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Performance

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Most measures today are based on billing data only

Population Health

• No one really knows what this is

• However, could one reimburse a region’s gastroenterologists by the size of the population and its risk adjusted colon cancer incident rate versus just the volume of colonoscopies performed?

• Regardless of how you feel, this would be a daunting task to implement.

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Where is this going?

• Getting people insured doesn’t answer how care will be financed or provided

• Do we have the appetite for “experiments” in provision of healthcare?

• Expect changes – but not too soon – ICD-10– Recent election

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Scenarios

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2014

2016

ACA remainsmostly as is

Much better congressional pictureWin the Presidency

2016

Attempt repeal knowing it will be vetoed but to set stage forthe presidential election

Veto results in the 2014-2016 provisions moving forward

Hold the CongressWin the Presidency

ACA repealed

• Innovative Payment Approaches• Tort Reform

• Single Payer System• Rational Regulation

Summary

• ACA will go forward for the next two years because veto can’t be overridden

• So will we just see delay until 2016 or .. – Might bipartisan efforts lead to locating a

middle ground– Could discussions of a single payer system

resurface– Will tort reform resurface in the discussions

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