The patient centered IBD medical home: Will this be the future of

IBD healthcare delivery?

The patient centered IBD medical home: Will this be the future of

IBD healthcare delivery?

Miguel Regueiro, M.D.Professor of MedicineAssociate Chief for EducationClinical Head and Co-Director, IBD CenterUniversity of Pittsburgh School of Medicine

A New Model for 360o Subspecialty Patient Centered Care

Miguel Regueiro, M.D.Professor of Medicine

Building the IBD Home of Tomorrow

What is a patient centered medical home? The History

3

• 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– 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

• 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

What about subspecialty medical homes? (Casalino, NEJM 2010)

4

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.

Developing an IBD Medical Home: The Pittsburgh experience

Collaborating with the UPMC Health Plan (Insurance Company)

Initial Health Plan Meeting: “Tell us more about your IBD Center. Your IBD Home must cut costs!”

6

• Top 10 costs for IBD pts - #1 and 2 (mostly biologic), #3 surgery

Rank Financial Service Type Total PMPM% of Total Claim

ExpenditureUnits/ 1,000

Unique Members with at least 1 Claim

% of Members in population with at 1 least

1 claim1 Pharmacy $616.13 31.6% 32,591 2,190 92.2%2 Injectable Drugs $370.18 19.5% 4,549 1,126 47.4%3 IP Medical Surgical $306.48 16.2% 408 523 22.0%4 Specialist $130.21 6.9% 10,553 2,226 93.7%5 Outpatient Surgery $71.08 3.8% 924 1,238 52.1%6 Emergency Room $67.94 3.6% 1,389 1,119 47.1%7 Lab Services $58.84 3.1% 5,785 2,197 92.5%8 PCP $40.26 2.1% 5,577 2,013 84.7%9 Observations $35.04 1.8% 200 292 12.3%10 High Tech Radiology $34.25 1.8% 478 975 41.0%

What Types of Service do these Members Utilize?

2014 UPMC IBD Center Executive Summary – Pt #s

7

FY11 FY12 FY13 -

1,000

2,000

3,000

4,000

5,000

6,000

7,000

1,283 1,491 1,829

5,202

5,878 6,319

New Total

UPMC IBD Center – Increasing Numbers of IBD Patients

• Physicians are enrolled in the Physician Quality Reporting System (PQRS)– 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)

16 IBD Quality Parameters (incorporated 2011 in EMR)

8

2014 UPMC IBD Center Executive Summary – Press Ganey

9

1 2 3 4 5 680

85

90

95

100

Physician Communication CGCHAPS Score-CY13 for the 6 IBD MD’s (avg. 97%)

DOM

GI

• 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.

Why would a patient want to enter an IBD Home?

10

Personal Nurse Coordinator assigned to each patient entering medical home.

Coordination across entire health system to meet

individual needs of the patient

IBD schedulers IBD surgeons

Rapid Access <72 hour new and return

visits

Telemedicine Patient visits

IBD LIVE (MDs)

VIP Center

DietitianIBD Connect

Quality Prevention

all patients entered in Patient Portal

24/7 IBD physician on call

with access to EMR

Inpatient Consult Service 365 day inpatient IBD physician care

• 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?

Second Phase of Meetings with Health Plan: “We want the IBD medical home, let’s start with High Utilizer patients”

Super-utilizers 1) tertiary centers 2) surgery/mental health interventions 3) most costly

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)

12

> 150 admissions/ year

50- 150 admissions/ year

<50 admissions/ year

UPMC PUH-SHY

$24.3 million of total $36.9 million from UPMC PUH-SHY

34 pts account for $10.2 million inpatient charges

A minority of patients lead to the highest cost

The Nurse identifies high risk and high utilizer patients

• 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%)

UPMC Study: Frequent Telephone Encounters of Patients with IBD (C Ramos-Rivers, M Regueiro …D Binion Clin Gastoenterol Hepatol 2013)

14

The Number of Phone Calls predicted ED visits

15

15% of UPMC IBD Pts account for 48% of ExpendituresNovel Patient-Centered care for the “Super-Utilizers”

16

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 high-utilization patients with chronic conditions, frequently with concomitant mental illness, pain, and often poor social support.”

• > 50% of IBD patients have pain, stress, coping difficulties, anxiety/depression, and fatigue that lead to worsening inflammation and increased healthcare utilization.

UPMC IBD HOME: The BESST Approach for IBD(BESST = Behavioral (skills), Social (support), Stress (reduction) Training)

17

Brain

Gut

Behavioral Health• Psychiatrists• Psychologists• Social Workers

Shared Decision Making• Co-design treatment• Telemedicine• 24/7 access

Results:• Better Coping• Individualized• Empowering• Reduced Stress

Leads to:• Better Quality of Life• Improved Adherence• Trust in Healthcare

team

• 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-to-face, 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.”

Example of BESST approach – Ann’s story

18

Impact of BESST on Clinical Outcomes and Medical Utilization

19

Pre VIP Post VIP Variable Mean (sd) Mean (sd) p-value Phone Calls (n=46) 8.8 (9.8) 8.2 (10.3) 0.131 PCP Visits (n=14) 2.9 (1.5) 1.6 (1.5) 0.015 IBD Visits (n=53) 3.5 (2.7) 2.8 (3.4) 0.013 Total Clinic Visits (n=54) 6.2 (5.6) 5.9 (6.8) 0.142 ED Visits (n=23) 3.6 (3.4) 2.3 (2.6) 0.034 Hospitalizations (n=16) 1.7 (1.1) 1.5 (1.9) 0.388 Hospital Days (n=17) 10.4 (8.3) 6.2 (11.7) 0.061

• 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

Optimizing Surgery for Crohn’s and Colitis Patients

20

• 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.

Biologics have revolutionized IBD Care, but are expensive – the Health Plan’s approach, “Cut costs, use biosimilars”

22

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

23

1) Keep the patient at home and at school/work2) Collaborate with IBD colleagues virtually

Telemedicine and The IBD LIVE conference – Innovative Technology for the Medical Home

Telemedicine in the IBD Medical Home (courtesy of Ray Cross MD,

U of Maryland)

25

UPMC Center for Connected Medicine (Dr Andrew Watson) and IBD Medical Home

26

IBD LIVE – last Thursday of the month at 7am

27

The Inflammatory Bowel Disease Live Interinstitutional and Interdisciplinary Videoconference Education (IBD LIVE) SeriesInflamm 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

Start Date January 2015 – Identifying the Population

Moving toward the UPMC IBD Medical Home – Health Plan IBD Database Tool

Summarized Target Population by County

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

� �

� �

��

��

��

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 PMPM Total Spend

1 INFLAMMATORY BOWEL DISEASE 554 77% $ 733 $ 5,386,494

2 NEOPLASM MALIGNANT 7 1% $ 36 $ 264,188

3 CENTRAL NERV SYS DISEASE 2 0% $ 1 $ 7,678

4 MIGRAINE 34 5% $ 1 $ 7,316

5 HYPERTENSION 50 7% $ 1 $ 5,156

6 DM 14 2% $ 0 $ 3,066

7 HYPERLIPIDEMIA 38 5% $ 0 $ 2,740

8 LIVER DISEASE 13 2% $ 0 $ 2,728

$- $100 $200 $300 $400 $500 $600 $700 $800 0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Key Chronic Conditions Prevalence and PMPM

Chronic Condition PMPM

Chro

nic C

ondi

tion

Prev

alen

ce %

IBD Medical Home Starts in January by targeting 722 (of ~5,000) UPMC HP High Utilizer patients

Total Members: 722 Total Medical Paid Medical

PMPM Total Rx Paid Rx PMPM Total PMPM Total PMPY Average Age: 32.2

% Female: 50.7%

$ 7,813,907 $ 1,063 $ 5,745,724 $ 782 $ 1,845 $ 22,144

% Allegheny: 34.1%

  Shared Savings PCMH GIM IBD Stratification UPP Gastro.

Members In: 251 215 10 41 189

1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52 55 58 61 64 67 70 73 76 79 82 85 88 91 94 970

10

20

30

40

50

60

70

80

Age Distribution of Target Population

Age as of December 31, 2013

Num

ber o

f Mem

bers

• 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)

IBD Medical Home – Adding Value/Quality and Reducing Cost

35

The 3 “Pillars” necessary in creating an IBD Home– to start, a strong IBD center with pts and multidisciplinary care

36

IBD Home

Hospital

Physician

Servic

es Dvsn

Health

Plan

• IBD Center – collaboration with hospital/medical center– 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

Moving from IBD Centers to IBD Homes and what is the difference?

37

The question remains: Will this be the future of IBD healthcare delivery????????

The Patient Centered IBD Medical Home