In just 1 year, 34 out of about 5,000 patients seen at the inflammatory bowel disease center at the University of Pittsburgh Medical Center cost more than $10 million to treat.
“The insurance people said, ‘You have to fix this,’” recalled Dr. Miguel Regueiro, codirector of the IBD center.
So, in addition to asking the insurer for ideas, Dr. Regueiro did the most cost conscious thing he could think of: He asked for ideas from his colleague, Dr. Eva Szigethy, a psychiatrist specializing in the treatment of pain and psychosocial issues faced by IBD patients.
“Nearly half of our patient population has some behavioral, stress, or mental health component that is driving their disease, [leading] to high health care utilization,” Dr. Regueiro said.
Dr. Szigethy’s work of late, both on her own and with others such as Dr. Douglas Drossman, an emeritus psychiatrist and gastroenterologist at the University of North Carolina at Chapel Hill, has focused on the so-called brain-gut axis and includes the impact of narcotics on the gastrointestinal tract, the correlation between inflammation and depression, the effectiveness of cognitive-behavioral therapy in IBD, and the use of self-hypnosis to manage chronic pain.
“The vast majority of IBD patients have mood disorders, depression, reactive adjustment disorder, anxiety both [before and after] their diagnosis, and chronic pain,” Dr. Szigethy said in an interview.
In practical terms, this means patients benefit from the partnership between Dr. Regueiro, who brings a deep medical knowledge of IBD, and Dr. Szigethy, who combines her research with her psychiatric skill for asking the kinds of questions that evoke the patient’s larger story. Together, said Dr. Szigethy, they assess patients as a whole, directly accounting for the emotional complexity inherent in IBD, with an eye toward helping patients regain control of their lives, often made chaotic by the unpredictable indignities that are the hallmarks of the disease.
“Often, if we listen in the lines and between the lines, our patients tell us exactly what other factors are involved: why their disease is not getting better, why they are getting headaches, why they have such continued suffering,” Dr. Szigethy said.
“You don’t need to know the basic science to understand the stress these patients feel,” Dr. Regueiro recounted to an audience at a recent Advances in IBD meeting in Orlando, sponsored by the Crohn’s and Colitis Foundation of America.
He shared with his audience the story of 45-year-old Anne, a Crohn’s disease sufferer treated at his center. Anne is not the patient’s real name. Despite her disease being inactive, Anne was hospitalized 23 times, and given 19 CT scans and seven endoscopic procedures in one calendar year alone, qualifying her as one of the center’s top 34 “health care frequent fliers.”
Empowering patients like Anne, whose costly care Dr. Szigethy and Dr. Regueiro recognized was attributable more to her psychosocial rather than medical IBD needs, not only improves their quality of life, it saves the system money.
This is why the same “insurance people” who told Dr. Regueiro they’d like to see cost reductions have partnered with him and Dr. Szigethy to develop a specialty care medical home pilot program that combines specialty, primary, and mental health care in one location. The program officially opened in mid-January of this year.
In the mid-1990s, the UPMC Health Plan was conceived by the medical center as a “strategic move to combine the intellectual capital of the provider system with that of the payer system,” according to Sandy McAnallen, UPMC Health Plan’s senior vice president for clinical affairs and quality performance.
The result, she said in an interview, is greater flexibility when it comes to what care is provided and how it is delivered. “The physicians are setting the evidence-based pathways on the kind of care that patients need to receive, and we have the ability to be very proactive with [how we pay for that] with this kind of relationship.”
Over the course of 2 years, Dr. Regueiro and Ms. McAnallen met several times to parse data on more effective ways to address the fractured way IBD patients, particularly those with undiagnosed psychosocial concerns, were seeking and receiving treatment. The pair also honed in on ways to cut the high cost of surgeries and pharmaceuticals with the overall goal being to create a healthier IBD patient population who perceived their care to be the best possible.
To develop their specialty medical home model, Dr. Regueiro, Dr. Szigethy, Ms. McAnallen, and other key UPMC hospital system and health plan administrators, as well as other IBD specialists, met many times over the course of 2 years to plan what Ms. McAnallen calls their proof of concept.
The program is offered automatically to those covered by the UPMC Health Plan, although anyone is welcome to opt out if they choose. Participants are asked, but not required, to submit to genetic sampling for IBD research purposes, and other data also are gathered with consent at the center. Those not covered by UPMC insurance also are welcome to participate. “The center is payer-agnostic,” Ms. McAnallen said.
Dr. Regueiro is the primary doctor for all patients who want to be seen at the IBD center for their chronic condition, while episodic illnesses such as colds, flus, and rashes are treated by a newly added advance practice nurse. All patients are now offered behavioral and psychosocial support, depending on the concern, either from Dr. Szigethy, a psychologist, or a social worker who was added to the team for the pilot project.
“Part of what we are defining [with this project] is when a psychiatrist is needed, and what can be done by a less expensive, but well-trained behavioral health, medically trained person like a social worker,” Dr. Szigethy said.
A new patient peer group offers patients the chance to discuss their IBD-related struggles with others who can empathize directly, and a nutritionist and pharmacist both specializing in IBD needs have been added to the payroll. A 24/7 call center also has been established.
“We want patients to be in the habit of calling one place where their entire history is known,” said Ms. McAnallen. “Whether they need primary care or specialty care, we want these patients to go to the specialty medical home.”
It’s a patient-centered, rather than an institution-based model, where the referrals are controlled by the payer, “but the system is value based not volume based,” said Dr. Regueiro.
To that end, Dr. Regueiro said he hopes the center will expand its use of telemedicine to further accommodate patients, who often find it difficult to take time off from work or school, find and afford child care, and travel long distances to their doctor appointments. “Right now, some patients have to drive hours to see us, but a lot of what we do for these patients is cognitive care,” he said.
The IBD center’s additional personnel have been paid for by the health plan, in order to cover the cost of adequately serving the approximately 725 IBD patients the insurer determined were the most expensive to treat out of the more than 5,000 IBD patients, a notably high number according to Dr. Szigethy, that the center serves.
In exchange for underwriting the cost of a portion of the staff, the health plan expects Dr. Regueiro and his team to cut treatment costs for this cohort. “If we save a certain amount on patients each year, the health plan will give that back to us,” Dr. Regueiro said.
One way Ms. McAnallen said the program is projected to save is by reducing the number of times frequent fliers of UPMC’s emergency department arrive with an IBD complaint.
“An ER doc is a jack of all trades,” said Ms. McAnallen. “But they don’t know how to treat someone who might be in an acute pain crisis because their IBD has flared up, and maybe they will give the person a narcotic that they don’t need or should not have.”
To wit, in her health care high-utilization heyday, Anne’s treatment typically began in the emergency department, where she arrived seeking narcotics for her condition.
“She said she hated that the people in the ED treated her like a drug addict, but she hated the pain even more,” Dr. Regueiro told his Orlando audience.
This was particularly troublesome for Anne, since Dr. Szigethy determined she was a potential sufferer of narcotic bowel syndrome.
Although at present, much of the research into this phenomenon is still bench science, Dr. Szigethy said a growing body of evidence provided in part by advanced neuroimaging techniques indicates that chronic narcotic use changes opioid receptors in some human adults from creating an analgesic effect, to a hyperanalgesic one instead, where the narcotics themselves start to create pain and exacerbate any existing bowel issues.
“In Anne’s case, she was going up and up in her opiates, but her pain was getting worse,” Dr. Szigethy said.
Dr. Szigethy obtained permission from Anne’s insurer, which happened to be UPMC Health Plan, to give her a 5-day inpatient medical hospitalization during which time Anne was weaned from her narcotics. For 6 months prior to her detoxification from the opiates, Anne learned self-hypnosis techniques from Dr. Szigethy and her colleagues, which she used to support her withdrawal from the pain medication. Anne’s self-reported favorite technique was that whenever the pain would start, she would visualize filling a balloon with it, and then letting the balloon drift away until it eventually evaporated into the air.
“I know it sounds corny, but guess what? Last year, Anne had zero hospitalizations,” Dr. Regueiro said.
According to Dr. Szigethy, Anne still has occasional pain, “But she can deal with it.”The exact savings UPMC Health Plan expects to realize by way of reimbursing the IBD center for treatment models created in response to emerging research such as that of Dr. Szigethy is still unknown. But Ms. McAnallen is optimistic the program will meet its broader targets.
“We are at a point where costs are becoming out of control and the consumer can’t afford health care. You have to be in a position where you can rely on your physicians to develop evidence-based pathways for treatment of acute and chronic disease, which Eva and Miguel are doing, and to do be able to do so in a laboratory where you have the premium to support that,” Ms. McAnallen said, adding that had Dr. Regueiro approached an outside payer to help him create the medical home model, she doubted it would have come to fruition.
“Because we’re part of an integrated system, we’re all aligned with the same goals, which include improving the health status of our community and decreasing the cost of care so it’s affordable.”
Analysis of data collected on total cost and quality of care, and patient perception of care, will begin within the next 6 months, said Ms. McAnallen, who did not offer specific margins but noted that if gains are made, UPMC would look at how to apply this integrated approach to treating other chronic diseases such as rheumatoid arthritis and multiple sclerosis.
One central question the pilot program is expected to answer is whether it is feasible to do away with fee-for-service provider reimbursements, which Ms. McAnallen said are, in her opinion, at the crux of the current national health care crisis.
“You go to your physician, they do something, they submit a claim, they get a check. We haven’t put in a system that makes providers, whether hospitals or physicians, step back and say, ‘Let’s do this differently. I’m on a treadmill of fee for service. The more I produce, the more I get paid.’ This IBD pilot program is to really help us transform that payment structure.”
Intangible factors such as how much of a specialty medical home’s success is predicated on the verve of its leadership will also be evaluated. “If you don’t have a physician who will be the [medical home’s] champion, it will be very hard to replicate,” Ms. McAnallen said. Attracting ambitious specialists with the opportunity to create such an integrated care model could become a recruitment tool for UPMC, she added.
If the concept of a one-stop-doc-shop sounds slightly “what was old is new again,” harkening back to the days when physicians were called doctors, never “providers,” and largely were thought of as family friends who made house calls, said Dr. Szigethy, it’s because it is that model, amplified by modern means.
“We can’t go to patients’ homes because they’re even more widespread than they were back in the day of the village, but what we can do is provide care through the ancillary team members who are extraordinarily well trained, and can provide education on nutrition and medication. Whether it’s by telemedicine or face to face, patients are getting treated in an integrated way, and we’re doing it as efficaciously as possible. That is brand new.”
Dr. Regueiro said in an interview at least one other insurance company has expressed interest in learning more about the IBD center’s integrated approach, causing him to reassess the payer’s role in health care’s revolution. “There is more common ground between us than I once thought. Insurers are not the devil. They are central to improving value.”
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