We are witnessing an extraordinary downward pressure on reimbursement for all medical services from every type of payer. There also is an emerging shift to value-based reimbursement where revenue for medical services is linked to patient outcomes. As this trend continues, AMCs may need to compete directly with integrated delivery networks (IDNs) that are emerging as an increasingly dominant care delivery model characterized by close clinical and financial linkage among primary and specialty providers, hospitals, and ancillary services1 in areas where this is relevant.
Figure 1 illustrates a comparison of the total cost of care among three major types of IDNs. IDNs that are "closed," meaning all aspects of care are contained within a single financial umbrella (eg, Kaiser Permanente), control costs by owning and aggressively managing all aspects of care delivery (primary and specialty providers, hospitals, and ancillary facilities). They usually have an enterprise-wide EMR that simplifies transmission of information (1 patient, 1 chart). Few patients are referred outside the IDN, and the total cost of care for a purchaser of health benefits can be low in comparison with other regional delivery networks (Figure 1).
Another IDN model comprises partially owned (or employed) providers and hospitals but affiliations with independent specialty groups. The fact that all providers are not employed and often have different EMRs compared with the core hospital system adds additional costs. The third type of IDN includes AMCs that increase costs compared with other IDNs because of the fundamental missions of research and teaching. Despite the importance of their tripartite missions, some AMCs are being forced to compete for market share with well-managed closed network IDNs. Consequently, increased costs must be balanced by clearly defined added value that would be important to purchasers and individual patients alike.
Finally, as state and federal exchanges mature (2014 and beyond), the health care purchasing market will shift from a "wholesale" to a "retail" viewpoint where decisions about joining health systems will increasingly be at the level of individual patients. Exchanges organize price and quality information about regional provider networks in a manner that allows individuals to choose their providers with greater price and quality transparency. If AMCs in these mature markets are out of network or too costly, patient co-pays and deductibles will preclude large segments of patients from seeking their care at those centers.
In regions of the country where purchasers have organized to negotiate health care contracts, narrow provider networks and highly managed referral patterns have specifically excluded some well-known (but expensive) tertiary and quaternary referral centers. Examples of AMCs that have been excluded from significant provider networks can be found already in mature managed care markets such as California, Minnesota, and Massachusetts. Dr Martin Brotman articulated these concepts in unambiguous terms during his Presidential Plenary presentation at Digestive Disease Week® 2013. (An interview with Dr Brotman can be accessed on YouTube, available at: http://www.youtube.com/watch?v=hquW3NZtnxM).
Five steps that will help AMCs survive
Because of the changes we have defined, what are the key steps that AMC GI divisions can implement now to help build a sustainable practice model? There are five basic suggested steps that may be useful.
Focus on patient-centered care
As health care delivery moves to a patient-centered model, demands on faculty have changed. Clinical faculty members now are expected to be accessible to patients, complete medical records promptly, and follow lab and biopsy results in a timely manner. Federal and commercial payers both are developing robust Web sites that distinguish quality and cost at a provider level. This unprecedented focus on transparency of practice will affect all gastroenterologists equally, no matter what their practice setting.GI divisions must respond to these changes by building a robust clinical infrastructure to help support academic faculty, while allowing time for research and educational activities combined with an information technology platform that facilitates collection of performance and value metrics. Many AMCs structure care around specific patient conditions and have developed Centers of Excellence that provide cutting edge, coordinated care for populations of patients (inflammatory bowel disease, foregut disorders, hepatology, for example).
Enhance clinical efficiency
Economic pressure on AMCs is growing rapidly, so division funds will increasingly be tied directly to clinical productivity of faculty. GI divisions can develop or augment efficient clinical enterprises by focusing on easy and rapid patient access, development of clinical service lines that distinguish faculty from community physicians, efficient endoscopy practices, and other measurable activities that enhance and expand clinical service. Much of this redesign will require joint investment shared by GI divisions and their hospital systems.
