CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2012;10:609 – 611
PRACTICE MANAGEMENT: OPPORTUNITIES
AND CHALLENGES
How May the Transition to Value-Based Payment Influence
Gastroenterology: Threat or Opportunity?
PARAMBIR S. DULAI,* ELLIOTT S. FISHER,‡,§ and RICHARD I. ROTHSTEIN*,§,储
*Department of Internal Medicine, 储Section of Gastroenterology and Hepatology, Dartmouth Hitchcock Medical Center, Lebanon; ‡Dartmouth Institute for Health
Policy and Clinical Practice, Lebanon; §Department of Medicine, Dartmouth Medical School, Hanover, New Hampshire
G astroenterology has experienced a surge of innovation
and growth over the past decade, with major advances
in diagnostic and therapeutic endoscopic procedures and in
the basic understanding of disease pathology, including ge-
netics and molecular mechanisms. These advances have been
facilitated by the entrepreneurial efforts of innovative gas-
troenterologists, reasonable federal funding levels, invest-
ment opportunities with a high profit potential in an era of
increasing obesity, an aging population, and a fee-for-service
payment model that has favored procedure-based specialties.
Change, however, is coming. On the one hand, the threat
posed by increasing health care costs is clear: increasing
federal deficits as far as the eye can see,1 state budgets in
which increasing Medicaid costs crowd out education,2 and
declining take-home pay for the average American owing to
increasing insurance premiums and federal borrowing to
finance Medicare.3 On the other hand, evidence that much of
US health care spending is wasted has shifted the conversa-
tion4 and contributed to the sense of crisis. Whether under
Republican proposals (such as the Ryan plan), private health
plans’ pay-for-performance5 and global payment initiatives,6
or current federal policy, benefit designs and payment policy
are moving inexorably toward approaches that will empha-
size value over volume.
Accountable Care Organizations (ACOs) represent a major
focus of both public policy and private health plan activity.7
These organizations represent collaborations of health care
professionals and service providers structured around pa-
tient-focused aims (better health, better technical quality,
and improved care experience), provider accountability (per-
formance measures), and payment reforms that provide fi-
nancial incentives for quality improvement and lower costs.
Given the emphasis inherent in ACOs on improving care and
lowering costs for enrolled populations, some have expressed
concern that specialties such as gastroenterology may be
threatened by declining investment to support innovation.
Although it is unclear what ultimate role ACOs or the shift
to value-based payment will have in changing health care
Resources for Practical Application
To view additional online resources about this topic and to
access our Coding Corner, visit www.cghjournal.org/content/
practice_management.
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delivery, physicians will need to rethink the focus of inno-
vation—whether in traditional clinical and translational re-
search or models of care delivery.
Bench to Bedside: The Translation of a
New Health Care System in
Gastroenterology
Bench research, which provides the foundation of bio-
logical insights that can contribute to improving health and
more effective disease treatment, receives its funding largely
through federal grants and, to some degree, organizational
investment. Allocation of the federal financial resources cur-
rently is based on a public appropriation model (National
Institutes of Health), which has seen a recent decline in growth
rates—a direct result of current economic stress and increasing
federal deficits.8 Under global payment models such as ACOs,
financial investments within organizations likely will shift from
favoring specialties that generated revenue under fee-for-service
toward investments more likely to improve the organization’s
capacity to succeed under these new models: infrastructure
expansion such as electronic health records and registries, im-
plementation of quality-improvement initiatives, and care co-
ordination. Although there is uncertainty in the amount of
funds that will be available, there is little uncertainty about how
the available funds will be redirected. Research with transla-
tional potential that is likely to impact large populations, re-
duce overall long-term costs, and result in value-producing
investments, will be supported preferentially. This prioritiza-
tion will be largely institutional dependent and influenced by
their strategic plan as it integrates into their specific emerging
health system.
We also can anticipate changes in the clinical research en-
terprise in an ACO era. Investment for clinical research of
products heading to commercial application is currently largely
through industry support, and stratified based on business
models that highlight profitability and marketability under a
fee-for-service system that rewarded high-cost procedures with
little regard for their actual impact on health outcomes or
© 2012 by the AGA Institute
1542-3565/$36.00
http://dx.doi.org/10.1016/j.cgh.2012.02.032
610 DULAI ET AL
Figure 1. (A) Current equation for return on investment (ROI). (B) New
equation for ROI under an ACO model.
overall cost (Figure 1A). Under value-based payment ap-
proaches, decisions about investments in translational technol-
ogy development and its adoption increasingly will hinge on
the degree to which new treatments and devices improve quality
and value, leading to a system in which profit was linked
directly to long-term health improvement and cost savings
(Figure 1B).
One example of the possible outcomes resulting from this
new equation can be found in the advances being made in
treatments for obesity and diabetes. Surgical gastric bypass in
the management of morbid obesity is a costly late intervention
rather than a less-expensive earlier interventional or preventive
measure. Preliminary research on the mechanism of weight loss
from gastric bypass has stimulated industry to create novel,
mainly reversible, endoscopic therapies that mimic these mech-
anisms. Given the disappointing success rates to date with
standard medical therapy for sustained weight control, endo-
scopic alternatives to surgery may offer a cost-effective earlier
intervention for weight control and diabetes. At the same time,
increased research on interventions, whether behavioral or clin-
ical, to reduce future risks of obesity is highly likely. Outcomes
research to characterize pretreatment features for success will
allow for individualization and optimization of treatment
through a multidisciplinary team-care approach, resulting in an
increased value of care delivered.
Although the future is hard to predict, the alignment of
research investment with patient-centered clinical program de-
velopment could result in re-invigoration of domestic innova-
tions and regional centers of excellence with the highest-value
patient care, able to create and disseminate new knowledge and
technology ultimately aimed at improving population health.
Endoscopy: How Will a Major Focus of
Clinical Gastroenterology Be
Impacted?
Endoscopy has transformed gastroenterology into a
procedurally dominated specialty. Through progressive innova-
tions and technologic advances, endoscopy has become a plat-
form through which a broad array of advanced imaging and
therapeutic interventions can be performed. Examples of recent
major advances include capsule endoscopy, endoscopic ultra-
sound and microscopy, mucosal ablation and resection, pan-
creatic cyst drainage and debridement, endoscopic sphincterot-
omy with stone extraction or stenting, and percutaneous
gastrostomy, to mention a few. These interventions, however,
come at a cost, and a transition to a new health system may
have considerable impacts on the future of endoscopy. Inter-
ventional endoscopy has continued to evolve, becoming more
invasive, complex, and often surgical in nature. This evolution
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CLINICAL GASTROENTEROLOGY AND HEPATOLOGY Vol. 10, No. 6
has been fueled in the past by an industry focused on profit
potential in conjunction with progressively interventional cli-
nicians who pushed the limits of their current technology. A
current example of innovation can be seen in the advances
being made in flexible endoscopic surgery and natural orifice
translumenal endoscopic surgery. Some have argued for the
need to develop these procedures given the success and relative
safety of laparoscopy. Although for some approaches a patient
benefit may not be clearly or immediately evident, the push to
develop natural orifice translumenal endoscopic surgery has led
to the creation of new flexible endoscopic multipurpose devices
and platforms. These tools can be applied to other endoscopic
procedures leading to higher procedural success, lower compli-
cation rates, and better health care delivery. As described for the
investment in innovation in the basic sciences, organizations
will need to consider the allocation of resources to these inves-
tigational endeavors, balancing the overall impact with cost to
the health system that may arise through these technologic
advancements. Given the incentives inherent in value-based
payment and the ACO model, endoscopic innovations and
technology that has strong evidence of clinical effectiveness and
efficiency should have broad implementation. This should pro-
mote better outcomes, lower cost, and higher value.
Clinical Practice and Health Care
Delivery: The Gastroenterologist Next
Door
One of the fundamental principles behind an ACO
model is the population-based focus and team-based care that
strives to have all clinicians practicing “at the top of their
license.” An example of this is the patient-centered medical
home. This is a team-based approach led by a personal physi-
cian who provides and directs continuous and coordinated care
to enhance access, quality, and safety.9 These depend on an
emerging nonphysician workforce that is capable of delivering
much of the care needed by patients. Furthermore, the long-
term success of the patient-centered medical home model is
likely to be dependent on the availability and alignment of the
medical neighborhood and/or subspecialty environment.10 It is
this structure that will create an opportunity for the gastroen-
terologist at regional practices in an ACO model to innovate
through development and implementation of practice guide-
lines and strategies for health care delivery: the specialist as a
source of expert knowledge and advice, but not necessarily
responsible for face-to-face care. An example of this approach
can be seen in the Extension for Community Healthcare Out-
comes project of New Mexico. This model used videoconferenc-
ing technology to train primary care providers on treatment of
patients with chronic hepatitis C virus. The outcome was sub-
stantial with high rates of cure in the rural community-based
setting, similar to those seen in the university hospital.11 These
models of integrated care, along with other cost-effective strat-
egies such as shared appointments, shared decision making,
and increased use of midlevel providers for routine procedures
such as colonoscopies,12,13 may lead to profound and initially
disruptive changes in clinical practice, but ultimately will allow
for not only cost-effective health care delivery, improved inno-
vations, and technology adoption, but also a standardization of
care to best practices in gastroenterology and hepatology. Of
course, whether it is nonphysicians performing endoscopy or
the delivery of care by primary care physicians previously pro-
June 2012
vided by gastroenterologists, we must acknowledge and plan for
the likely consequences: the need for fewer practicing gastroen-
terologists in the future—and the accompanying changes in
training programs to adapt to these new care models.
The transition to delivery and payment systems focused on
improving the value of care for both patients and communities
will not reduce the need for continued innovation in gastroen-
terology and endoscopy. It is likely, however, to lead to a more
prioritized and goal-directed use of currently available resources
focused on developing and disseminating those innovations
that help to achieve higher quality of care at a lower cost.
Although the goals are fairly clear, success is far from certain.
How we respond will make a difference.
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Reprint requests
Address requests for reprints to: Parambir S. Dulai, MD, Department
of Internal Medicine, Dartmouth Hitchcock Medical Center, 1 Medical
Center Drive, Lebanon, New Hampshire 03756. e-mail: parambir.
s.dulai@hitchcock.org; fax: (603) 650-6122.
Conflicts of interest
This author discloses the following: Richard Rothstein is a consul-
tant to SafeStitch Medical, Inc, and receives funding from National
Institutes of Health, Olympus, and Boston Scientific. The remaining
authors disclose no conflicts.