Innovative care delivery models for the clinical practice of hepatology

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Abbreviations

ACO

accountable care organizations

ER

emergency room

HCV

hepatitis C virus

PCMH

Patient‐Centered Medical Home

PCSP

patient‐centered specialty practice

Introduction

Populations with one or more chronic illnesses have placed a substantial burden on health care systems worldwide.1 In the United States, nearly three‐quarters of adults over the age of 65 suffer from a chronic illness,2 which accounts for over $1 trillion in health care expenditures.3 Although passage of the Affordable Care Act has expanded health insurance coverage as a start to begin resolving serious cost and quality issues, the system of medical care in this country remains highly fragmented because the majority of physicians practice independently or in small groups for which payment is predominantly fee‐for‐service. In the pursuit for identifying delivery systems that meet the needs of the chronically ill, a number of innovative care delivery models have been tested for which coordinated care and improved quality are tied to new payment incentives.1 Although these innovative models have been directed toward primary care, emerging data suggests that they will also play a major role in the delivery of specialty care, including the clinical practices of general and transplant hepatology.

Novel Care Delivery Models Applicable to Hepatology

Accountable Care Organizations

For a defined population of patients, accountable care organizations (ACOs) accept responsibility for quality of care, efficient spending, and performance measurement. This organizational structure is intended to create economic incentives for hospitals, physicians, and other providers to work together to prevent unnecessary utilization (i.e., emergency room [ER] visits, hospitalizations).4 Currently, health care policy for measuring quality of care is focused on the individual patient–provider interaction. In the ACO model, the level of measurement moves to the entire system or population of patients assigned to the organization. Specific metrics used to assess population‐based outcomes might include disability days, functional health status scores, and patient experience measures.1 Currently, there are five health‐system organization types that could serve as functional ACOs: integrated delivery systems, multispecialty group practices, physician hospital organizations, independent practice organizations, and “virtual” physician organizations.1, 4 Notably, the majority of academic health centers housing major hepatology and liver transplant programs are structured as integrated delivery systems or multispecialty group practices that are affiliated with a medical school.1, 4, 5

Within the realm of internal medicine subspecialty disciplines, the organization of liver transplant centers is arguably the best example of hepatology care delivered along the principles of ACOs. In addition to providing multidisciplinary, coordinated care for wait list patients and liver transplant recipients in a longitudinal manner, liver transplant centers have also financed their care delivery through bundled payments for the entire episode of transplant services. Furthermore, liver transplant programs are held accountable for center‐specific patient and graft survival rates that are publicly reported.5 Institutions or groups with nontransplant clinical hepatology practices would be served well by studying the organizational principles underlying liver transplant care delivery models if a goal is enhanced performance while the gradual transition to global or shared payment reform moves forward.

Patient‐Centered Medical Home

The Patient‐Centered Medical Home (PCMH) is a team‐based model housed in primary care that aims to deliver coordinated care over time. Tools including electronic health records, disease registries and practice guidelines, and continuous quality improvement initiatives are used by the PCMH to track patient referrals and treatments, including those supplied by specialist physicians. Although early evidence suggested that the quality of care, patient satisfaction, and access to care were improved by PCMH models, recent data from larger studies could not reproduce these benefits.1, 6, 7

Notably, there has been growing interest in developing a parallel care model known as the patient‐centered specialty practice (PCSP). A major driver of the PCSP concept is to maintain or improve the quality of care for patients who rely heavily on specialty and acute care services outside of a PCMH.7 Within clinical hepatology, the care delivery model used for patients awaiting liver transplantation has essentially functioned as a PCSP that coordinates care and manages ER and hospital visits through dedicated provider, nursing, and administrative support. Preliminary studies examining specialist team‐based8 and chronic disease management strategies9 versus usual care for nontransplant populations with cirrhosis have also demonstrated significant advances in quality, cost, utilization, and clinical outcomes. It should be noted that both PCMH and PCSP models are likely to fall within the larger domain of ACOs as time goes on. Reassuringly, the experience of shared responsibility for patient care in liver transplantation should facilitate a similar acceptance of shared responsibility among clinical hepatologists with primary care providers in this context.

E‐Health

E‐health can be described as the deployment of novel technologies to facilitate health care practices and communication between provider and/or patients. In the context of innovative care delivery models, the concepts of electronic consultation (eConsult) and telemedicine have received the most attention to date.

Electronic consultation uses health information technology in order to link primary care providers and specialists to increasing access to care and optimize the efficient use of specialty resources. Approaches have typically included one or more designated specialist provider who reviews a request for consultation to determine the need for 1) a routine or expedited clinic visit, 2) additional evaluation before scheduling a clinic visit, or 3) education and management strategies without in‐person consultation. Exchanges between providers are captured in the electronic health record to facilitate point‐of‐care and longitudinal care delivery when necessary. Notably, the clinical practice of hepatology is recognized as a suitable area to develop and promote the use of eConsults given the cognitive, disease‐focused evaluations that characterize the work in this field.10, 11 A recent retrospective study of referrals for ambulatory hepatology consultation identified 13% of eConsults as appropriate for this care delivery platform. Notably, 40% of referrals did not include enough information to determine the appropriateness for preconsultation exchange, which suggests the opportunity for improvements in primary care–specialist communication.11 It has also been noted that integrated delivery systems may be best situated to adopt this approach given their incentives to manage care globally in the context of a salaried physician culture.10, 11

Telemedicine is another disruptive yet innovative care delivery method that has been successful in providing more timely access to populations requiring subspecialty care. In clinical hepatology, Project ECHO is considered by many to be one of the most successful endeavors utilizing telemedicine as a care delivery model. In Project ECHO, community providers take part in a weekly video conference and share patients' clinical histories with university‐based specialists to design care plans according to evidence‐based protocols. Since 2003, there have been more than 5000 case presentations and 800 patients treated for chronic hepatitis C virus (HCV) infection. A recent prospective cohort study of 407 treatment‐naïve chronic HCV patients demonstrated similar treatment response rates when compared to patients treated at the university‐based subspecialty clinics.12

For both eConsult and telemedicine approaches, there has yet to be a definite path forward in terms of reimbursement for services rendered. Furthermore, the issues of medical licensure and practice across state lines have limited the dissemination of these care models. The approval of a recent proposal for rapid interstate medical licensure could address in part the physician shortage in rural areas and other underserved areas as well.13

Conclusion

The opportunity to incorporate novel care delivery models is likely to reach organizations housing clinical practices of hepatology while health care reform continues to evolve. Fortunately, the discipline's long‐standing experience with the practice of transplant hepatology will serve as a resource for rethinking the way that medical care is delivered to patients with chronic liver disease. For practices outside of large, integrated, or multispecialty settings, the challenge will be to adopt electronic medical record technology while forming health care teams in the context of practice redesign. Care delivery by eConsult and telemedicine can provide remote access to specialty care once regulatory issues surrounding multistate licensure are resolved.