Practice Management Toolbox

Cultivating competencies for value-based care


It is my privilege this month to assume responsibility for the “Practice Management: The Road Ahead” section of Clinical Gastroenterology and Hepatology. I am honored to join an impressive board of editors led by Dr Fasiha Kanwal, and anchored by global leaders in the field of gastroenterology and hepatology. This board of editors promises to continue the high level of excellence that has propelled the journal to its preeminent position among clinical journals. I am confident that the practice management section will uphold that tradition and continue to meet the expectation of our readers. I would like to mark this transition by acknowledging the history of the practice management section of Clinical Gastroenterology and Hepatology and outlining a vision for the future.

The section was introduced in 2010 under the leadership of Dr. Joel V. Brill. The section, titled “Practice Management: Opportunities and Challenges,” aimed to help practices navigate the disparate issues facing the field. Some of these issues included use of capnography in endoscopy, the importance of registries for quality reporting, and the burdens of meaningful use on physician practices. Dr Brill introduced this section in a video in May 2010 ( Dr. Brill’s reference to these “interesting and challenging times” in gastroenterology resonates even more loudly today.

Organizational competencies for reform, adapted to gastroenterology
With the transition of the board of editors in 2012, Dr. John I. Allen assumed stewardship of the practice management section, which was subsequently named “Practice Management: The Road Ahead”, to match a parallel initiative within the American Gastroenterological Association. Dr Allen’s experience as a practicing gastroenterologist and his clairvoyance on health policy issues is unparalleled. One has to look no further than his first paper as special section editor where he outlined the dominant themes of the next 5 years, namely: the importance of demonstrating value, population management, consolidation of medical practices, increasing importance of cost, and the rise of value-based payment.1 The Road Ahead has kept focus on these topics through educational pieces on health care reform and payment policy,2,3 case studies in alternative payment models,4,5 primers on quality improvement methodology,6-8 and astute commentaries on important issues facing practicing clinicians.9-11

Over the next 5 years, the Road Ahead section will continue and strengthen its focus on the current and emerging issues facing gastroenterology and hepatology practices. I believe that high-value care will continue to be a high priority for patients and payers alike. Early results with payment reform around value have been mixed, in large part because of challenges in health systems and practices developing the competencies required for such reform.12 These competencies include governance and culture, financial readiness, health information technology, patient risk assessment, care coordination, quality, and patient centeredness. I will use this conceptual framework of organizational competencies, and their application in gastroenterology and hepatology, to help curate the Road Ahead section (Table 1). Key themes will include the following:

  • • Governance and culture: The structure of health delivery systems, as conceptualized by Donabedian,13 is a key determinant of quality. Structural attributes include regulatory requirements on gastrointestinal practices, such as the rules governing use of anesthesia providers in ambulatory surgical settings; role of allied health professionals in clinical settings; and the impact of financial incentives in driving provider behavior.
  • • Financial readiness: Value-based reimbursement, accountable care, medical homes, reference pricing, and physician tiering are some of the new terms in this era of value-based medicine. It is important for practices to assess patient costs longitudinally and manage financial risks. The Road Ahead section will continue to include papers that describe the impact of these reforms on gastroenterology and hepatology practices while providing guidance on implementation of these new models of care. Some examples include papers on the effect of payment policy on specialty practices, the development of a medical home in inflammatory bowel disease, and the physician experience with episode-based payments for colonoscopy.
  • • Health information technology: All of the organizational competencies required for reform rely on a robust information technology platform that collects meaningful data and harnesses that data for analytic purposes. These platforms can be enterprise systems deployed by large health delivery systems or smaller, more nimble platforms, created by innovative start-up companies. The Road Ahead will include papers that share best practices in the use of these platforms to provide high-quality and cost-efficient care. In addition, the Road Ahead will continue to explore the use of health information technology to expand the reach of clinicians beyond brick and mortar clinics.
  • • Patient risk assessment: Tailoring interventions to high-risk patients is necessary to deploy limited resources in a cost-effective manner. Risk assessment is also needed to more accurately and effectively personalize care for patients with chronic conditions. The Road Ahead will include papers that evaluate risk assessment tools and/or describe real-life implementation of these tools in different contexts.
  • • Care coordination: The ability to provide team-based longitudinal care across the continuum of care will be integral to providing high value health care. The Road Ahead will serve as a means to disseminate best practices and innovative methods to care for increasingly complex patients, especially those with chronic diseases, such as cirrhosis and inflammatory bowel disease. For example, papers will explore the implementation of specialty medical homes, patient navigators, community-based care services, and involvement of patients in their own care.
  • • Quality improvement: Providing high-value care by definition will require clinicians to accurately measure the quality of care provided to patients and use data to guide process improvement. The Road Ahead will continue to serve as an educational resource for clinicians with papers that discuss challenges and opportunities in quality measurement and improvement. Similarly, this section will present data on novel or impactful quality-improvement initiatives.
  • • Patient centeredness: Patient experience measures and patient-reported outcomes are becoming increasingly important as meaningful indicators of quality. These measures are designed to ensure that patient perspectives are incorporated into the governance, design, and delivery of health care. The Road Ahead will serve as a dissemination mechanism for sharing best practices in developing, validating, implementing, and tracking patient-reported outcomes.

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