2015-09-11 20:56:28 UTC

Population Health: Strategies for GIs to Survive and Thrive

Sept. 8, 2015

The focus on population health will impact our reimbursement as we move from fee for service to value-based payments.


Lawrence R. Kosinski, MD, MBA, AGAF

Illinois Gastroenterology Group, Elgin, IL; Practice Councillor, AGA Institute Governing Board

The article originally appeared in the August/September 2015 issue of AGA Perspectives.

Population health, one of the pillars of the triple aim,1 is defined as “the health outcomes of a group of individuals, including the distribution of such outcomes within the group,”2 thus requiring providers to focus on their entire population of patients with specific diseases rather than the traditional “one-at-a-time” approach.

The focus on population health will impact our reimbursement as we move from fee for service to value-based payments. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA),3 signed in April 2015, creates a Merit-Based Incentive Payment System which, beginning in 2019, will convert fee-for-service into a value-based payment system with the goal of the majority of physicians’ income being value based. It will also provide incentives for practices to embrace alternative payment models for patients across their commercial and Medicare patients.4

How do GIs participate in population health? How do we transform from a procedural-driven model to one based on value-based payments?

A majority of the wRVUs generated by gastroenterologists are commonly from the colonoscopy procedures performed for colorectal cancer screening, surveillance and removal of lesions. Unfortunately, screening colonoscopy is a vulnerable “mature service” facing compressed margins, reduced fees and competition from new technology. Now is the time for GIs to build additional competitive advantages.

The next major diagnosis that drives significant revenue in a GI practice is IBD. A typical GI practice may derive about 25 percent of its revenue from the management and treatment of IBD.5 Management of IBD requires significant knowledge and expertise and, as such, should represent a competitive advantage for GIs. Unfortunately, most GI practices have not leveraged this opportunity.

Data from BlueCross BlueShield of Illinois (BCBSIL) revealed that their average IBD spend is $11,000 per commercial patient per year for Crohn’s disease.6

More than 50 percent of this spend is on inpatient treatment and complications of this condition. Yet gastroenterologists receive only 3.5 percent of this spend, despite being the most knowledgeable physicians about this disease. Tremendous variation in physician practice and hospitalization rates exists, which may persist even when normalized for patient risk and comorbidities. Clearly there is an opportunity to improve care management and deliver value.

Population health requires a new level of patient engagement. Only a minority of patients who are admitted to a hospital for a complication of IBD were seen by a provider within 30 days prior to admission. This is the result of our “reactive medicine model,” where physicians are often not engaged until the patient realizes they have a problem that they cannot fix themselves. Like submarines, patients “run silent and run deep,” surfacing only when they are in trouble and need help. Unfortunately, by that time, serious complications may have already ensued.

Project Sonar

Recognizing the need to address care management and patient engagement for patients with IBD, the 45-physician Illinois Gastroenterology Group developed Project Sonar, a care-management solution for patients with IBD. Project Sonar utilizes nurse care managers and physician medical directors in a team approach to coordinate care for patients with IBD, along with clinical decision support and patient engagement.

The “Sonar System” pings the patient, bringing structured data on patient-reported outcomes to the practice.

Complex clinical decision support tools are embedded into the practice’s EMR. These tools facilitate:

  • Implementation of AGA’s Crohn’s Disease Care Pathway into the care workflow, with risk assessments for inflammation, disease burden and co-morbidities.7  
  • Reporting CMS PQRS and AGA Digestive Health Registry IBD measures.
  • Capture of clinical data fields for immunizations, labs and imaging results.

Patient engagement is facilitated through several structured questions derived from the Crohn’s Disease Activity Index9 sent to the patient’s smartphone via a proprietary platform/application. The “Sonar System” pings the patient, bringing structured data on patient-reported outcomes to the practice. Using these measurable responses, the slope of each patient’s “Sonar Score” can be followed over time. The data is fed back into the clinical decision support tools and dashboards used by the nurse care managers and physician medical directors for population health.

The success of Project Sonar in a 50-patient pilot in 2013 led to a partnership between Illinois Gastroenterology Group and BCBSIL in 2014 to develop a specialty-based intensive medical home, a joint initiative to improve the care of patients with Crohn’s disease.10

The intensive medical home utilizes the Project Sonar structure in an attributed population of IBD patients. Illinois Gastroenterology Group receives a supplemental per-member per-month care-management payment for each attributed/ enrolled patient, and a shared savings opportunity at the end of each study period.

The data produced from the clinical decision support tools and Sonar Scores creates a unique set of physician risk assessments, medical decisions and patient-reported outcomes not typically available in most EMRs. These data are used to refine the care provided through the development of care algorithms, which update the clinical decision support tools and the content of the smartphone app.


Population health and value-based payments will mold and shape how we can position our GI practices. Three pillars are essential to our success:

  1. Changing our focus from one patient at a time to improving the health of populations.
  2. A team approach that embraces midlevel professionals, care managers, social workers, dietitians, pharmacists and others is required.
  3. Engaging patients as partners in their care alongside their health-care team is crucial.

All of this requires changes to how we structure the policies, procedures and compensation models for our practices. Incorporating clinical decision support tools and patient engagement will be essential components for GI to manage cancer screening, IBD, liver disease, obesity, dyspepsia, GERD, etc. Gastroenterologists can survive and thrive in the new population health. Through engaging with patients, decision support and demonstrating value, we can establish our competitive advantage. Enjoy the ride!

Dr. Kosinski has no disclosures to report.


1. http://www.ihi.org/Engage/Initiatives/TripleAim/pages/default.aspx

2. http://www.ncbi.nlm.nih.gov/pmc/articles/ PMC1447747/

3. https://www.congress.gov/bill/114th-congress/house-bill/2

4.Gastroenterology, Vol. 147, Issue 4, p927–929

5. Illinois Gastroenterology Group Data.

6. BCBSIL Data.

7. http://campaigns.gastro.org/algorithms/ IBDCarePathway/

9. Best WR, Becktel JM, Singleton JW, Kern F Jr. (March 1976). “Development of a Crohn’s disease activity index. National Cooperative Crohn’s Disease Study”. Gastroenterology 70 (3): 439–444. PMID 1248701.

10. http://www.bcbsil.com/company-info/news/ news?lid=i18dwg7e

More on Crohn's Disease

Crohn's & Colitis Congress™ (A Partnership of the Crohn's & Colitis Foundation and American Gastroenterological Association)

Feb. 7, 2019

Expand your knowledge, network with IBD leaders, spark innovative research and get inspired to improve patient care.

Principles of GI for the NP and PA

Aug. 10, 2018

Hear from the experts as they provide you with critical updates on treating and managing patients with a variety of GI disorders.

Best Practices in IBD: Differential Diagnosis

March 15, 2018

This activity outlines the different pathophysiologic processes and symptoms that differentiate IBD and from functional bowel disorders such as IBS, and it reviews AGA’s Crohn's disease and ulcerative colitis “Clinical Care Pathways.”