Hello, I would like to welcome you to the Value-Based Medicine and Hepatology Program for AACLD 2020 Delivery Meeting. I'm Zubair Nasri, I'm the Chairman and Professor of the Department of Medicine at the NOVA Fairfax Medical Campus and the President of the Medicine Service Line for NOVA Health System. I'd like to also take this opportunity to welcome you on behalf of my co-chair, Professor Fasiha Khanwal, who is the Chief of Gastroenterology as well as a Professor of Medicine at Baylor College of Medicine in Houston. Now before we get started, let me just make a few comments and then I'll introduce the program for you. Before we get started with the program, let me just quickly review some of the historic anomalies in the healthcare composition structure that has led to really a rapidly rising healthcare cost in the United States as well as some other countries. In fact, in 2019, the total health spending as a percent of GDP in the United States is almost 18%. And in fact, some of the other countries in Europe, they're also catching up. And this is not a unique one-year anomaly. If you look over the past two or three decades, there has been a rising rate of healthcare expenditure in the United States as well as in the other countries. Also, the rate of rise in the United States is probably much faster. When you look at the healthcare spending without value assessment, this has led to a number of inefficiencies and waste. In fact, in 2014, it was estimated that top 5% of healthcare spenders account for almost half of spending. And a study in 2012 from the Institute of Medicine suggested that about a third of healthcare expenditure could have been considered waste. To address some of these issues in the past three decades, there has been a movement to focus on value-based care. And in this context, value is defined as the health outcomes that are achieved relative to the amount of money spent to achieve these outcomes. In fact, outcomes could be clinical outcome or quality outcome, and the cost is really the total cost of delivering these outcomes. And there are a number of principles that governs outcome measurements. Given the importance of maximizing value, this program in value-based medicine and hepatology was designed because hepatologists are increasingly being included in value-based arrangement between payers and providers. Therefore, the goal of this program is to educate and empower hepatologists to be valuable contributors to the success of these new programs and arrangements, and play an active role in developing and implementing beneficial approaches. As a part of this program, we would like to gain fundamental knowledge in alternate payment models and novel approaches to delivering care to patients with cirrhosis, to understand the importance of specific coding to capture the complexity of patients with chronic liver disease, and to actively engage with the system leadership as it relates to value-based arrangement for hepatology and care of patients with chronic liver disease. So we have five fantastic speakers who are going to review some of these topics over the next hour or so. Dr. Asrani is going to review the value of value-based care. That will be followed by a talk by Dr. Sami Saab from UCLA to review the role of individual hepatologists in value-based care, what can I do to improve outcomes and lower costs of liver-related care. Dr. Jilad is going to follow up with another talk on episode-based and bundled payment models for hepatology, and the question is, are we there yet? And next, we'll have Dr. Vincent Wong review value-based practice of hepatology in Asia and Europe, some of the lessons that we can learn from other parts of the world and how this is applicable to the United States. And finally, Dr. Elliot Tapper is going to review the implementation of value-based care during an era of COVID-19, which is what we have been experiencing over the past six to seven months. And finally, my co-chair, Dr. Fasiha Khanwal, will make some closing remarks to summarize what we heard in this program. So without any further delay, let's just go ahead and get started with the program, and again, thank you very much for your attention and for your participation. Thank you again for this kind invitation to talk about the value of value-based care. My name is Sumit Asrani. I'm a hepatologist at Baylor University Medical Center in Dallas, Texas. I have no disclosures. The three things I wanted to touch on today was, what are the principles of value-based care? Two is, what is the value of value-based care? And what are the barriers to achieving true value of value-based care? And now I've used the word value at least seven times. So what are the principles of sort of value-based care? You know, when we think about the trajectory of a patient with cirrhosis, a patient with cirrhosis has decompensation, undergoes maybe transplant, but in most cases has premature mortality or even develops liver cancer. And each of these aspects, there are several gaps. Early recognition of cirrhosis is lacking. There's high burden of cirrhosis, and this burden is increasing relative to other chronic conditions. Decompensation management is hard. It's expensive. There's significant duplicative tests. There's a 10% population, which is high risk with decompensated cirrhosis, which account for a majority of costs in any system. There's this vicious cycle of ER utilizations, readmissions, access to transplant is low. And finally, there's significant premature mortality and high number of years of life lost. So value-based care theoretically fills that gap. How can we provide care, which is high quality at low cost? So in terms of the numerator, how can we improve high quality and provide high quality, which is not mediocre? Quality care, which is appropriate, timely, and improves patient outcomes. And on the other side of the equations, how do we do this at the lowest cost? How do we minimize unnecessary and duplicative care? How do we avoid unnecessary hospitalizations? And the benefits of value-based health care tend to be shared by all parties. If it works well for patients, it's lower costs and better outcomes. For providers, it's higher patient satisfaction rates and better care efficiencies. For the payers, it's stronger cost controls and reduced risks. For the supplier, there's alignment of prices with patient outcomes. And for society as a whole, if done well, theoretically, this can reduce health care spending and improve overall health. Value-based care sort of is in contrast to episodic or fragmented care. There's several interconnected interventions that sort of follow this circle. There's multidisciplinary care, there's community-based care, there's rapid learning. The overall concept is that the hepatologist sort of serves as a quarterback. And there are several models that can be applied, which I will go to in a little bit, such as chronic disease management model, care coordination, specialty-centered medical home. Because what we're trying to avoid and to really get the value is avoiding episodic and reactive care. Because this is sort of the trajectory that most of our patients follow. Patient visit, ER visit, inpatient visit, outpatient visit, and then continue this circle. But can we fill the gaps between this fragmented care? Can we add things such as extenders, educators, nutrition, social workers, trained caregivers? Can we provide alternative care, such as tap clinics? Can we add protocols that are robust, both in an inpatient as well as an outpatient setting, and standardize the way we do things? And finally, can we coordinate this transition from inpatient to outpatient? Let me walk through some of the examples that have been studied in the literature. So this was a randomized controlled trial looking at a chronic disease management model, which had four aspects. One was care coordination, which is their delivery system design. Two was decision support, which is development of evidence-based protocols. Three is self-management support, education provided to both patient and caregiver. And four is a robust clinical information system network where there's comprehensive review of all the data. And so even though patients assigned to a chronic disease management model as compared to the controls did not meet its primary outcome, liver-related admissions were the same, length of stay was the same, risk of death was the same. However, there was more engagement in the outpatient setting. There was higher quality of care with regards to screening for AHCC, referral for liver transplantation, assessment or commencement of hepatitis B as well as hepatitis A vaccination. And in a subsequent study, applying this model to a different population where they compared two units, one that had these elements put in, in the inpatient setting, and the other one that did not, survival was higher in those patients with chronic disease management model. On adjusted analysis, receiving standard care as compared to the CDM was associated with increased mortality. There's been a focus of thinking of the hepatologist, again, as a quarterback and certification for being established as a patient-centered specialty practice. There are standards and guidelines that have been developed along this concept. And several of us sort of dabble in different aspects of this, but we don't do this comprehensively. And one of the seven elements and standards that need to be met, one is how do we refer management initially? How well do we know and manage our patients? Do we provide access? Do we provide continuity? How well do we manage their care? How do we coordinate their care and transition them from one aspect to another? And finally, in all of this, are we measuring performance and improving quality? Third aspect is care coordination. So in this study of patients presenting to the emergency room with ascites, a care management protocol was developed, which ranged from five to nine hours. Once included, a patient comes in with needing an ascites in the ER. They get admitted to a day hospital. If they needed an endoscopy, they get an endoscopy. If they need surveillance, they get surveillance. They get tabs as needed. But in addition, they also get a care management check-in by a dedicated team, labs, education, treatment. There's real-time communication with the primary care provider. And follow-up is set up right then and there. And repeat care management check-ins are set up as needed. In this group, patients that were assigned to the care management program as compared to standard of care had improved survival. Outcomes were overall better with regards to 30-day readmissions, ER visits, days for hospital stay, risk of death, and again, all at a lower cost per patient month. There are, however, several gaps to get to that value of value-based care. And we need to sort of discuss the where, what, and how. First question is, when we think about incorporating value-based care, where can we impact to have the largest value? Is it starting off with the sickest patients and having processes in place for early hospice? Is it early referral for transplant, if appropriate? And if not, then incorporating early palliative care, decreased procedure cost, and also cost of terminal hospitalizations. Is it establishing protocols for transitional care and care coordination early on in decompensation? Is it incorporating quality measures and treatment of complications? Is it early structured HCC surveillance? Or is it all the way upstream where we target the patient at the chronic liver disease level with wellness, weight loss, abstinence, antiviral therapy, and other interventions to have the largest value so that all these downstream things do not happen in a majority of patients? Second is, what is defined as a successful outcome with regards to quality? Are we simply talking about survival, readmission, or liver transplantation rate as successful high-quality care? Or instead, should we be talking about equal access, patient-reported outcomes, quality of life, prevention of decompensation, and, if appropriate, early palliative care? Third, what is a successful outcome with regards to cost? Is it simply decreasing readmissions, duplicate testing, and managing the high-risk patient better? Or is it also looking at the cost of end-of-life, avoiding transplant if not needed, and avoiding decompensation? And finally, how do we develop and implement quality measures? Now, the AASLD is already on a path for this. Through leadership with Dr. Volk and Dr. Conwell, there have been a set of quality measures developed for patients with cirrhosis. Through the Practice Metrics Committee, about 29 quality measures were developed. These were subsequently specified, and now currently through a pilot program sponsored by the AASLD, the Cirrhosis Quality Collaborative, which is a pilot study with 10 sites, is looking at implementing these quality measures and seeing if they can decrease the variation in outcomes at a reduced cost, as well as improvement in overall patient-centered outcomes. So to really realize the value of value-based care, we have to be able to address every single bucket. For the patient, it's letting the patient define what are the goals beyond survival, getting the patient to accept that there are alternate care models besides the episodic and fragmented care, at the provider level, really defining success with regards to both quality and cost, and getting providers to be willing to serve and be rewarded as a quarterback for patient-centered care, because for our cirrhosis patients, we are the providers that they look forward to and pay attention to. Third is really adherence to quality measures and guidelines. But all this will not work if we don't have system buy-in, and the system really needs to define what are the goals. Is it simply to decrease the financial burden, and is it willing to support more upstream interventions that may not be clearly visible in just one-year follow-up or two-year follow-up? It may require a longer time frame. Second is really the system helping design appropriate tools to measure and implement some of these processes. And finally, is the system willing to invest in infrastructure for appropriate healthcare delivery from a care coordination standpoint, transitional care standpoint, as two examples? Thank you again for taking the time to listen to this. Welcome. My name is Sami Saab, and today I'm presenting under the Value-Based Healthcare. So the title of my talk is The Role of the Individual Hepatologist in Value-Based Care. What can I do to improve outcomes and lower costs of liver-related treatment? Here's my disclosures in terms of my affiliation. I work at UCLA. And here's my disclosure for research, consulting work, and member of the Speaker's Bureau. So, in the next 14-15 minutes, we want to cover two very important objectives. We want to review the gaps in healthcare delivery in the United States and identify major drivers of these costs. Then we want to talk about the role of the hepatologist in the changing reimbursement paradigm scheme of going from free-for-service to value-based healthcare. So basically, we're going from volume healthcare reimbursement to one based on quality. So, the U.S. spends more money on healthcare than any other country in the globe. We spend up almost 17% of our gross natural product on healthcare. And this overshadows every other country across the globe. If you look at rates of Switzerland and Germany, France, Sweden, and the list goes on and on, the average is near 9.5% or 10%. We're about 17%. And if you look at the source of funding, where is the money coming from? Public spending is pretty similar across the globe. Out-of-pocket is also not too different although we're on the higher end but most of the source of funding comes from the private sector. You see here that really no other country is even close to us in terms of the source of funding being from the private sector. So what do we get for our dollar? Well you would think intuitively that the more money you spend the better your outcomes should be. Indeed in this relationship here between the health spending per capita and life expectancy at birth, you see here it's pretty consistent that for most of the world the more health care dollars you spend per capita the higher your life expectancy will be except the United States. You see here that we're all the way on the right-hand side spending between nine to ten thousand per capita and yet our life expectancy at birth is similar to countries that spend a third or fourth of what we spend. If you look at the proportion of health care expenditures you know it really hasn't changed in 10 years. The same pie is true to hospitals and physician and clinical, to prescription drugs, nursing care facilities and others. But although the proportion is similar, the total dollar spend has increased significantly from two billion to close to three billion dollars. And if you look at the source of funds, again private sector overshadows everything else. Medicare has gone up, private sector has gone up, Medicaid has also gone up, both federal and state. So the relative proportion spenders have remained the same but there's been a steady short increase in the source. In this very nice study by Shranks, the authors looked at what are potential sources of waste and they defined six buckets of waste domains. Failure of care delivery, failure of care coordination, overtreatment or low value care, pricing failure, fraud and abuse, administrative complexity. And they estimate that there's about an annual waste of between seven, sixty, nine, thirty five billion dollars. There are some areas that resonate with hepatologists like the readmission rate. Across the United States this translates to about twenty billion dollars of waste money. Overuse of end-of-life care, forty four billion dollars. And as you know as hepatologists we deal with very sick people. Patients who we hope are transplant candidates but unfortunately not all patients are eligible for liver transplantation are able to make it to transplantation. So we're evolving from a fee-for-service based on volumes, procedures, clinic visits, to one based on a value system that incorporates quality and cost. And the quality and cost can be further scrutinized. When you think about quality, think about clinical outcomes and we'll talk about that very shortly, plus a patient experience. What matters to a patient and the resource, the cost, money, time, people, energy and materials. So the idea is that we will be the system will be reimbursing more on the quality of care and less so on the volume. Now there are a lot of theoretical arguments in favor of this and this has been nicely summarized in the Journal of Medicine. And the benefits could be seen by the patients, providers, payers, suppliers in society. Patients may see lower costs and better outcomes. Providers may reap the benefits of higher patient satisfaction and perhaps better care efficiencies. So this is an area that's emerging. The data for this, I think, is not all consistently good. There are some studies that argue that this approach is beneficial. Others show that it really depends on how you define it. In chronic liver disease, you know more than I do that it's a major public health concern. There are about 4.5 million Americans with some form of liver disease. And this represents a proportion of 2% of the population in the United States. In terms of mortality rates, this means about 40,000 people die. And then the death per 100,000 individuals is 12.8. So these are not trivial numbers. And as you work in, you know, as you have any contact in the hospital, you know that, you know, we're seeing more and more patients coming to our hospital doors with liver failure. And indeed, if you look at this study that just goes at least seven years, but found that a steadily but sure increase in discharge due to cirrhosis. And if you know, this is a reflection of people with fatty liver coming to our offices and in our hospitals with liver complications. Patients with ulcerative liver disease and patients with hepatitis C that have been left untreated. So we're seeing more, not less hospitalizations and subsequent discharges. The problem is that one of the things that we all face as a hepatology community is the idea of a readmission. And unfortunately, there is a very high readmission rate. The factors that predict one readmission rate may be different from one month readmission rate. But the overall readmission rates over 70%. So and this is a, this is an area that's been identified as a source of wasted dollars. A lot of reasons for readmission, and again, I would argue that the reasons for a one-week readmission are very different one month. And one week may include, you know, barriers to receiving medications. You know, problems getting laboratory tests or including visits. So there's a problem with the readmission rate that we need to address. As part of the definition of outcomes is this idea of horizon. And depending on your practice, you know, your outcomes can be very different. In communities, in a community atmosphere, you may be looking at, for instance, hepatitis C screening, diagnosis and linkage to care, and curing, and reinfection. In a tertiary center, you may be looking at something else like survival, liver failure, liver cancer. So that when you look at value, the outcome in terms of time really may differ. This is from a 1905 Fessia Conwell published 10 years ago. And what it looks like that, you know, how do we know we're doing a good job when treating hepatitis C? And she identifies seven quality indicators to define quality. You know, and we know this very well, but many of our colleagues outside of pathology may have been unaware they had a confirmed hepatitis C viremia with the PCR test. Or you have to immunize patient against hepatitis A and B if they're naive. You know, checking viral load in a therapy, in a treatment, to confirm viral suppression. So there are a number of collaborative efforts used to define these quality factors. And this is one short example of both short and long term. So going back to the idea of value-based therapy in the patient experience. This is from a nice review article, nice study, looking at patient-related outcomes and what matters to the patient. And I'm the first to admit that I forget to ask people about about medication side effects. Although for over almost three quarters of patients surveyed, this is a very important issue. Or there are things about how they're burning to their families, or a problem with memory, or pruritus, or cramps. So these are all things that when we talk about value, we need to incorporate as the patient-related outcome that needs to be. A paper from Michael Volk looking at and how we're doing in terms of providing recommended care. And you can see as well as I do that there's much to be desired in terms of varicose screening, and prophylaxis, and liver cancer, antibiotic prophylaxis, etc. So to look at this, you know, to look at this outcome of readmission, Dr. Caldwell and her colleagues looked at a database of over 100 VA hospitals. And they stratified patients according to whether they were seen within 70 days of discharge or after 70 days of discharge. And what they found that that patients who were seen within 70 days of discharge, you know, higher higher readmission rate. 15 versus 13.8 percent. It has a ratio of 1.1. But if you stopped there, you would miss the whole point. If that was your outcome, you would have missed it. If you look at mortality, Dr. Caldwell and her colleagues did a wonderful job of looking at not just readmission but mortality rate. And they found a significant lower mortality rate by this early post-discharge clinic. So there's something that could be easily done. Increased value and lower cost. This is from another study published several years ago by Dr. Lena from American Drug Oncology, looking at some things that we take for granted, like receiving abdominal ulcer, undergoing a paracentesis within 30 days of a size diagnosis, or SVP prophylaxis. And it found that by following these guidelines, guidance, that you actually improve survival and you improve health utilization. Again, adding value to your practice. These next two studies look at palliative care consultation and the role it would have in our practice. Again, I mentioned earlier that end-of-life eats up a lot of health care dollars. And we deal with patients who are very, very ill. They need hand-holding in every step of the process. And from this review article that looked at a number of retrospective core studies, prospect studies and low-cost improvement studies, they found that the utility of palliative care and hospital intervention actually led to reduced health utilization, improvement of end-of-life care, and improvement of patient-related outcomes. In a separate study by the Stanford group looking at a large database, they found also that palliative care consultation not only resulted in lower 30-90 readmission rates, but when patients were readmitted, there was decreased length of stay and costs with prior utility of palliative care consultation. So the authors concluded that palliative care consultation resulted in declining readmission rates and resulting in a lower burden on health utilization and improvement of cost savings during subsequent readmission rates. So some takeaways from this conversation is we're in the midst of a shifting model for health care reimbursement with more emphasis on quality and volume. And there's ample opportunity for gastroenterologists to increase the quality of care and yet lower the cost of health care delivery. Thank you very much, everybody. Hello, my name is Ziad Jalad. I'm an Associate Professor of Medicine in the Division of Gastroenterology at Duke University Medical Center. I'm also an Associate Editor for GI and Hepatology News and on the Board of Editors of Clinical Gastroenterology and Hepatology, where I curate the practice management section. That section is tailored of a theme around competencies for value-based care. And it's in that context that it's my pleasure to present to you today a talk on episode-based and bundled payment models for hepatology. Are we there yet? And I do want to thank Dr. Kenwall and Dr. Yannosi for the invitation to speak today. My disclosures are listed on the slide. The objectives for the talk today are to review the concept of episodes of care and bundled payments and to also highlight opportunities for episode of care models in hepatology. I'd like to start with the first. This is Michael Porter's definition of value, published in the New England Journal about a decade ago, where he described value as health outcomes achieved per dollar spent. And I like this definition of value because it contains both components of quality and cost. And really the levers that we have to improve value are, of course, to increase the quality of care or decrease the cost of care. There are a number of different ways that we can attempt to lower health care costs, many of which we've seen in GI. The first is limiting utilization. So the idea here is to limit the utilization of expensive therapies in the hopes of decreasing overall costs. Examples of this would be step utilization in inflammatory bowel disease or pre-authorization for imaging. The second way to lower health care costs is actually to lower the unit cost. So examples of that would include re-evaluation of CPT codes, which we've seen quite a bit of in gastroenterology recently, and also the concept of reference pricing, where a set price is given for a particular service. Finally, the aim is to redesign the system to lower costs. And that's where vertical integration, such as we see in the cartoon on the right between CVS and Aetna, comes into play, as well as alternative payment models. And that's really where I want to focus the talk today is around how alternative payment models work and how they can lower health care costs. There are a number of different alternative payment models that exist in the current health care market. This is a review from Dr. Patel and colleagues in clinical gastroenterology in 2016, where they described three different types of alternative payment models. Bundle payments, a per member per month or partial capitation model, and then a shared savings model. Each of the models has particular strengths and weaknesses and have been seen in gastroenterology. What I want to focus on today are bundled payments or episode of care payments. And these are lump sum payments for a specific set of services provided during a defined episode of care. And that lump sum can be divided among all the stakeholders that participate in that particular episode of care, whether it's the physician, an anesthesiologist, a hospital, lab services, etc. Now the strength of a bundle payment model is that it's very efficient and transparent and market-based pricing is tied to quality, not demand. Now the weakness here is that there's potential for inappropriate treatment, given there's a perception that you have constrained resources and you might be limiting particular care to meet your target price. The other potential weakness is that care coordination outside the bundle is not supported. So you become limited to some extent in the types of services you're able to offer in the context of that bundle. Finally, I'll add another weakness is that you're not really impacting the particular demand or utilization of a particular bundle. So I can set a bundle price for colonoscopy, for say, but that's not going to do anything to decrease inappropriate utilization of colonoscopy. It's just fixated on that episode itself. And of course, bundle payment for colonoscopy is an example of a alternative payment model or bundle payment. Now the Centers for Medicaid Services has come up with its own approach to bundle payments, which they've called BPCI or Bundle Payment for Care Improvement. And in this model of care, a clinical episode is triggered by either an inpatient hospital stay, which is called the anchor stay, or an outpatient procedure, which is called the anchor procedure. Now that clinical episode, whether it's an inpatient hospital stay or an outpatient procedure, is attributed to a physician group practice or PGP or a health system. Now care is provided for that bundle under standard fee-for-service payments. At the end of each performance period, however, quality and cost in that particular bundle is assessed, and there is a payback if certain targets are not met. So some key points on the BPCI model is that it's a voluntary model. It provides a single retrospective bundle payment and one risk track. There's a 90-day clinical episode duration. Payment is tied to quality measures and performance relative to a target price. And participation in the BPCI qualifies the physician group practice or health system as an advanced APM under MACRA, which entitles them to a 5% bonus on their Part B Medicare payments. This slide shows the quality measures that are incorporated into the BPCI programs. You can see there are some measures such as all-cause hospital readmission or presence of a care plan that are applied to all clinical episodes. There are other quality measures listed in the slide that are specific to particular clinical episodes, and these could include things such as the appropriate selection of prophylactic antibiotics in perioperative care, complication rates following specific surgeries such as total hip arthroplasty or knee arthroplasty, and others as you see on the slide. Now, for those of us in gastroenterology and hepatology, there are limited episodes that are part of the BPCI program, and those are listed here. Those include bariatric surgery, disorders of the liver, excluding malignancy, cirrhosis, and alcoholic hepatitis, GI hemorrhage, GI obstruction, inflammatory bowel disease, and a major bowel procedure. And as you see, this program has been going on for three years, and in the newest year, that is year three, bariatric surgery and inflammatory bowel disease were included. Now, we'll come back to this category here, which is disorders of the liver, excluding malignancy, cirrhosis, and alcoholic hepatitis, as it becomes relevant when we think about bundles or episodes of care in hepatology. Now, when you look at the report from the first year of the BPCI program, you find that hospitals were much more likely to choose medical episodes over surgical episodes, whereas physician group practices were more likely to choose surgical episodes. Of all the different opportunities within the BPCI program, disorders of the liver was actually the least chosen episode, as you see in the graph on the left. When a study was done looking at the effectiveness of BPCI in achieving the goal of improved value of care, the evidence suggests there was not a major impact. This is a study published in the New England Journal in 2018 that looked at a number of conditions and looked at systems that participate within BPCI and those that don't, and found that over time, there really was no difference in the improvement or the cost reduction for a particular condition, or the cost reduction for particular conditions in systems that were participating in BPCI as compared to those that weren't. So the data really suggests that as it relates to chronic conditions, has not been effective. So what are the opportunities for episodes of care models in hepatology? So when we go back to the slide I showed earlier around the BPCI programs that relate to GI and hepatology, I mentioned again disorders of the liver. And I actually think that cirrhosis actually presents a unique and appropriate opportunity to develop an episode of care model for hepatology. And Michael Volk and colleagues have written and spoken a great deal on this topic and have noted that cirrhosis is an ideal target for value-based care in episodes because it's a well-defined disease. It has high impact in terms of morbidity and mortality with high rates of readmissions, defined quality of care gaps, with an estimated direct cost to the healthcare system on par with other diseases such as congestive heart failure. And when you look at the cost for cirrhosis care, this slide shows the deciles of cost and the actual cost in dollars for that particular decile. And these are per member per year total costs in a commercially insured patient population. And you find that the top decile of patient costs nearly as much as all the other deciles combined, suggesting that there really is an opportunity if you can care for that particular population of patients to substantially impact cost of care. There are a number of ways to impact cost of care and value in cirrhosis that are listed here. Those would include decreasing rehospitalizations, decreasing duplicative testing and unnecessary testing, and identifying, as I mentioned earlier, high utilization patients. And by applying intensive case management or palliative care approaches, it's possible to decrease costs for those patients. Now, there are some models of insurance companies that have developed episode of care models outside of CMS. And I provide this example from Horizon Blue Cross Blue Shield of New Jersey to illustrate all the possible ways in which episodes can be applied, and also the fact that there are no hepatology conditions in this list. So this is really still a wide open area in terms of opportunities to develop these episode of care models. The ASLD has a cirrhosis quality collaborative that's been developed by Dr. Canwell and Dr. Volk that is a multi-site learning health network that combines quality improvement and research to improve the care and treatment outcomes of patients with cirrhosis. And what it's doing is really building an infrastructure for an episode of care model for cirrhosis. And there are tremendous opportunities out there and there are tremendous opportunities in that space. And I provided the link for more information about that program on this slide. There is some tension in the market about where to go next in terms of value-based care, especially it relates to specialists. There are of course bundles or episode-based models that I discussed where there's linked quality and costs for a specific episode. And those can apply to elective procedures, hospital admissions, and specific diagnoses. There's also the opportunity to develop and build patient or population-based measures of quality and cost reduction programs. And these would be things such as ACOs, medical homes, and specialty-based care teams with accountability for the total cost of care. And when you look at the finances of alternative payment models, it turns out that those types of population-based models or shared savings models may provide a higher financial opportunity for hepatology practices and thus make it a more sustainable alternative payment model. And this is from Dr. Patel and colleagues again in 2016 in clinical gastro and hepatology, which illustrates the total cost of care for a particular episode. And the vast majority of those costs are non-physician payments, ER visits, hospitalization, drug costs, lab tests, et cetera. Total physician payments, and specifically gastroenterologists or hepatology payments are just a very small portion of those total costs. If we're able to impact the total cost of care and take a percentage of that total systems savings, the financial benefit to GI and hepatologists could actually be more than what's seen in fee-for-service medicine. And we've seen examples of that in other specialties such as inflammatory bowel disease. So the key messages are that bundle payments are alternative payment model that provides a lump sum for a discrete episode of care. There are limited existing opportunities in liver disease for episode of care models. I think the AASLD Cirrhosis Quality Collaborative is an opportunity to build infrastructure to compete successfully in future bundle payments specifically as it relates to cirrhosis. And it's important to keep in mind that shared savings arrangements may offer a more advantageous alternative payment model for specialists and one that will continue to develop. Again, I wanna thank Dr. Cadwall and Dr. Yannosi for the opportunity to speak today. And I look forward to feedback and questions from you either by email or Twitter. Thank you again. Hello, ladies and gentlemen. I'm Vincent Wong from the Chinese University of Hong Kong. First of all, I wish that everyone would stay safe and healthy during the COVID-19 pandemic. I'd also like to thank the organizers, especially Dr. Cadwall and Dr. Yannosi for the invitation. Here are my disclosures. Although I'm honored to speak at this meeting, I must confess that we don't practice value-based medicine in Hong Kong. Nor could I represent all the countries in Europe and Asia. Therefore, I'm grateful for the input from my friends from different countries in my preparation of this talk. When I asked about the practice of value-based medicine in different European and Asian countries, the usual response was that it wasn't exactly the healthcare model there. Dr. Hedstrom even told me about the resignation of several senior people at the new Karolinska Hospital after some major setback and said Sweden would unlikely try value-based medicine again in the foreseeable future. Nonetheless, in the UK, although clinicians have fixed salaries, the Commissioning for Quality and Innovation system allocated resources to hospitals in part based on outcomes. The famous NICE guidelines in the UK also emphasize on cost-effectiveness in clinical practice. Germany has established the Institute of Quality and Efficiency in Healthcare, while the adoption of value-based medicine may be seen in selected areas through negotiations at the hospital level. Spain has also been trying value-based medicine with some early efforts to bundle payment with successful treatments. On the other hand, the Netherlands is at the forefront of value-based medicine. A number of hospital groups are developing models to make it possible. The CENTION model is a good example. It involves seven teaching hospitals. Within three years after the implementation of our value-based model, they could reduce unnecessary hospital stays by 30% and re-operations for breast cancer by 74%. Their model also highlights important steps to implement value-based medicine. First, we need to know what to measure and a multidisciplinary team instead of a single administrator should define this. There will be unforeseen hiccups on the way. Rather than seeing it as a failure, healthcare providers should share their experience and learn from each other and refine the model accordingly. When the model is stable and validated, it is important to engage with patients and payers. In contrast, the Asian healthcare systems are largely a mixture of fixed salaries in the public sector and fee-for-service in the private sector. According to experts from Japan and South Korea, they don't have a strong incentive to maximise values because they don't have much restriction in prescription and arranging procedures. In other systems, in other systems where a medical unit is given a fixed budget every year, value-based medicine could be relevant as we still want to make the biggest impact on patients' wellbeing with the same amount of money. Recently, Singapore has introduced value-based care programmes for 17 high-impact medical and surgical conditions, although hepatology has not been included yet. Although many of us are not exactly practising value-based medicine, respondents from Europe and Asia eagerly suggested a number of areas where value-based medicine may work for hepatology. Indeed, many of us have developed models to improve clinical care, which may be suitable for value-based medicine. For chronic hepatitis B, we need to treat the right patients ensure drug adherence, ensure that HCCs and hepatic decompensation are reduced. There is a lot to be done to prevent, survey for and treat HCC. Although we haven't got a registered drug for NASH yet, most respondents agreed that it is important to identify patients with advanced liver disease and achieve standards for metabolic management. We also need metrics to see how well we are preventing and managing cirrhotic complications, such as varicose hemorrhage, ascites and spontaneous bacterial peritonitis. We are all familiar with the natural history of chronic liver diseases. All chronic liver diseases go through the common path of progressive fibrosis progression towards cirrhosis, hepatic decompensation or HCC, with possible acute exacerbations of the liver disease or acute complications in between that may alter the natural history of the disease. Eventually, patients would require hospitalizations or liver transplantation and many would die from liver disease. Numerous studies have demonstrated that hospitalizations for liver problems are very expensive. The more advanced the liver disease is, the more money you need to spend to improve one quality-adjusted life year. Although we clinicians spend much of our time managing chronic liver diseases and their complications, our impact is rather small compared with many primary prevention measures like universal hepatitis B vaccination, policies to reduce high-risk parenteral exposures, avoiding harmful drinking, as well as healthy diet and exercise. Essentially, if we can prevent the onset of chronic liver diseases, no one needs to suffer from the subsequent complications. So no liver disease, no liver-related complications. The next best approach would be to manage patients with established chronic liver diseases properly. This would involve good coordination between primary and specialist care in terms of early case identification or screening in some situations, detection of significant liver disease and evidence-based treatment of chronic liver diseases. Last year, Srivastava and colleagues reported their experience in the UK primary care setting. They screened patients with suspected non-alcoholic fatty liver disease with the FIP4 index. Patients with FIP4 in the grey zone would check the specific liver fibrosis biomarker Enhanced Liver Fibrosis Panel. Those with abnormal ELF or high FIP4 above 3.25 would be referred to a specialist. Using this model, they could reduce unnecessary referrals by 80% and yet increase the detection of fibrosis by fivefold and cirrhosis by threefold. While this type of models are attractive, it is noteworthy that it would not work if the reimbursement or funding systems for primary and specialist care are totally independent. Coordination among the relevant stakeholders and payers is of paramount importance. If we find value in identifying significant liver disease in primary care settings, it would be even more rewarding to focus on selected high-risk groups. Our chairman, Dr. Yunozi, published a systematic review last year and showed that 55% of the patients with type 2 diabetes worldwide have NAFLD. In Hong Kong, our endocrinologists have established a diabetes complication screening program in all major hospitals to look for retinopathy, neuropathy and other complications in a systematic manner. A few years ago, our group introduced transient elastography in the screening program and found that 18% of the patients with type 2 diabetes had high liver stiffness, suggestive of advanced liver fibrosis. When we repeated the assessment at an interval of three years, 12% had a 30% or more increase in liver stiffness. It would be a strong case to advocate screening because you only need to screen five to six individuals with type 2 diabetes in order to find one case of significant liver disease. Colleagues from Italy demonstrated the importance of careful selection of outcome measures. In a series of projects, investigators from Northern Italy defined the indicators using the Delphi method. These have to be measurable within a reasonable timeframe and relevant to the disease of interest. Moreover, the investigators then prospectively applied the indicators and determined their implementation. Another important area would be HCC surveillance. For surveillance to be effective, we need to pick the right patients, use the right tools and ensure adherence. In the past decade, a number of investigators have derived and validated risk scores to predict future HCC development. Traditionally, we assumed that patients requiring antiviral treatment for chronic hepatitis B would be at risk and thus need regular HCC surveillance anyway. However, we now know that antiviral treatment can modify the natural history of chronic hepatitis B. In fact, we recently showed that almost 30% of patients on antiviral treatment might have such low HCC risk scores that they no longer fulfilled the ASLD threshold for HCC surveillance. There is certainly room for using healthcare resources more wisely. For indicators, we should measure adherence to surveillance, the detection of not only HCC but early HCC that are suitable for curative treatment, and of course, overall survival. For patients with cirrhosis, much can be done for primary and secondary prophylaxis for variceal hemorrhage. One important component is identification of high-risk varices. However, endoscopy is unpleasant. If a patient refuses endoscopy, he would be left unscreened and unprotected. Therefore, the BARFINO-6 consensus recommends the use of transient elastography and platelet count as the first step for screening. For patients with low liver stiffness and normal platelet count, the risk of varices needing treatment is low and they may not need endoscopy. Recently, our group provided Level 1 evidence for this kind of approach. We randomized patients with radiological cirrhosis to transient elastography or endoscopy and showed that the former was non-inferior to endoscopy in detecting varices needing treatment. Importantly, the two groups had almost identical incidence of variceal hemorrhage during follow-up. Currently, this cost-effective and less invasive approach is widely practiced in Europe and Asia. In summary, chairpersons, ladies and gentlemen, value-based medicine isn't exactly practiced in most European and Asian countries, but the concept is relevant for healthcare providers and organizations that wish to maximize impact with limited resources. It is important to identify suitable outcome indicators through discussion among stakeholders, not only clinicians and specialists, but also our patients, payers and also administrators. I would also emphasize that we clinicians should care more about patients' point of view, and it is important to determine how best to apply patient-reported outcomes not just in research but also in clinical care. With this, I thank you very much. It's my privilege to be here to talk about value in the post-COVID era. Here are my conflicts of interest and contact information. Let's start by defining value as a function of quality over cost. We want the highest quality care at the lowest possible cost. But what's quality? Quality is not a checklist of procedures, tests and visits, although it can feel that way. You see, when the pandemic hit, it made it impossible to deliver on those process measures. It forced us to adapt in a way that made some of those checkboxes more challenging to fulfill, and it made us think about new ways that we can go about achieving the true aims of quality and value, which are improved overall patient outcomes, with or without those standard process measures. So I want to start by exploring this concept by discussing a threat to quality and value. That's right, ultrasound. I'm trying to be a little provocative here with the intention of having us confront this possibility so that we can think about how we would adapt as a practice and a field. We all agree that screening for liver cancer with a combination of ultrasound and AFP is a good idea. It improves outcomes. It fulfills the aims of quality and value. But it's also possible that by requiring people to drive four hours to our clinic for an ultrasound, we may actually be relying on something which disincentivizes the uptake of an innovation that reduces overall costs, namely telehealth. Problem is, you can't really limit HCC screening. And the vast majority of our patients have compensated cirrhosis. There's no risk score out there that says who you can safely forego HCC screening on. Now the question is, for these people with compensated cirrhosis, why are they coming to clinic? They're happy to come see you, I'm sure, for a social visit. But the true value added of that visit may very well be the ultrasound that you arranged one hour beforehand. And if you're seeing them through a video or telephone visit, two things could happen. One, they could be less interested in follow-up and you'd lose them. Or two, because that workflow of cancer screening happens outside of the visit, it may be harder to arrange the appropriate screening. So in order to make sure that we're preventing adverse outcomes, particularly for liver cancer, we need at least two things. First, we need a robust system to track our patients to know who's at risk for HCC and other complications and who's due for screening. And two, we've got to accommodate our patients' wishes. If they want to have their ultrasound done locally, this could mean for us a financial hit because our centers are not billing for that ultrasound and other ancillary services. But it simply doesn't make sense to have a visit over video and then have that person drive two hours to your facility. We all have many patients like this, and it's likely to expand our loss of services. I think this is actually having an impact on the way that we're delivering care in the post-COVID era. Take a look at these graphs. These data come from a claims database from across the United States. You can see in the top left-hand column, during quarantine, there was a precipitous decline in the number of visits that were being performed. Now, there's two lines here, blue and orange. Orange is in-person visits, and blue is all types of visits. So that means that the distance between these two lines is made up of telehealth, and the distance is narrowing over time. Look at the bottom right-hand graph. What this shows you is that the relative share of telehealth visits overall, it peaked in April, but it's been declining steadily ever since. These data run through July, and currently, the national rate is somewhere between 5% and 10%. Why is this happening? I don't know the exact reasons, but it could be that there are conversations that people think they're more comfortable having face-to-face. It could be that clinics feel a financial incentive to get more people in the door to be seen so they can have their ancillary testing done in-house. I don't know, but these are the questions that need to be addressed in order to nurture cost-saving innovations like telehealth because if it brings benefits, and I believe it does, it simply may be more fragile than we think. So assuming that we can nurture and keep things like telehealth alive, we now have to ask how quality and value are going to thrive while care is being provided more remotely. The answer is collaboration. There simply may come a time when we need a patient to be seen face-to-face to determine what their volume status is, or to make sure that there's someone out there that can help us arrange the kind of testing that we need done locally. Now it turns out that cirrhosis care takes a village. Dr. Shirley Cohen-Meckleberg showed in CGH a few months ago that if care is concentrated in the hands of one clinician, like the primary care doctor or the hepatologist, a patient's outcomes actually suffer. They're more likely to be hospitalized. They're more likely to die, be readmitted. But if that care is equally distributed amongst many people, then the patient's outcomes are optimized. This is actually something that's unique about cirrhosis in contrast to other conditions like diabetes or hypertension, and it's true in many ways. So not only do we need our primary care doctors and colleagues in remote settings to be available for us to optimize care for our patients, but we also have to be available for other clinicians. This is a study that was published in the Annals of Surgery this year, and what it shows is that using a national claims database, if a patient with cirrhosis was scheduled for a non-liver-related surgery, if they had what the authors called a pre-optimization visit with a hepatologist where diuretics were adjusted or prescribed, then that person with cirrhosis had a 30% lower risk of post-operative complications. So the opportunities for enhancing quality through these kinds of visits, they are obviously enabled by telehealth. But if time is an issue and we have a bottleneck of access that's only exacerbated by what's happening as we're trying to recover from the first phases of the pandemic, there are other models of care that are going to be necessary to ensure collaboration. My boss, Dr. Grace Sue, she applied the ECHO model where you have primary care clinicians present patients to you in a round-robin sort of way over a video conference. Over the course of an hour, you could quote-unquote see 12 different patients and provide advice. And while you're providing advice through an e-consult, you're also teaching the PCP a little bit about how you arrive at your specific recommendations. Now, Dr. Sue, she compared what happened to patients who were discussed in these e-consult type visits to those who were not. And using propensity matching, she actually found that the patients who were discussed in the ECHO visit had a lower overall risk of mortality, even though they never physically saw the liver specialist. Collaboration is key. So we've talked about the way that quality and value will survive. What remains for the next couple of minutes is to talk about how it will thrive. I present to you three ideas. The first we've already discussed is population health. There's simply no way that we can fulfill the stated aims of value without having a rigorous way of tracking our population. If people fall through the cracks because they couldn't connect in time to a video visit and we couldn't arrange that screening test, we simply need a way of reminding ourselves that there is a person out there that needs a specific, important service. And the only way to do that is to have a robust tracking mechanism within our medical records. Many of us have that and many of us do not. The second way that quality will thrive is by expanding its definition. Rather than focusing exclusively on process measures, the endoscopies, the ultrasounds, we should ask what matters to patients and we should judge the quality and value of care that we provide based on how well the patients say they are doing. Dr. Fasiha Kanwal led a group of us through the practice metrics committee of the ASLD to explore what patient reported outcomes to include as quality measures. We did a systematic review and we put our findings to focus groups of patients. We asked patients, do symptoms like itching, muscle cramps, falls, depression, ability to avoid alcohol, do these things matter to you? And uniformly, they said they did and mostly that it was extremely important to them. So because we're not spending time rooming our patients, because we're not spending time on physical exam, this is a moment to seize and to focus on what's truly bothering the patient to elevate the quality and value of care from their perspective. There are validated one-sentence questionnaires to get at how severe these symptoms may be. The itching, the cramping, the sexual function, the sleep disorder. And each of these have, for lack of a better word, druggable targets. It's very easy to ask, it's easy to address, and I hope you'll review this slide at some point in your free time. Finally, the time has come to be proactive. Let me give you a couple of examples. The first is for variceal bleeding prevention. None of us would argue in this day and age that every person with cirrhosis needs to be screened for varices. We're using a decision rule, the Bovino criteria, to select patients for endoscopy with a higher pretest probability of large varices. The question has to be asked, if we find those large varices, what are we going to do? We're going to start non-selective beta blockers. If we can't do the endoscopy because of the quarantine, or because physical distancing is such that we're cleaning our rooms longer and harder, and there's fewer endoscopy slots, then that means that there's going to be a backlog. And that means, one, that there are people out there waiting for an endoscopy with unknown risk of variceal bleeding, who are at current and present and future risk of variceal bleeding. And two, it's possible that a screening endoscopy is simply not how we want to spend this precious resource. Because, after all, if we'd simply start beta blockers, if we found large varices, we could short-circuit this whole thought process by just starting patients at high risk of portal hypertension on those beta blockers. Proactive beta blockers have a role in shared decision-making in this post-COVID era. Ask a patient, do you feel comfortable waiting three to six months for your endoscopy? Are you afraid of coming to the hospital and exposing yourself to coronavirus? What do you think about the risk of orthostasis and the possibility that I could be starting you on a medication that you may benefit from, but may not? You can also tell that patient that pre-emptive beta blockers for patients with known portal hypertension were associated with a reduced risk of all-cause decompensation according to the PREDISCI trial. Yes, proactive beta blockers require further research for the general population, but there's no easy choices in the post-COVID era. The same is also true for hepatic encephalopathy. If we knew that a patient had a high risk of HE, we'd start therapy like lactulose, change their diet, high protein, adjust medications, get them off of benzos if we could, and ideally this would work pretty well. Well, how do we find this risk? Well, we know there's an app for that, the Encephalab Stroop, for example. In fact, I think that we should be using more things like apps to accompany the rollout of telehealth. We can track how people are doing, what their weight is like, and we can make early interventions before they show up in our emergency room. The problem is that not everybody is comfortable or facile with technology. Dr. Jeremy Louis-Saint showed that if you approached the group of people with cirrhosis, like the ones that come to my clinic, and you said, Hey, would you download this app? They all said yes. However, if you follow up with them, only one in eight actually did. So if our goals are to prevent complications, we're going to need to come up with other strategies that apply to the whole population. So perhaps the best way forward might not be to focus on gold standard type tests, but do the simpler, safer things that apply to the whole population. For example, there's validated ways to predict the risk of encephalopathy without specialized testing. You could, for example, ask a patient how many animals they can name in one minute. Very easy to do over the phone. And that number is positively correlated with their risk of overt HE. We recently found that if a patient can't rise from a seated position or rates the impact of cirrhosis on their daily living at a very high rate, they're at a very high risk for encephalopathy. There's ways to stratify risk for HE and initiate therapy early. So I think that the way forward for value is to collaborate, expand the definition of quality and be more proactive. And I hope I've convinced you today. Hello, I am Fasiha Khanwal, and I wanted to thank you for joining us for the value-based care and hepatology session for the liver meeting. We had a great lineup, wonderful talks. I learned a lot. I hope you learned, too. We started with Dr. Sumit Asrani giving us his perspective on value-based care. Dr. Sami Saab spoke to us from a hepatologist perspective. What can we do as individual providers in improving the care that we deliver to our patients? Dr. Ziad Jalad spoke about bundled care, episode-based care, and what it might look like in the years to come. Dr. Vincent Wong joined us from Hong Kong, and he spoke about the value-based care from Asia and from the European perspective and how that might apply to our practices here in the U.S. And in the end, Dr. Tepper wrapped up the session by talking about what value-based care might look like in the COVID-19 era, the era that we are living in. Great session. Again, we want to thank you for joining us. Stay safe. Stay well. And we look forward to seeing you again next year, hopefully in person. Bye-bye.

Value-Based Medicine

Hepatology Program

AACLD 2020 Delivery Meeting

Value-Based Healthcare

Chairman Zubair Nasri

Dr. Fasiha Khanwal

Value Assessment

Episode-Based Payment Models

BPCI

COVID-19 Era

Chronic Conditions