Keeping on top of current medical literature and monitoring industry trends are essential ways we help ensure quality, affordable care for your members. By understanding how our industry evolves, we’re better able to tailor our solutions to meet the needs of your organization, your providers, and your members.
Created for health plan executives, our Trio series spotlights compelling trends in complex medical specialties for your organization. In this edition of Trio, Matthew Patton, MD, Associate Medical Director of the Surgical Procedures Solution at AIM Specialty Health, presents three important trends in avoiding unnecessary GI procedures and optimizing surgical care settings.
Gastroesophageal reflux disease (GERD) is one of the most frequent conditions seen by gastroenterologists and one of the most common indications for upper endoscopy. In fact, GERD affects a startling 20% of the U.S. population1. Proton pump inhibitors (PPIs) are the primary treatment for GERD, both for symptom relief and their ability to promote faster healing of erosive lesions in the stomach and duodenum. PPIs have been found to deliver complete symptom relief in up to 80% of patients. Moreover, endoscopies reveal that most patients with uncomplicated GERD are found to have a normal mucosa, or stomach lining, after treatment with PPIs.
These findings were included in the 2022 updated guidelines on GERD management from the American College of Gastroenterology (ACG), in which the ACG recommends an empiric 8-week course of PPI treatment for uncomplicated GERD prior to performing upper endoscopy2. These recommendations provide powerful insight for managing the majority of patients with GERD, who will respond to an appropriate trial of medical management, thereby avoiding the risks and costs of an endoscopy.
In a rare alignment within the healthcare landscape, patients, providers, and payers are increasingly seeking to move outpatient services away from the hospital and into standalone ambulatory sites. As with most utilization trends, this seems to be multifactorial and driven by lower costs and higher convenience, as well as the potential for improved patient outcomes for specialized surgical services in ambulatory surgical centers. This movement has become widespread and now includes:
Despite this momentum, it’s critical to keep patient safety and service quality central in these redirection decisions.
While specialized surgical centers may have lower complication rates, fewer nosocomial infections, and more efficient patient throughput, patients with significant comorbidities such as (ASA) class III or higher may be more appropriately treated in a hospital setting with access to higher acuity ancillary support services.
It’s for reasons such as these that AIM offers a systematic review of risk factors in ensuring that safety overrides convenience and preferences as the predominant consideration when determining where care is administered.
Strategies for moving medical services out of the hospital and into higher value and more appropriate sites vary based on the service being performed. For example, redirection of imaging services is largely limited by the geographic availability of alternative sites capable of performing the same service and facilitated by lower patient cost sharing and scheduling availability. Redirection of procedures, such as colonoscopy and cataract removal, is similarly limited by available alternative facilities. However, even when available, a significant proportion of providers lack privileges at non-hospital sites, thus preventing the shift to a potentially higher value and more appropriate non-hospital setting.
One approach aimed at addressing these limitations is the development of high-performance provider networks, or centers of excellence, which match value and quality throughout a patient’s care continuum. While this strategy may not be geographically accessible to all patients, it offers earlier linkage to appropriate sites of care during a patient’s care journey, ensuring that any eligible downstream services can be captured within the preferred setting.
In furtherance of care setting optimization objectives, AIM can leverage its clinical appropriateness review process to engage with providers and members, promoting utilization of a health plan’s high-performance network.