Two years ago, when Mississippi-based gastroenterologist Dr. Reed Hogan, M.D. suggested adding nonalcoholic fatty liver disease (NAFLD) as a comprehensive ancillary service to the physicians at his practice, they nearly laughed him out of the room. Now, Dr. Hogan and his colleagues at GI Associates and Endoscopy Center (GIA) — comprised of three locations in Flowood, Madison and Vicksburg — have added services to treat a disease that has a $103 billion economic impact and affects 100 million Americans.
When Dr. Hogan made his proposal to establish a NAFLD/metabolic syndrome comprehensive ancillary, why were his GIA partners laughing?
It comes down to reimbursement and the scope of practice because GI docs think about endoscopy first as their backbone to financial survival. A FibroScan examination to find a patient with fatty liver made GIA approximately $33 each. The low margin is unattractive to primary and specialty care providers throughout our country. The disease is care-intensive and offers little monetary incentive at face value. When left unaddressed, NAFLD leads to increased complication rates, more severe chronic conditions and is an underlying factor in liver-related fatalities. The low reimbursement rate for NAFLD services had created a treatment desert for the condition in the US healthcare system and intense demand for care.
Today, Hogan and his colleagues have discovered far better treatment for their patients and a very profitable revenue source by embracing a comprehensive approach for NAFLD.
“It’s just an unbelievable ancillary,” says Dr. Hogan. “It wouldn’t have been possible if it wasn’t for the Chronic Liver Disease Foundation (CLDF). The Foundation approached the practice looking for help to screen high-risk patients, identify those at risk for nonalcoholic steatohepatitis (NASH) and fill the CLDF registry database to help fill the current FDA NASH studies. The Foundation provided a FibroScan for GIA to use and the patients soon followed. The big catch was that the practice would be providing the care for free, in exchange for the temporary use of the FibroScan.”
In the first month, GIA screened 180 patients. Demand remained strong through the second and third months, and Dr. Hogan realized the practice would see 500 patients within the first few months, easily blowing past the goal of the entire campaign before the year was over. Dr. Hogan projected what the potential earnings would be if the organization could charge for the services with the current demand and decided to return the machine early. The Foundation was devastated, but Dr. Hogan didn’t let them stew for long. GIA purchased a FibroScan and began seeing NAFLD patients, billing for services on a permanent basis and filling up the CLDF registry.
“At first, my CEO and all partners thought I was crazy,” Dr. Hogan said. “But that changed in the first year.”
After designing an algorithm for NAFLD screening, GIA performed 1,800 examinations with FibroScan in the first year of the program and 2,800 in the second year. Now, two years into offering the scans, the practice has an annual profit margin of more than $100,000 from the FibroScan piece of their ancillary.
No one is laughing now. In fact, GIA recently acquired a second FibroScan. Once that machine becomes operational, with the added influx of patients to Chronic Care Management (CCM), NAFLD clinic, and research, Hogan estimates the practice will make $500,000 in profits, and eventually surpass more than $1 million. Not only is GIA experiencing fiscal benefits from its NAFLD program, but the organization is also providing a valuable service to its community where viable treatment options for the chronic condition have traditionally been scarce.
“I never wanted to fill my clinics up with fatty liver patients, and now I’ll take any fatty liver patient you find because I want to give them better care than they could otherwise find in our community,” Dr. Hogan said.
FibroScan’s role in CCM
NAFLD’s reach stretches far beyond the borders of Mississippi. An estimated 100 million Americans have NAFLD. There is no simple treatment available. When left unaddressed NAFLD patients can develop NASH, which currently affects 25 million Americans. NASH is rapidly becoming the leading cause of liver transplants and hepatocellular carcinoma. As NASH case rates have increased, liver transplant rates have risen 68 percent over the last decade.
FibroScan measures the fibrosis and steatosis of the liver and provides simplified readings that can be used to track changes in a patient’s liver and inform future treatments.
While finding fibrotic NASH is important to address liver disease, patients with steatosis alone are at greater risk of cardiovascular mortality and morbidity. For these patients, FibroScan has become the centerpiece of the GIA CCM plan, which is subsidized by Medicare and has been shown to reduce costs and improve outcomes in this population. Unfortunately, CCM is vastly underutilized in our population by our primary care providers. In the GI setting, where the volume of NAFLD / metabolic syndrome patients is overwhelming, the profitability of CCM really drives this ancillary.
The practice uses FibroScan in screening of high-risk patients with a BMI over 30, Type 2 diabetes, dyslipidemia, hypertension, elevated fatty liver triglycerides or displays fatty liver on imaging, and then, depending on their CAP score, proceeds appropriately. A score under 240 is generally fine unless liver function tests come back abnormal, and these patients generally have no follow-up appointments at GIA. Patients with CAP scores higher than 240 are channeled into two treatment pathways:
1. CAP scores between 240-270 are funneled into a fatty liver disease pathway. The pathway largely centers around implementing a healthy weight loss plan, cutting alcohol and providing education on diet and exercise with the goal to lose one pound per week. In six months, the patient repeats the FibroScan and continues on the weight loss plan.
2. CAP scores over 270 and elevated stiffness are evaluated for the practice’s research programs, which are supported by clinical trials.
Dr. Hogan believes that despite the value of the GIA CCM program, primary care physicians (PCPs) at-large are reluctant to buy into similar programs. In a Quest Diagnostics survey: 77% of PCPs said they did not try a CCM program at their practice; 43% said reimbursement was too low; 37% said the documentation work was too burdensome; and 23% criticized the reimbursement rate. While some PCPs have bought into the CCM programs, these providers see on average 47 patients, with a median number of 10 patients per PCP. GIA, on the other hand, has put at least 1,000 patients through its CCM program since its inception.
Dr. Hogan attributes the high enrollment number to the resources GIA uses for each patient, stating, “Primary care doctors are not being rewarded for CCM programs so there’s no way they’re going to push for them. They are so busy and overwhelmed, they cannot get their heads around the entire issue. Their care tends to be crisis-to-crisis. While the focus on NAFLD with metabolic syndrome is often outside the usual PCP’s practice, this ancillary fits perfectly in the GI physicians’ wheelhouse, if the processes are in place to efficiently provide the services.”
He adds that even GIA needed help with their program, contracting with MetaPhy Health, a physician services group focused on assisting gastroenterologists with their efforts to manage NAFLD patients. Like most other groups, GIA found it impossible to set up a CCM program in house due to the complexity needed for comprehensive care. Working collaboratively with MetaPhy, GIA developed a CCM program that took the cost of development out of their office, rapidly turning it profitable. Without MetaPhy and FibroScan, the GIA CCM program wouldn’t have been as successful.
Why NAFLD should be the centerpiece of a gastroenterology practice
As evidenced by the booming CCM ancillary and the number of enrolled patients, the GIA program for fatty liver patients has been successful to date. Nationwide, CCM programs are also booming. According to research from the Mathematica Policy
Research Group, patients that went through CCM programs were:
• Hospitalized at lower rates
• Used fewer emergency services
• Cost CMS $95 less per month
• Saved CMS more than $38 million annually
“I honestly believe that in the very near future, this may be our best ancillary,” Dr. Hogan says. “It may be better than pathology. It may be better than endoscopy.”
The data backs up that claim. When comparing projected revenues from separate cohorts of 10 patients over a 10- year period that received a colonoscopy or entered the CCM program, the returns are significant. For CCM patients, the 10-year-rolling revenue estimate was $95,110. With respect to profit, the colonoscopy group generated $18,000 in profit to the CCM pathways’ $37,000.
The bottom line: what would have gotten a gastroenterologist laughed out of a room five years ago is quickly becoming a quintessential aspect of a gastroenterology practice and one that cannot be ignored. While the financial returns are encouraging, patients have the most to gain from this pathway.
“If you simply look at patient care, we as GI doctors can change the game for these underserved patients,” Dr. Hogan said. “We can provide unavailable healthcare pathways that will improve outcomes and save lives. And in these times of decreasing reimbursements and the desire for income repair, this ancillary is a no-brainer for the GI profession. This is in our wheelhouse.”
Reed B. Hogan is a practicing gastroenterologist at G.I. Associates and Endoscopy Center in Flowood, Mississippi. Dr. Hogan received his a Doctor of Medicine at the University of Mississippi School of Medicine and completed a fellowship in gastroenterology at Baylor University Medical Center. He is board certified in internal medicine and gastroenterology. Dr. Hogan has been recognized as one of the Best Doctors in America®: 1996-2018. Dr. Hogan has previously served as clinical assistant professor of medicine at the University of Mississippi School Of Medicine and is chairman of the American Society of Gastrointestinal Endoscopy special interest group for Ambulatory Endoscopy Centers and has served on the practice management committee for ASGE. Dr. Hogan has also been listed in the 2012 Beckers’ “The 125 Gastroenterologists to Know.” Dr. Hogan is a medical consultant for MetaPhy.
This article is sponsored by Echosens, the developer of FibroScan.