Michael J. Misialek, MD, FCAP
Newton-Wellesley Hospital, a 300-bed community hospital, is part of Partners HealthCare, a Boston-area integrated health system with Massachusetts General Hospital and Brigham and Women's Hospital as its anchors. In December 2011, the Centers for Medicare & Medicaid Services (CMS) Innovation Center selected Partners HealthCare to participate in the new Pioneer Accountable Care Organization (ACO) Model, accelerating its transition to more fully coordinated care.
Massachusetts had already introduced a state-sponsored plan for universal health insurance in 2006; passage of the "Affordable Care Act" did not present a major cultural challenge for the medical staff at Newton-Wellesley Hospital. They were already using the vocabulary. Most of the working parts were in place. By 2013, the clinical integration had picked up speed.
Michael J. Misialek, MD, FCAP, associate chair, Department of Pathology, Newton-Wellesley Hospital, and a clinical assistant professor in pathology, Tufts University School of Medicine in Massachusetts, says that Newton-Wellesley pathologists and oncologists have been collaborating on strategies to make workups more efficient for a couple of years. As more of its patients have come in on risk contracts, the staff has seen more focus on cost containment. The risk contracts, Dr. Misialek says, are "where the network is on a 'budget' for a significant number of our patients, up to 30%. Providers and the insurers share risk when payments exceed that budgeted number. So we are on a budget to save the system money and improve the quality of care."
Recently, hospital leaders asked the pathologists to join a medical staff group being formed to brainstorm ways to sharpen awareness of utilization and create cost efficiencies. Their meetings resulted in four projects, all involving pathology. Two of those, involving gastroenterology, would be pathology led.
The first project tackled endoscopy specimen workups. "It's a very common procedure, upper and lower both, that is done every day across the country," Dr. Misialek says, "and it's a high-cost procedure that will be coming under some scrutiny for utilization. We approached the gastroenterologists to see if there was a better way to work up stomach biopsies to look for H. pylori, which is implicated in ulcer disease and as a risk factor for neoplasia as well. It has been estimated that approximately 50% of labs do up-front IHC on stomach biopsies."
Under the old algorithm, they had stained every stomach biopsy using an immunohistochemical (IHC) stain. "One of my colleagues, Dr. Kenan Sauder, looked at data for the last couple years, categorizing the different histologic patterns and subsequent H. pylori positivity," Dr. Misialek says. "We looked at different algorithms to limit utilization of the IHC stain."
Dr. Misialek's team eventually decided to change the algorithm so that staining for H. pylori would not be done before they had first ascertained the characteristics of the specimen and determined if it was appropriate. "And that," Dr. Misialek says, "simply leaving out that one stain, was estimated to save the system $200,000 in one year in the bundled total cost (both technical and professional components)."
"Obviously some of that comes out of pathology's bottom line," Dr. Misialek says, "but that's what is being asked of all physician groups. We have been doing it for four or five months now, and so far it's been fine. We haven't had any pushback, we haven’t missed anything we know of, and we still found bugs where we thought we would find them. In other words, our percent positivity for H. pylori has remained the same, which is another indicator that we're not jeopardizing patient care."
"It gets to the diagnosis quicker, it saves the system money, and it saves the laboratory a lot of work," Dr. Misialek says. "We had been using an IHC stain for the bacteria and staining every biopsy up front, taking up a lot of space on the instruments. This frees up those instruments to do a lot of other, more appropriate testing. It's a domino-type change that results from just tweaking the system a tiny bit."
"Best of all," Dr. Misialek says, "the pathologist was being seen as a clinical consultant."
Counting the colonoscopies
A second pathology/gastroenterology collaboration—this one designed to control colonoscopy utilization—is expected to save Newton-Wellesley Hospital another $350,000 per year.
"Gastroenterology purchased computer software that would more actively manage patients for scheduling based on the American Gastroenterological Association guidelines," Dr. Misialek says. At its request, the laboratory staff found a way to populate the laboratory diagnosis section in that software to facilitate scheduling at the right interval. "It's a perfect example of how we can manage and mine data to provide clinically useful results," Dr. Misialek says.
At Newton-Wellesley Hospital, renewed emphasis on cost containment has prompted creative thinking around strategies to effect efficiencies and economies without sacrificing quality. Pathologists have embraced resulting opportunities to innovate, educate, and position themselves as more tightly knit members of the patient care team. Clinical integration has had a fortuitous domino effect.
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