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White Paper AGA: An Episode-of-Care Framework for the Management of Obesity—Moving Toward High Value, High Quality Care: A Report From the American Gastroenterological Association Institute Obesity Episode of Care and Bundle Initiative Work Group

https://doi.org/10.1016/j.cgh.2017.02.002Get rights and content

The American Gastroenterological Association acknowledges the need for gastroenterologists to participate in and provide value-based care for both cognitive and procedural conditions. Episodes of care are designed to engage specialists in the movement toward fee for value, while facilitating improved outcomes and patient experience and a reduction in unnecessary services and overall costs. The episode of care model puts the patient at the center of all activity related to their particular diagnosis, procedure, or health care event, rather than on a physician’s specific services. It encourages and incents communication, collaboration, and coordination across the full continuum of care and creates accountability for the patient’s entire experience and outcome. This paper outlines a collaborative approach involving multiple stakeholders for gastrointestinal practices to assess their ability to participate in and implement an episode of care for obesity and understand the essentials of coding and billing for these services.

Section snippets

The Basic Concepts of an Episode-of-Care Framework

An episode of care covers all services provided to a patient during treatment for a clinical condition or procedure. An episode-of-care framework should address a construct that does the following:

  • Covers a predefined set of services across the entire continuum of care, encompassing multiple providers and settings, for the management of a condition or procedure for a predetermined period, with a relatively measurable and clearly defined start and end point.

  • Could be used as a “unit of accounting”

Components of an Obesity Episode-of-Care Bundle

Management of obesity should be a multidisciplinary continuum of care that includes the following core services:

  • Obesity assessment

    • Patient assessment

    • Medical evaluation

    • Dietary evaluation

    • Psychological evaluation

  • Intense weight loss intervention program

    • Cornerstone/first-level therapy implementation

      • Diet/nutritional counseling

      • Behavior counseling

    • Second-level therapy implementation

      • Pharmacotherapy

      • Endoscopic bariatric therapy

      • Bariatric surgery

  • Weight loss maintenance

  • Reassessment/monitoring and second-level

Obesity Preventive Services

Effective for plan years on or after September 23, 2010, the Patient Protection and Affordable Care Act (PPACA), public law (PL) 111-148,14 as amended by the Health Care and Education Reconciliation Act of 2010, PL 111-152,15 with the exception of groups maintaining “grandfathered” status, requires plans to provide 100% coverage for preventive care services. It is unclear whether this requirement will continue in calendar year 2017 and beyond. Grandfathered groups are not subject to this

Telemedicine

Telemedicine is the delivery of health care services by using interactive audio, video, or other electronic media for the purpose of diagnosis, consultation, and/or treatment. Although the definition may vary by payer, telemedicine does not generally include the use of audio-only telephone, facsimile machine, FaceTime, Skype, or non-secure email or electronic communication. Telehealth is a broader term that includes telemedicine and may also include ancillary preventive, educational, and

Disease Management and Education Services

Disease management is the concept of reducing health care costs and improving quality of life for individuals with chronic conditions by preventing or minimizing the effects of the disease through integrated care. As a system of coordinated health care interventions and communications for defined patient populations with conditions where self-care efforts can be implemented, disease management empowers individuals, working with other health care providers, to manage their disease and prevent

Pharmacotherapy

Medications approved by the US Food and Drug Administration (FDA) for chronic weight management can be useful adjunctive treatments for patients who have been unsuccessful with cornerstone lifestyle diet and exercise therapy alone.31 Many medications commonly prescribed for diabetes, depression, and other chronic diseases have weight-altering effects, resulting in weight gain or loss. Knowledgeable prescribing of medications with weight-reducing effects can aid in the prevention and management

Coding Endoscopic Placement and Removal of Gastric Devices for the Management of Obesity

Available clinical data and manufacturer recommendations indicate 6 months to be the current standard duration of therapy for the intragastric balloon (IGB) devices approved by the FDA as of January 1, 2017.

The ORBERA Intragastric Balloon System (Apollo Endosurgery, Inc, San Diego, CA) is indicated for use as an adjunct to weight reduction for adults with obesity with a BMI ≥30 and ≤40 kg/m2 and is to be used in conjunction with a long-term supervised diet and behavior modification program

Learning From the Bariatric Ecosystem

To date, more than 700 bariatric surgical programs in the United States are accredited by the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program.44 Bariatric programs, especially those that are hospital-based, have resources, policies, and procedures regarding the provision of services that can support the gastroenterologist’s management of patients with obesity. Nonsurgical management of patients with obesity should be viewed as a continuum of evidence-based care

Conclusion

Obesity is a chronic disease with complex pathophysiological and behavioral components that require a long-term multidisciplinary approach to therapy. The cornerstone of treatment is the adoption of a reduced calorie diet and increased physical activity program, along with education and behavioral support. Because obesity has reached epidemic proportions, innovative coordinated approaches to care are needed. Pharmaceutical treatments and endoscopic bariatric therapies are likely to play an

Acknowledgments

Any mention of specific pharmaceuticals, devices, diagnostics, or companies is for informational purposes only and does not represent endorsement by the American Gastroenterological Association. Any mention of specific HCPCS or CPT codes does not constitute coding advice or recommendations by the American Gastroenterological Association. Inclusion or exclusion of a procedure or service does not imply any health insurance coverage or reimbursement policy. This episode framework is not intended

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      Dietary evaluation and counseling are often performed by a dietitian or nutritionist to address nutrition intake, diet modification, and behavioral change. Depending on the outcome of a depression screening test such as the PHQ-9, a formal psychological evaluation may be conducted to address factors contributing to weight gain, determination of underlying psychological or social factors leading to obesity, assess the patient's expectations and beliefs about weight gain or loss, and identify any contraindication to weight loss treatment [22]. Many payers require psychological evaluation as part of the approval process for bariatric surgery procedure [22-24].

    Reprint requests Address requests for reprints to: Wendy Cohen, Vice President, Practice & Quality, AGA National Office, 4930 Del Ray Avenue, Bethesda, Maryland 20814. e-mail: [email protected]; fax: (301) 652-3890.

    Conflicts of interest These authors disclose the following: Joel V. Brill has consulting and/or advisory board participation with Endogastric Solutions, FAIR Health, Avella Specialty Pharmacy, Cardinal Health, Eli Lilly, Indivior Pharmaceuticals, Braeburn Pharmaceuticals, OrexoUS, Halt Medical, Bayer, Natera, Nestle Health Sciences, AstraZeneca, Blue Earth Diagnostics, Vermillion, and Medtronic; has consulting and options in EndoChoice, GeneNews, and SynerZ; and has governing board and options in SonarMD. Kelli E. Friedman has company relationships through her spouse who has received grant support and serves as a consultant and proctor for Medtronic, serves as a consultant for Mederi Therapeutics, received an educational grant from Gore, serves as a consultant and speaker for Teleflex, and serves as a consultant and speaker for Novadaq Technologies. Anthony A. Starpoli is a consultant for EndoGastric Solutions® and holds equity share in GI Windows™. The remaining authors disclose no conflicts.

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