IBD Drive Time: Miguel Regueiro, MD, on Providing Multidisciplinary Care in IBD
Dr Regueiro and IBD Drive Time host Raymond Cross, MD, discuss the importance and the challenges of providing multidisciplinary care to patients with IBD, including dietary guidance, mental health services, and more.
Miguel Regueiro, MD, is professor of medicine and chair of the Digestive Diseases Institute at Cleveland Clinic, Cleveland, Ohio. Raymond Cross, MD, is director of the IBD Center at Mercy Medical Center in Baltimore, Maryland, and professor of medicine at the University of Maryland School of Medicine.
Transcript:
Welcome, everyone, to IBD Drive Time. I'm Raymond Cross from Mercy Medical Center in Baltimore, and I'm delighted to have my friend Miguel Regueiro from Cleveland Clinic as a return guest to talk to us about alternate care models for IBD. Miguel, welcome back to IBD Drive Time.
Dr Regueiro: Great, thank you, Ray. Thanks for having me.
Dr Cross: Of course. So I think, Miguel, providers that take care of patients with IBD clearly recognize the importance of multidisciplinary care. What would you say are the key components of a multi -D practice and maybe highlight how this might differ in academic or hospital -based practices compared to the community?
Dr Regueiro: That's a great question. I think the multidisciplinary care for IBD really, in my opinion revolves around a core minimum of a gastroenterologist, ideally a colorectal surgeon, a psychologist or behavioral health specialist, and a dietitian. It's really those 4 entities because you have the medical surgical care, but then the whole person care, which we've learned a lot about the brain-gut connection and all of our patients want to know about diet, so a dietitian is key as well. So, for academic practices and hospital-based practices, it's easier to integrate those resources.
Dr Cross: So, in the community, how are they doing that? Your experience in talking about this, how are they incorporating that in community practices?
Dr Regueiro: I think you're right. I think, you know, initially, these started in tertiary academic centers, but I've seen them evolve into private and community practices. There's certainly a number of large community practices that almost function like a tertiary center and that they'll have IBD specialists. And in those practices, the entities that I just mentioned in terms of surgery, behavioral health, dietitian, they have those and they've incorporated them.
Where I think it's more challenging are the small private practices, certainly solo practitioners or maybe 3 or 4 people in a practice. They might have some APPs working with them. And then I think that's where there's really been a change towards linking with those practices with larger practices to maybe support the entities of dietitian and behavioral health. We see this all the time in Cleveland. I know it happens in Maryland and I know it happens in other parts of the country as well.
Dr Cross: Yeah, I think for the community practitioners out there, I think learning— and you've taught me this—when you get to a new place, learn what your place does well, what resources you have, but it doesn't just have to be in your center or practice, it could be in your community. So trying to figure out who is the psychologist or mental health person in your community that has an interest in particular in patients with chronic illnesses, GI illnesses, you know, is there a dietitian or dietitians in the community that are willing to see your patients. So I think just doing a little bit of homework. I think it was Millie and I were doing an episode and I think Lin Chang mentioned there's GIpsychology .com, which gives patients a list of certified psychologists. I don't know how they certify them but they're interested in GI patients and I've been giving that to my patients until we hire psychologists here. So I think you can try to find resources in your community. We've talked about like maybe having these regional hubs where regions sort of integrate together to refer patients for dietician and mental health, but that really hasn't happened yet. It's more informal, I think.
Dr Regueiro: Yeah. And I think just to add to that, I mean, a couple of things. So for maybe a new person starting in a new city, taking care of IBD, you said it just now, and I usually coined it as know the strengths in your own backyard. So your backyard can be your city, your region, your community, whatever you're practicing in. If it's within your own, either entity, institution, private practice, great. But sometimes there might be other people in a geographic area that really work well. And then the other part, like you said, especially for behavioral health, telemedicine, telepsychology, telepsychiatry. And some of the licensing around that sometimes, not always, makes it easy to do virtual care even across different states. So I completely agree that this has really changed the way we care for IBD, whether it's a small private practice or a large tertiary center.
Dr Cross: So I'm going to make sure that we don't want to get anyone upset with us, but I was going to have Miguel maybe highlight a few examples of these integrated multi -D care teams and maybe just cite a few of them and maybe high-level results of those programs.
Dr Regueiro: I think there are certainly several, just maybe to start with a couple of the ones that I've been involved with at the University of Pittsburgh Medical Center where I had been and now at Cleveland Clinic. But outside of tertiary centers, which lots of people, as you listen to this across the center, Vanderbilt, other tertiary care centers have these programs. And like you said, the list is longer than I could even mention. But what I think is also important is this is now involving private groups or community groups or larger groups. So in DC, so for example, Capital Health is looking at this. Project Sonar, which came out of Illinois, which is working with insurance companies around this whole person care model and delivering in a telemedicine way. Those are few. I mean, there are so many across the country. And again, not just in a tertiary center like you and I practice, but also in other private and regional centers as well.
Dr Cross: So, you know, as my practice got bigger and we started incorporating more people, I definitely feel like the outcomes are better. If someone asked me how to prove it, sometimes it was hard to sort of prove that. So, do these improve outcomes or is that just, you know, is that just a subjective feeling we have?
Dr Regueiro: I think, first of all, again, for your listening audience, there are many excellent caregivers who treat IBD, whether it's a solo practitioner, whether it's a large group. So I think IBD care has gotten a lot better in general. However, for the group of high-utilizer patients, so the patients who might have other parts of their care that are involved, whether it be malnutrition, whether it be behavioral health, whether it be a reactive depression, anxiety, patients that go back and forth to the emergency room or the hospital, maybe the psychosocial support and network
around them is limited. These are the patients, what private insurance companies or payers would deem as high-utilizer patients, those are probably the 20 -30 % of patients that we see that probably does benefit from this medical home model, this wraparound care model, because it really does take a village. It really does take a team to take care of those patients. And even my colleagues that are excellent IBD providers and private groups say, "Look, I can't manage these patients.” So to answer your question, we published on this, others have published on improving outcomes in terms of decreasing hospitalizations, decreasing emergency room visits, and even decreasing total cost of care. And there has been some data on IBDQ, so the quality of life improving, even disease activity. But that's probably for the 20 to 30 % of high utilizers. I would say the other 70 to 80% are really well cared for by gastroenterologists who specializes in IBD, whether it's private practic3 or tertiary center.
Dr Cross: Yeah, I think sometimes with our patient reported outcome measures that we often utilize in practice, I was just thinking I saw a patient this week who you would sort of red flag them because they have a pretty high positive rate on their review of symptoms, multiple drug allergies, lots of systemic complaints that aren't necessarily GI complaints and saying that I'm flaring and
trying to spend a lot of time and explaining what a flare is and referring to psychology or treatment of concurrent mental health symptoms and so forth. And I just saw her back and we went back and looked at her quality of life scores and they're actually about the same. Depression scores are lower, but the quality of life scores actually were a little lower and she was sort of surprised. But at the end of the visit, she said, "You know, when I first started seeing you, there's no way I would’ve thought about knowing in grad school, and I feel well enough now that I'm going to consider doing that. And so sometimes the really objective things don't capture globally how patients are doing.
Dr Regueiro: Yeah, and we've even looked at absenteeism and even presenteeism. So people who are going to work or school, they're missing a lot or they're going to work in school and they're not able to concentrate because of their IBD or the behavioral health aspects with their IBD. So I think what you bring up is an incredibly important point.
Dr Cross: So how do you pay for all this? So, and this is probably a question you can't completely answer. Yeah, certainly psychologists are able to bill for their service and pay for what they do. Dietitians, it's not really well covered and there's all kind of different methods for that. But these big teams, how are you billing for the multi-D care? Are you trying to convince a payer or your system that you're going to do cost avoidance and decrease some of this expensive stuff that's avoidable? How do you get it all paid for?
Dr Regueiro: So I think there are probably two ways. And like you said, it's given that the challenges we're having we're having in healthcare and paying for healthcare, I'm not going to make it simple that I have all the answers. But I think one way is through value -based contracts and working with payer provider models. So we have a couple of these at Cleveland Clinic and these are, again, across the country where you contract with a payer around a group of patients that they have with IBD and that group of patients by that payer is then seen at that medical home. And I'm using the medical home loosely to use multi-D care and that out of that, one of the value -based improvements has to be decreasing utilization of care. And the contract will then also potentially,
and it depends how each contract is formulated, will pay for say a nurse coordinator or a social worker or maybe part of a psychologist So that that's one way and that can be accessible to some and it can be difficult for some to do. But that's around the value -based contracts, which I think we're seeing more and more of these.
And then the other way is, you mentioned it a minute ago, and and I think we sometimes lose track of this but the dietitians and the psychologists can bill for their time and can bill for their care. So some of our cost modeling around this, if they're breaking even and essentially billing enough to cover their own salaries, what we also see is then the downstream benefit to the team. So for example, we see complex IBD patients, but now if I have a behavioral health specialists, and a dietitian, and they're spending time with the patient, they're billing for their care, I can see more new patients because I'm able to offload that part of it and use that team -based approach. There are certain, and APPs can certainly bill for themselves, there are certain groups that are more difficult. So the nurse coordinators, which are really important for these care models, they can't bill themselves, so there has to be some reliance on the group, essentially operationally billing for them and offsetting and pharmacists.
We found that there's some variability and pain for pharmacists, which I think are becoming more important in the IBD medical home model. And although there might be some ways to bill for their time, we usually just absorb that within the center. So It can be tricky, but value-based contracting and then just building off of normal operations are the two general ways.
Dr Cross: Yeah, and I don't know what the metric is for the patient experience, but certainly the patient experience in being involved in all these providers and helping that it does improve that experience. So maybe there's a potential selling point for your system or hospital.
Dr Regueiro: I think I think there's a referral that also is he said there's more referrals then come in.
Dr Cross: I just wanted to remind note listeners that we are sponsored by the AIBD Network. For those that are subscribing to drive time we are on Spotify and we are on Apple podcast. And I wanted to also mention that the next AIBD regional is going to be in Dallas June 21st and June 22nd.
So Miguel you mentioned the role of telemedicine so and certainly telepsychiatry is really common so how are you integrating telemedicine but also like remote monitoring in your multidisciplinary care model?
Dr Regueiro: You're one of the leading people in this. So I'm probably going to ask you the question back and you can share your research and experience as well, especially in remote monitoring, which I think you've probably done more even than I. So I think, you know, one of the unintended silver linings of COVID, which was a horrible time, was an increase in virtual care telemedicine. And there was obviously a time when the insurance barriers were gone and we could see patients in any states and really I think that made us realize even more in our medical homes that a lot can be
delivered virtually and many patients even prefer that telepsychiatry, telepsychology has been doing this for a long time and actually there are some data that patients even do better in a virtual format. There's less intimidation, less about coming into an office that actually allows the psychologist and psychiatrist to even deliver more. So I think where we are today, certainly virtual
care is, I think, part of every IBD practice. Fortunately for now, it's being paid for. There was some concern that that might go away from Medicare. It seems like that's at least put on hold for now, which I think is good. And then for places like us in Cleveland, we do have contracts across eight or 9 states, and we're expanding that. So I think what we're seeing is that it's becoming easier to deliver this virtual care. We're doing some remote work through AI platforms and behavioral health, or psychologists is involved in that. And I think that we're seeing some neat things, but maybe Ray, I'll ask you the same question about remote monitoring and maybe you can fill in the audience a little bit on your work and what you've seen for that.
Dr Cross: When you were at Pittsburgh, you collaborated with me along with David Schwartz at Vanderbilt and we studied this and I've done a couple studies looking at remote monitoring as an addon. And what we found is that when you just add it on to your current treatment algorithms, your evidence-based things that we're all doing, perhaps there's some decline in the expensive unnecessary health care utilization, but also you're going to get an increase in your number of contacts with the office which are unreimbursed. So your MyChart messages, if you use EPIC, telephone calls . And that can be in whether it's questionnaires or nurse calls and so forth. So I
think the devil is in the detail there and I think if you were in a large system
like Kaiser where you had limited number of providers, you could definitely think of a way where you could do a monthly like a pro two, maybe a PHQ two, something like that and decrease the number of office visits. I think that would be totally acceptable for your well patient. The question though is who's going to pay for that? Like in a model where it's a fee for service model, someone has to be looking at those in a timely fashion and act on those and it's going to need to be reimbursed. And there's a little bit of that now with remote monitoring that you can get some reimbursed. But we're not doing that here at Mercy. I haven't explored that, but I'm very sensitive to the crush that IBD providers have in the electronic record and the number of results and messages and all the things that we have to deal with and not wanting that to be more than what we already have. I think we have to try to figure that out, and that's a good segue into, if you had to put on your crystal, look at your crystal ball, where do you think multi-D alternate care models is is going to be in the next five or 10 years, Miguel?
Dr Regueiro: Yeah, I think across the country, what we're going to see is a consolidation into larger tertiary care centers. This isn't just for IBD, but IBD obviously is a big part of it. And as we see that, I think there's going to be more regionalization of patients and more virtual and medical home multidisciplinary care that's delivered virtually to larger geographic areas. It's just the, you could say the sad reality or just the reality, I think we're going to see, unfortunately, smaller health systems close, larger health systems absorb more of this. And I think this multidisciplinary care model will really be a distinguisher, probably for all chronic diseases like IBD. And that's where I think we're headed in the future.
Dr Cross: All right, Miguel, the fun question. So Rebecca has reminded me that that if we have return guests, we ask them a fun question, we've already asked them a fun question. So she's encouraging me to try to ask a different type of fun question, because everyone knows that you and I really like the Steelers and that we're suffering along with them right now. But what did you want to do before you decided you want to be a doctor. Did you have a career plan before you chose medicine?
Dr Regueiro: So it's interesting. In college, I was largely undifferentiated in my first couple of years. So for today's standards, that would be really late because people need to figure out if they're going into medicine even earlier. And I thought I was a pretty good athlete, which in hindsight, I really wasn't. I played soccer and lacrosse, but I also like teaching. So to answer your question, I actually thought about becoming a teacher and a coach in maybe a high school or some type of school. And I was even halfway through college entertaining some boarding schools or private schools and trying to get into coaching and teaching. And then it just happened that I think my parents said that also consider other career opportunities because they were teachers and saw some challenges in that environment. I think we need more teachers in general, but so then I pivoted a little bit, got interested in the sciences and the rest is history, but I was relatively late to that decision and could have easily been a teacher and a coach somewhere.
Dr Cross: You know, I've known you for probably almost 20 years and I did not know that. I I did that. I'm glad I asked the question, but I'm not surprised that teaching and mentoring is something you had an interest in, because that's what you do now. You're probably the IBD community's mentor for everyone, so I'm not surprised.
All right, Miguel, thanks for doing this. It was great. We'll have you back on for sure, and hopefully I'll talk to you soon.
Dr Regueiro: Great. Thanks for having me.
