Three gastroenterologists weigh in on bundled payments and what this payment model could mean for the GI field.
Ask a Gastroenterologist is a weekly series of questions posed to GI physicians around the country on business and clinical issues affecting the field of gastroenterology. We invite all gastroenterologists to submit responses. Next week's question: Do you think independent GI practices have a sustainable future?
Question: Do you think colonoscopy and other GI procedures are a good fit for a bundled payment model?
Maxwell Chait, MD, FACP, FACG, FASGE, AGAF, ColumbiaDoctors Medical Group (New York): The National Commission on Physician Payment Reform evaluated ways for physicians to bear some or all of the financial risk of patient care and share in the savings or bear part or all of the increased cost. One of the models identified was bundled payments in which a fixed price is paid in return for care related to a specific condition, event or episode similar to diagnostic-related groups that Medicare uses to pay hospitals. With a fixed price for the total episode, costs can be capped and physicians have a financial incentive to be more cost effective.
Creating a bundled payment system may become a necessary evil, but requires an understanding of many additional costs to the procedure and the impact to the physician of such factors that may put the endoscopist at risk. There are a number of practical difficulties: defining what is in the bundle; finding ways to divide payment among participating physicians; determining what to do when some physicians involved in the care do not share in the bundled payment; and factoring in the health status of patients. Reimbursement cuts were instituted by CMS already for upper GI endoscopic procedures. Colonoscopy will be next with final decision by the CMS that will take effect in January 2015.
The AGA identified as an initial target for developing a bundled payment option colon cancer screening that should be restricted to screening colonoscopy, diagnostic colonoscopy and surveillance colonoscopy. The proposed bundle specifically excludes situations that put the endoscopist at greater risk, such as acute bleeding, abdominal pain, foreign body, volvulus, inflammatory bowel disease, radiation proctitis, follow-up of patients with a diagnosis of colorectal cancer or procedures that have required a previous partial or subtotal resection of the large bowel, and patients with an ostomy.
The bundle has three components: pre-procedure period which includes physician/staff consultation, bowel preparation instructions; procedure: includes professional and technical fees of colonoscopy, sedation/anesthesia, facility, pathology; post-procedure period: includes post-procedure communication with patient, and repeat procedures if post-colonoscopy bleeding occurs or poor bowel preparation/unable to intubate cecum requiring repeat procedure. The proposed bundle excludes services for post-colonoscopy services that would place the endoscopist at greater risk. These include emergency room/urgent care visits, surgical consultation, inpatient hospitalization, observation services or any other endoscopic procedure other than a repeat colonoscopy to treat post-polypectomy bleeding or a repeat colonoscopy due to poor prep in the initial procedure or inability to intubate the cecum.
If successful and accepted, this may be a starting point for gastroenterologists to develop episode bundles for other cognitive and procedural service lines. It would be better for them to be at the table to help define the payment system rather than on the table and be at the mercy of others splitting up the financial pie at their expense.
Richard Dwyer, MD, Chief of Gastroenterology, CHA Hollywood Presbyterian Medical Center (Los Angeles): It's inevitable that gastroenterologists will have to adapt to and learn to work within the bundled payment system. This model has been proposed for almost a decade by insurance companies and governmental regulatory agencies in an effort to save money and align hospital and provider goals. However, the new reimbursement model will tend to mold physicians into a hospital-based practice, reducing their time with patients.
The bundled payment method will dehumanize the doctor-patient relationship and create proceduralists instead of physicians. This payment method tends to reduce the effectiveness of an old-style diagnostician. About 95 percent of my patients tell me what's wrong with them—but I have to ask the right questions. This model presents more opportunity for misdiagnosis and oversight, as physicians will increase volumes to maintain profitability.
We don't know if the reimbursement percentages will be appropriate and fair, but for certain, as we move away from fee-for-service for colonoscopies and other GI procedures, physicians' income will decline. The bundled payment method is a manifestation of the changing face of medicine, and it seems it will inevitably affect patient care.
Yuliya Rekhtman, MD, pediatric gastroenterologist, MedStar Health (Washington, D.C.): I completely disagree with the whole concept of bundling procedure payments. In general, the approach of curbing the cost of healthcare by cutting a physician's reimbursement is wrong. It is a knee jerk reaction. Nobody disagrees with the fact that healthcare costs are out of control, but physician reimbursements are a very small part of it. It is the giant administrative umbrella that is killing us. There are so many people telling us what to do: from insurance companies to government officials. Everybody seems to forget that if I do not get reimbursed for my work, I cannot support personnel around me, including insurance companies.
In reality, physicians are the only ones earning money (and this work is not easy) and everybody else in healthcare is living off these earnings. Physicians spend more and more time doing paperwork and dealing with insurance companies and still somehow manage to take care of patients. They get less and less respect from the patients and overall community. Yes, it may take us less physical time in an endoscopy suite to do combined procedures, but absolutely no less time to schedule and authorize them.
We keep forgetting that the physician's job ultimately is to take care of patients and we need to be recognized and respected for it. We sacrifice, on average, 15 years of our lives and our family lives. The majority of us still have our student loans to pay, while our kids are going to college. We work very hard to make qualified decisions that affect our patients' health every day. It deeply offends me that I have to spend more and more time justifying my necessities to various entities. Everybody else in the world gets paid for their job with no questions asked!
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