Healthcare is experiencing an unprecedented time of change, and with change comes both opportunities and threats. Three practicing gastroenterologists enumerate some of the top barriers to success in the 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 response
Next week's question: What are you most thankful for in the GI field?
Please submit responses to Carrie Pallardy at cpallardy@beckershealthcare.com by Thursday, November 25, at 5 p.m. CST
Maxwell Chait, MD, FACP, FACG, FASGE, AGAF, ColumbiaDoctors Medical Group (Hartsdale, N.Y.):
The field of gastroenterology is facing all of the financial effects of the Affordable Care Act that have been underway for years. The changes are most profound for the individual physician trying to survive in traditional private practice. Fee-for-service is a dinosaur. For many gastroenterologists their future requires employment by a hospital and/or health system.
The overriding concern is a general decline in reimbursement for our work. There is a disregard from a reimbursement perspective for consulting or cognitive services under the new coding guidelines. With meaningful use forcing the use of EMR further costs will be incurred. The issue of how endoscopy is reimbursed unfortunately does not take into to account the true value of endoscopy that is very cost-effective when compared with other tests. It is likely that there will be a decrease in reimbursement on the professional side. We are also seeing declines in procedural reimbursement and a decrease in access to care especially for Medicare and Medicaid patients. The pathology labs reimbursement has been cut and in danger of being taken away completely. We are going to see bundled payments. Gastroenterologists increasingly are pushed to demonstrate the value they provide for CMS and other payers.
Quality measures such as adenoma detection rate will be collected with benchmark data from across the country. There is a 25 percent to 50 percent cost reduction when doing endoscopic procedures in an ambulatory surgery setting and endoscopic procedures are more cost-effective in the outpatient setting. As the physician's reimbursement is diminishing, more gastroenterologists will do more outpatient procedures.
A significant challenge to every gastroenterologist is making sure we don't sacrifice quality for efficiency. If physicians feel too much pressure to move quickly they might not provide the best quality of care. Patients will need to be vigilant in choosing a high-quality physician.
Patrick
Takahashi, MD, CMIO and Chief of Gastroenterology Section of St. Vincent Medical Center (Los Angeles): Threats to gastroenterology mainly revolve around financial cuts within the specialty. As Medicare continues to trim reimbursements, private payers often follow suit. With increased expectations regarding meaningful use, it will only be a matter of time before a failure to meet these thresholds will result in further decline in payments.
Another threat to the field will be the diminished availability of solo practitioners within the community, as decreased revenue streams will dictate consolidation among physicians. With overhead continuing to increase, it will be next to impossible to maintain solo practice without sharing the financial burden with others. With group physicians, access may become increasingly limited as everything, including office and procedure scheduling, becomes more centralized, thus taking the personal touch out of the office and specialty.
I fear that gastroenterologists will be further stratified as either office-based or procedure-based due to efficiency needs caused by financial constraints. Thus, the gastroenterologist performing a procedure potentially has no background information or ties to the patient, other than information found within an electronic health record submitted by another gastroenterologist or potentially a physician assistant in the office. The days of the renaissance gastroenterologist are truly at risk.
Pankaj Vashi, MD, Lead National Medical Director, National Clinical Director of Gastroenterology/Nutrition, Metabolic Support and Gastroenterology, Cancer Treatment Centers of America at Midwestern Regional Medical Center (Zion, Ill.):There are challenges that arise in every specialty, which if not monitored and acted upon, can potentially lead to unwanted consequences. As medical professionals and care givers, it is our responsibility to look at the threats facing our field, our patients, and turn them into wins for both sides. Four of the greatest threats I feel the GI field is facing today include: regulation, reimbursement, research funding and patient care.
With new regulations continually being introduced, it has become increasingly more difficult to focus solely on what’s best for the patient. We must factor in many more extraneous determinates to find the best possible pathway to care. The challenge here is that whichever pathway we need to follow based on the regulations at hand, must not come at the expense of the patient's health and well-being.
The subject of reimbursement is on the minds of everyone in the GI field. We’ve witnessed, over the years, a change in the reimbursement rates for some of the services we are providing. In an early Becker's ASC Review article by Carrie Pallardy, 6 Updates on Medicare & GI Reimbursement for Gastroenterologists to Know, she outlines areas that all can effect reimbursement. The areas of Payment cuts, Gastroenterologist compensation and Payment methodology shift are of great importance.
Research funding, and its availability, plays a crucial role in advancing the GI field. A recently published report from Cancer Australia shows GI cancers are faring poorly in research funding compared with other cancers. The report shows that from 2009 to 2011, pancreas, liver, esophagus, stomach and bowel cancer all fared significantly worse than other major cancers such as leukemia, breast, melanoma and prostate cancers, when compared to the number of deaths they caused.
As our patient populations continue to age there will be many more patients needing substantial levels of medical care. We'll continue to patients who are coming to us due to "old parts wearing out" and adverse lifestyles choices such as consuming too much of a non-nutritious diet, being sedentary, being chronically stressed and smoking. These all lead to chronic illnesses like diabetes type II, heart failure, cancer, chronic lung and kidney disease, etc. So there will be many more individuals with chronic illnesses. This increase in chronic diseases and diseases of aging will have huge impacts on GI patient care. With an already shortage of GI physicians the increase in patient population coupled with the need to maintain a sustainable business model, will undoubtedly lead to shortened patient physician interaction.