4 gastroenterologists on Medicare's plan to leave behind fee-for-service reimbursement

Approximately 50 percent of Medicare payments are expected to be delivered through alternative models by 2018. How will the move away from fee-for-service reimbursement affect GI practices?

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.

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Please submit responses to Carrie Pallardy at cpallardy@beckershealthcare.com by Thursday, February 12, at 5 p.m. CST.

Dr. Elliot EllisElliot Ellis, MD, Modernizing Medicine Team Lead, EMA Gastroenterology: Gastroenterologists have been using a fee-for-service model of reimbursement for years. Procedure-based specialties like GI in particular are likely to be affected by a move away from this model towards a more quality-based model. The writing is on the wall that the days of fee-for-service are numbered.  

Gastroenterologists are under a lot of pressure to start measuring indicators of quality, such as Meaningful Use and PQRS. These indicators will be published and used by payers to not only change payment levels, but also likely steer patients to "higher quality"versus "lower quality" physicians.

We all want the best quality of care for our patients. But I am always concerned about the unintended consequences. Will physicians in private practice be more leery of taking on the sicker population if this is likely to affect their "quality outcome measures?" Will a gastroenterologist be pressured away from performing a medically necessary colonoscopy in patients suspicious for HNPCC or Lynch because of outside factors? If there continues to be no substantial tort reform, will gastroenterologists be subjected to more lawsuits for missed lesions because they have significantly changing screening intervals between procedures? These are questions that at this point still have no answers.

What we do know for sure is that gastroenterology practices that utilize the most innovative healthcare technology – including EHR systems that have the ability to track patient outcomes and report quality of care in a way that doesn't slow down physician productivity – will have an inherent advantage. EHR systems that collect structured data, accurately document patient encounters and document medical necessity will help physicians during the inevitable transition away from fee-for-service.

Antonino Mannone, MD, gastroenterologist, Main Gastroenterology (Williamsville, N.Y.): I do understand that the fee-for service is not perfect and has been associated with abuses, but I think it would be better to "re-educate" the abusers then to re-invent the wheel. I strongly feel that the abuses in the fee-for service system are costly, but the abusers are a minority and should not be difficult to identify them.

The governing body must realize that the goal of all physicians is the well being of the patients. What we do is based on guidelines formulated by our specialty societies and based on large consensus. We don't do procedures to enrich ourselves, but to diagnose and properly treat our patients. Sometimes procedures need to be repeated within short intervals of time because presentations change. At the end of my office day my voice is down to a whisper for all the time that I have to repeat to my patients to change diets, to quit smoking, to drink less alcohol, to exercise more atc.etc. I have no control on what they do when they leave my office. Their well being is in their hands and if they continue in their bad habits chances are that tests will need to be repeated because symptoms are going to get worse. They will need more office visits and ER care.

There are no changes in the Medicare reimbursement that can change this reality. My fees are not breaking the system (they are one-tenth of the hospital fees), and more political interference is not going to make our patients any better.

Patrick Takahashi, MD, CMIO and Chief of Gastroenterology Section of St. Vincent Medical Center (Los Angeles): Medicare's plan to shift from fee-for-service reimbursement will affect the practices of gastroenterologists in a multitude of ways. Already, there has been a shift in medical economics, in that patients are increasingly associated with various IPA and other group plans. Obviously, this will affect the bottom line in the office, the endoscopy center and the hospital.  

As IPA and managed care plans begin to once again dominate the healthcare landscape, it is increasingly important for gastroenterology practices to continually renegotiate their contracts to maintain maximum reimbursement for their practices. In addition, a value-based model for reimbursement will require compliance with certain measures to garner proper payment. This will obviously affect physician workflows in the office and the endoscopy centers, as these points need to be addressed and documented. This documentation will take place through electronic health record systems, often times affecting the face-to-face encounter times for physician to patient. Increasing reliance on physician assistants and nurse practitioners may become the norm to ensure practice efficiency.  

Oren Zaidel, MD, Torrance (Calif.) Memorial Medical Center: While the quickly changing landscape of medicine continues to challenge the way we practice on an almost daily basis, I believe gastroenterology will be insulated from the move away from fee-for-service reimbursement. With the large influx of patients into the healthcare system due to the Affordable Care Act, there will be a commensurate increase in need for routine preventative care (i.e. colonoscopy). The proven benefit of colonoscopy in terms of colon cancer prevention will be valued even in this new era. The increased volume of patients will offset to some degree any decrease in reimbursement likely to result from new payment paradigms.

More articles on gastroenterology:
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