Defining moments: The top 2015 highlights in GI

Every specialty in healthcare has had its highs and lows this year. Two practicing gastroenterologists discusses some of the most important events in the gastroenterology field this year.

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. This week's question: What are you most thankful for in the GI field?

Please submit responses to Carrie Pallardy at cpallardy@beckershealthcare.com by Wednesday, Nov. 25, at 8 a.m. CST.

Maxwell Chait, MD, FACP, FACG, FASGE, AGAF, ColumbiaDoctors Medical Group (Hartsdale, N.Y.): There have been such wonderful advances in the field of gastroenterology that I would have liked to refer to as the most important event in 2015, such as the advances in the understanding the human biome, the successful treatment of hepatitis C, the remarkable advances in endoscopic techniques and technologies. Unfortunately, the most important event in 2015 is the rapid proliferation of governmental and managed care initiatives affecting the practice and reimbursement of gastroenterology. These changes definitely affect revenue.

The recently released 2016 Medicare Fee Schedule, with significant reductions in reimbursement rates for colonoscopies and other gastrointestinal procedures is the culmination this year of these initiatives. This is but one of the many challenging non-patient care related aspects of being a gastroenterologist that have been set in motion.

Coding with ICD-10 is yet another. Physician payment seems to be changing from a fee-for-service system to a system based on value, which will require a practice to use benchmarking, accountability and assessment and improvement in patient satisfaction.

The practice will need to implement and sustain quality assurance and performance improvement programs to demonstrate and maintain quality and patient safety in the endoscopy unit. These events are forcing the consolidation of healthcare networks where large hospital groups are behaving more as insurance companies and consolidating all physician practices into multi-group practices across regions.

We are being pushed into ACOs that will require significant reengineering in how we approach individual patients and how we stay profitable whether independent or part of hospital systems or large health care systems. The outpatient procedures we do are a commodity and we face tremendous pressures to perform them at lower cost.

Matthew Grossman, MD, Gastroenterology Associates of New Jersey (Woodland Park). In 2015, the most important event in GI was a financial one:

Medicare covered $4.6 billion in spending on treatments for hepatitis C for the first half of 2015. The majority of this spending was for curative hepatitis C therapy, Harvoni, introduced by pharmaceutical giant Gilead in October 2014. Harvoni costs $1,215 per pill!

Treatment regimens between eight and 24 weeks exist based on a patient's prior exposure to treatment and the presence/absence of cirrhosis with a total cost of $63,000 to $189,000 per regimen.   

Harvoni is a combination of two medications ledipasvir and sofosbuvir and is the first HCV regimen to avoid both ribavirin and interferon -- drugs with difficult-to-manage side effects. For patients, Harvoni seems like a miracle. It's an oral, once daily, 95 percent curative treatment for hepatitis C. Let's not forget that prior therapies involving interferon and ribavirin were used for the past two decades with a 50 percent cure rate (at best) and patients endured tremendous flu-like side effects and hematologic abnormalities from this regimen.

Medicare's agreement to cover the enormous cost of Gilead's treatment regimen is akin to the government's recognition of the tremendous downstream costs of untreated hepatitis C, which manifests as life threatening complications of cirrhosis and, eventually, liver transplant.

Medicaid patients have yet to receive approval for coverage of this expensive drug, raising the question of what to do for our society's poorest population afflicted with hepatitis C.

Gilead's Harvoni encountered only mild competition from manufacturer Abbvie's regimen named, Viekira Pak. Abbvie's regimen has similar cure rates to Harvoni, but it involves the drug ribavirin and its associated side effects. The FDA has recently warned against using Viekira Pak in patients with moderate and advanced cirrhosis.

With such limited competition, the price of Harvoni has remained sky-high and insurers have had no option but to foot the bill.

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