GI society roundtable: Putting together the game plan for potential colonoscopy cuts

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Medicare reimbursement for colonoscopy could be cut significantly in 2016, but the three sister GI societies are not sitting idly buy. Leaders from the American College of Gastroenterology, American Gastroenterological Association and American Society for Gastrointestinal Endoscopy weigh in on the impending cuts and what can be done to advocate for the GI field.

Question: How will these payment cuts affect gastroenterology practices if they go into effect?

Carroll D. Koscheski, MD, FACG, Chair, ACG National Affairs Committee: If finalized, these Medicare payment cuts will go into effect Jan. 1, 2016.  There also may be a domino effect in the private insurance and Medicare Advantage worlds as well.  Recently, ACG and the GI societies surveyed their membership to gauge how these cuts would impact practice management and services. Some respondents indicated that they anticipate having to change patient volume and mix in the endoscopy suites, or shift some of these services to an outpatient department.

Lawrence Kosinski, MD, MBA, ACAF, FACG, Practice Councillor, AGA Institute Governing Board: Practices that use only hospital as a location for their services will see devastating cuts. Since the three main colonoscopy codes are responsible for 54 percent of revenue generated by most GI practices, this will mean that they will see a significant effect. If they are 40 percent Medicare and obtain half of their revenue from colonoscopy, then they will see an immediate 2 percent to 3 percent drop in revenue. This comes right out of profit. If their Medicare population is higher, like in some of the retirement states, then the cuts will be more painful. Many commercial carriers tie their reimbursements to that of Medicare and so this could expand beyond government payers.
 
Academic Medical Centers and large IDNs tie their physician reimbursement to wRVUs. These physicians will immediately see a very significant fall across the board.   
 
Many GI practices generate an equivalent income from ASC payments, pathology and anesthesia. These practices will not feel the pain as much. However, as early as 2017, CMS plans to remove the value of moderate sedation from codes that currently include it, which will impact nearly all GI endoscopy procedures. Practices that use anesthesia will experience additional cuts when the value of moderate sedation is removed from GI procedures. Practices that use moderate sedation will most likely not be impacted. The value of the new moderate sedation code plus the procedure will likely equal the procedures previous value. CMS is currently proposing that the two GI anesthesia codes, 00740 and 00810, may be misvalued. They could be revalued in 2017, resulting in additional cuts for practices that use anesthesia.  

Glenn D. Littenberg, MD, FASGE, Chair, ASGE Reimbursement Committee: A typical community gastroenterologist spends about half of his or her time doing endoscopy procedures, primarily colonoscopy for screening and surveillance. If the cuts are 11 percent to 19 percent off the professional fees, many physicians would have to think hard about how to proceed. Unfortunately, for some, this is the tipping point, and they will be forced to reduce access to Medicare beneficiaries in their centers or practices. Keep in mind, colonoscopy fees already had fallen by 60 percent some years ago, and facility fees by 40 percent.

We've heard from hundreds of outraged members in response to our recent survey about the proposed cuts. Very few have indicated that they will be able to withstand/survive further cuts without changing their current practice substantially. Further facility fee cuts proposed by CMS will force some centers into the case that Medicare patients are directed to hospital outpatient centers. We should remember what recently happened to cardiology practices after major cuts were applied to cardiac imaging procedures--within a few years, a massive migration from private practice into hospital employment/affiliation. In California, for example, hospital-controlled care costs 20 percent more than care for the same types of patients when care is provided through independent practitioners. So, the question is, how is this a bargain to the public?

Q: Do you think colorectal cancer screening goals will be impacted?

CK: Yes. The College is concerned that these payment cuts will undermine the progress the United States and Medicare have made in the fight against colorectal cancer in recent years. Medicare coverage for colonoscopy is directly responsible for a tremendous public health success story when it comes to colorectal cancer: overall screening is up, new cases of colorectal cancer are down and colorectal cancer death rates are lower according to data from the American Cancer Society.
Despite this remarkable progress, more – not less – must be done to increase the use of colorectal cancer screening tests among Medicare beneficiaries, who are at higher risk for colorectal cancer because of advancing age. In fact, Medicare beneficiaries account for two-thirds of the new cases of colorectal cancer each year, according to the U.S. Centers for Disease Control and Prevention.     

LK: HHS has announced a goal of screening 80 percent of eligible patients for colorectal cancer by 2018, which the AGA supports. We're concerned that these cuts will hurt the progress we've made in reducing death and suffering from colorectal cancer screening and might prevent us from reaching our goals.

GL: If gastroenterologists reduce their access to Medicare beneficiaries as a result of payment cuts, or if the sites of service shift from efficient ASCs to less efficient hospital outpatient centers, then, yes, there has to be an adverse impact on screening goals. The "80 percent by 2018" national screening goal was within sight until now, but there could well be a reversal in the works. The public, who has gained tremendously from high-quality colonoscopy, need to realize that their access to life-saving and proven cost-effective procedures is being threatened by these proposals. Without question, colonoscopy has played a large role in the decline of colorectal cancer incidence and deaths over the past decade. There is a lot at stake here for Medicare beneficiaries, the very population most in need of colon cancer screening

Q: How can GI practices prepare for these cuts?

CK: The first thing GI practices can do is to help prevent the cuts from being finalized in the first place through advocacy with CMS and with congressional leaders.  The College has developed a "Medicare Colonoscopy Cuts Playbook" and is urging its members and their patients to voice their concerns to CMS and Congress by signing a petition.

LK: Control your expenses. AGA offer tools to help you prepare your practice and maximize revenue at http://www.gastro.org/practice-management/reimbursement.

GL: Some practices may be able to utilize more mid-level professionals for certain tasks to get more patients seen per day. We've heard some physicians will take early retirement, join hospital medical groups or otherwise migrate away from their current practice. All who remain must focus on greater efficiencies of our office schedule, minimize the open slots from cancellations/no shows, fix any gaps in the revenue cycle and negotiate more advantageous prices from our suppliers. Some will move to cheaper rent quarters, merge practices into smaller net square feet and extend hours to maximize revenue per hour of office time. There is no sufficient way, however, to still provide the same volume of high-quality colonoscopy and absorb these cuts without figuring on a substantial cut in take-home income.  

Q: What are the GI societies doing to work with CMS on combating these cuts?

CK: The ACG in collaboration with ASGE and AGA have already met with CMS this summer on July 21 to discuss the impact of these proposed cuts and highlight some of the flaws in the agency's analysis. The meeting was an opportunity to join together on behalf of all U.S. gastroenterologists to convey our mutual concerns regarding the significant impact these cuts will have on GI practices and Medicare patients. ACG and its sister GI societies will continue to engage in this dialogue with CMS.  

LK: The AGA will continue to work with ACG and ASGE to fight these cuts from a regulatory and legislative perspective. The three GI societies met with CMS to argue that the proposed colonoscopy reimbursement cuts were based on flawed data and should be revised. We're also working on Capitol Hill with lawmakers who champion colorectal cancer screening and rulemaking transparency to push CMS to reevaluate their methodology.

GL: The societies have already had one face-to-face meeting with CMS to present them with the realities of how these cuts will undermine the efforts CMS wants to make to reduce rates of colon cancer by improved screening. We've demonstrated to them that the logic behind their rationale for cuts is seriously flawed and unprecedented.  We showed them robust data that supports our premise that the work of colonoscopy hasn't changed – it is no less and in some ways it is more than five years ago, when the last AMA RUC survey was done. So how can cuts be justified?  We're planning further meetings with CMS. Our health policy groups plan to firmly fight this issue, taking it to Congress, working with public interest groups, and using social media and our grassroots networks across the country to deliver the message that these cuts are dangerous to the public's health.  

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