How Medicare colonoscopy reimbursement cuts could impact GI in 2016 & beyond

The Centers for Medicare and Medicaid Services' 2016 Physician Fee Schedule Final Rule includes reimbursement cuts for colonoscopy. The cuts were initially proposed in July and several societies, including the American Gastroenterological Association, American College of Gastroenterology and American Society of Gastrointestinal Endoscopy worked with CMS to mitigate the cuts.

"I think the cuts will adversely affect the ability of some gastroenterologists to provide services," says David Greenwald, MD, Director, Clinical Gastroenterology and Endoscopy, The Mount Sinai Hospital in New York City. “Colonoscopy provides an effective way to diagnose and treat a wide variety of gastrointestinal conditions. Cutting reimbursement for colonoscopy may make it more difficult for many gastroenterologists to provide these potentially life-saving procedures in a cost-effective manner."

However, several cuts were still in the final rule, including some that are more than 17 percent. The top 10 lower GI codes include:

1. Colonscopy with snare polypectomy (CPT code 45385): -12 percent
2. Colonoscopy (CPT code 45373): -9 percent
3. Colorectal cancer screen, high risk (CPT code G0105): 0 percent
4. Colorectal cancer screen, low risk (CPT code G0121): 0 percent
5. Colonoscopy with hot biopsy (CPT code 45384): -11 percent
6. Colonoscopy with submucosal injection (CPT code 45381): -13 percent
7. Flexible colonoscopy with ablation (CPT code 45388): -15 percent
8. Flexible sigmoidoscopy with biopsy (CPT code 45331): -1 percent
9. Flexible sigmoidoscopy (CPT code 45330): -13 percent
10. Colonoscopy with control of bleeding (CPT code 45382): -16 percent

"The direct effect of the decreased reimbursement is on the revenue of the physician or the practice," says Noel R. Fajardo, MD, of Las Vegas Gastroenterology and The Las Vegas Surgery Center. "As in any business, profit margins will definitely decrease given that operational costs are not only fixed, but in most cases, continue to increase."

Reimbursement cuts in the past have changed practice patterns with gastroenterologists limiting their availability to underinsured or uninsured patients. But, they continue to advocate on behalf of the patient.

"Gastroenterologists are reacting to this in a very pragmatic way, engaging their professional societies in efforts to have CMS better understand the impact of these cuts and to try to have CMS reevaluate their decision," says Dr. Greenwald.

Worst case scenario, GI providers will retire early, partially as a result of the lower reimbursements. "Given that a GI practices is a business that is run for profit, operational costs will be reviewed and will need to adapt to the decrease in CMS reimbursements," says Dr. Fajardo. "However, the reality is a 20 percent decrease in reimbursement is significant and the efficiency of the practice will need to be scrutinized closely in order to eliminate cost."

Private practice providers may also decide to take an employed or salaried position or merge with other practices to form supergroups that share operational costs. "In essence, solo GIs or small GI practices may eventually be part of a bigger network," says Dr. Fajardo. "That may or may not change the quality of care."

The cuts could also affect access to care. "It may be difficult to extrapolate the direct impact on patient care and access to care, however, given that demand for colonoscopy will increase as our population ages, it would not be surprising to see a long wait list for obtaining a colonoscopy, therefore risking the possibility of increased incidence of colon cancers due to delay in access to care," says Dr. Fajardo.

The cuts also make gastroenterology a less attractive specialty for new physicians coming out of medical school. The specialty may see a decline in gastroenterologists in the future.

The cuts could have a disastrous effect on GI physicians' ability to provide colonoscopy and access to patient care. The cuts come at an especially crucial time in the campaign to screen 80 percent of Americans by 2018; in 2010 only 59 percent of people 50 years or older had up-to-date colon cancer screenings. However, studies show increased colon cancer screening has lowered colon cancer rates 30 percent in the past 10 years.

"My concern is that continued cuts in reimbursement might affect patient access in a profound way," says Dr. Greenwald. "It's hard to predict what will happen, and I am certain most gastroenterologists will try to continue to find a way to provide access to care for the underinsured or uninsured. However, it would appear that reimbursements for colonoscopy are diminishing at a time when the costs of providing that care are staying the same or even increasing. As reimbursement gets closer to costs, the ability for physicians to provide services is impacted, and access to care becomes an even more significant issue."

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