Payment landscape forecast: 3 gastroenterologists consider the possibility of colonoscopy reimbursement cuts

CMS has released the 2016 Medicare Physician Fee Schedule proposed rule, which could put into action payment cuts for colonoscopy and other lower GI/endoscopy procedures of up to 19 percent.


Colonoscopy is a mainstay procedure in GI and the gold standard for colorectal cancer screening. Three gastroenterologists look ahead and consider how these payment cuts would affect their specialty.

Maxwell Chait MD, FACP, FACG, FASGE, AGAF, ColumbiaDoctors Medical Group (Hartsdale, N.Y.): During the MPFS Final Rule in 2012, CMS had identified colonoscopy, EGD, and other GI endoscopy procedures as potentially misvalued through the Misvalued Code Initiative. Over the last three years, representatives from the ACG, AGA and ASGE have successfully delayed the revaluation of colonoscopy and other lower GI procedures. They presented their proposal and recommendations, which were from survey data, regarding physician work and practice expenses related to colonoscopy to the American Medical Association’s Relative Value Update Committee in Feb. 2014. They were able to convince CMS to hold off putting the rate cuts into effect for the 2015 calendar year because there was a lack of transparency in the data that prevented the medical societies from properly responding to the rate cuts. The next steps will involve thorough reviews of the proposed rules of MPFS and Hospital Outpatient Prospective System/Ambulatory Surgical Center Payment Systems. All comments are due Sept. 8, 2015. Rates will reportedly be finalized in November, and the final action will take effect January 1, 2016.

These reductions are based on flawed methodology that did not use all the survey data that was provided. Rather, they used data from other specialties. The agency is relying on the same data sources as in the previous year. One might say that his follows the old adage "garbage in, garbage out," since they are using the same flawed logic. They contend that the RUC ultimately used data from another specialty to determine the value of colonoscopy services, resulting in the payment cut recommendations. The Government Accountability Office criticized the RUC, stating that members had conflicts of interest that could affect how physician services are valued.

What gastroenterologists are now getting paid from Medicare barely covers the costs of these procedures. At this time the anesthesiologists often get more money per procedure than the endoscopists for routine colonoscopy, which seems preposterous. If these severe cuts are implemented, patient access could suffer. It could have the consequence of driving colonoscopy costs higher overall by gastroenterologists limiting their performance of this procedure within the Medicare population or possibly withdrawing from Medicare altogether. Colonoscopy has been shown to have a positive impact on the incidence of colon cancer. These draconian cuts could possibly hinder public health efforts to reduce the incidence of colorectal cancer. Colonoscopy in the outpatient setting is more cost effective and presents a more patient-friendly environment. These cuts could also lead to more procedures being done in the hospital outpatient setting, where Medicare pays more for the procedure than in ambulatory surgical centers, driving overall costs even higher.

Elliot Ellis, MD, Team Lead, EMA Gastroenterology, Modernizing Medicine: No one wants a reduction in salary, but most people can agree that healthcare costs in the United States can be better managed by ensuring that patients receive the right care at the right time – not too much and not too little. It's a complicated equation, but across the board payment cuts for colonoscopies and other lower GI/endoscopy procedures won't solve the problem. Part of the responsibility rests with physicians to ensure any tests and procedures ordered are medically necessary, and one way that we as gastroenterologists can do this is through proper documentation of patient visits. An EHR system that captures all relevant patient information in a structured way can illustrate that a colonoscopy or other procedure is justified. This approach may be more difficult, but by measuring quality and outcomes both physician and patient – and the industry as a whole – win.

Dr. William Katkov, Providence Saint John’s Health Center (Santa Monica, Calif.): Proposed cuts in Medicare reimbursement for colonoscopy will have consequences not only for gastroenterologists, but for the aging population in the United States.  A small decrease in Medicare providers will amplify the physician shortage projected to become increasingly serious over the next 10 years.  A strategy to attenuate the imminent shortage of physicians is needed in the short term, and it must include incentives for doctors to continue participating in Medicare.  Decreasing reimbursement for professional services will aggravate the situation, and impede access to effective colorectal cancer screening. In addition, the financial impact of reduced payment for colonoscopy will continue to drive gastroenterologists away from private practice and towards alignment with large hospitals and health systems.

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