Solving the colonoscopy conundrum: 5 leaders' thoughts on shifting standards

Increased demand for colonoscopies paired with declining reimbursements are pushing many gastroenterology physicians to shift strategies. 

Here are five leaders' thoughts on colonoscopies:

Shakeel Ahmed, MD. Gastroenterologist and CEO of Atlas Surgical Group (St. Louis): We at least need to move elective surgery into the ASC. I'm a gastroenterologist, so I speak from my field, but I think that screening a colonoscopy in a healthy patient in an inpatient hospital setting should be malpractice. Over time this will become mainstream. People will realize what a huge expenditure we're wasting by keeping simpler electives — and I'm not talking about necessary procedures – but I'm talking about colonoscopies and other minor surgeries on healthy patients. These need to 100% move to the outpatient setting. 

A screening colonoscopy in the hospital setting is about 65% more expensive than an ASC. Same standards often apply for orthopedic and spine. At my ASC in South Illinois, we charge $150 for self-pay colonoscopy, which basically includes the professional fee for the gastroenterologist, the facility fee, the anesthesia fee and the pathology fee. I personally had a colonoscopy at a local hospital, which is close to my house, and the hospital got paid $10,000 for that colonoscopy. Additionally, in the ASC, according to CDC data, it's oftentimes safer to get a colonoscopy [at an ASC] compared to the hospital setting. The convenience is more effective. The cost is half as much.

George Dickstein, MD. Vice President of Clinical Affairs of Gastro Health Massachusetts: Clearly for Medicare, colonoscopy reimbursements are not keeping up with inflation and costs of doing business at practices and ASCs. The reality on the ground for the commercial market is more nuanced and harder to get at as rates are not easily shared and vary tremendously by geography. Gastroenterologists have invested a great deal of time, training and strategic planning around providing safe colonoscopies in high-quality, time-efficient settings. Ultimately, the rapidly increasing market of blood and stool-based screening tests will have an impact on screening colonoscopy demand. As the false positive, true positive, negative predictive value and positive predictive value of each of these emerging technologies is yet to be compared in well-done trials, we will better be able to strategize their impact on diagnostic colonoscopy demand.

Eugenio Hernandez, MD. Senior Vice President of Clinical Affairs for Gastro Health (Miami): The most challenging payer trends affecting ASCs right now are the policies that require prior authorization or advanced notification for colonoscopies and other relatively routine endoscopic procedures. While these policies place an additional administrative burden on ASCs, the bigger issue is that they could potentially harm patients because of limited, delayed, or denied care.

Omar Khokhar, MD. Gastroenterologist at Illinois GastroHealth (Elgin): I would love to see payers and clinicians sit down at a table and have a conversation about the benefit of early endoscopy for diagnosis and screening. In particular, how EGD/colonoscopy can potentially prevent patient morbidity and decrease downstream cost to the healthcare system. Yes, endoscopy isn't cheap, but cancer is a bad diagnosis and is more expensive. I would welcome that holistic approach.

Benjamin Levy III, MD. Gastroenterologist at University of Chicago Medicine: The U.S. Preventive Services Task Force recently changed the colonoscopy guidelines to begin screening at age 45 due to an increased incidence of colorectal cancer being diagnosed at age 49. The thought was to perform screening colonoscopies on patients at age 45 in order to remove polyps before they have a chance to grow into cancer. Also, colorectal cancer is more easily treated when caught at earlier stages. The market for outpatient colonoscopy procedures at ASCs and in hospitals has skyrocketed because all of a sudden, there are 19 million additional Americans between the ages of 45-49 who need screening colonoscopies. ASCs and gastroenterologists should work to increase colorectal cancer screening rates in local communities to help prevent cancer. If we were able to get everyone between the age of 45-49 screened on-time, we could diagnose early onset colorectal cancers at earlier and more easily treated stages. The American College of Gastroenterology has been working to help raise awareness about the new colorectal cancer screening guidelines through Tune It Up: A Concert To Raise Colorectal Cancer Awareness. Over the past three years, we have seen enthusiasm for colonoscopies among 45-49 year-olds increase, which is awesome. Our gastroenterology public health campaigns are working. It also would be helpful to increase the number of post-graduate fellowship training spots nationally to help keep up with this new demand in gastroenterology.

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