The colonoscopy conundrum

Gastroenterology physicians and practices are facing a major challenge: increased demand for colonoscopies amid declining reimbursements. 

Gastroenterologists are facing low reimbursement rates, affecting the financial stability of their practices as procedure demand continues to grow. From 2007 to 2022, unadjusted and adjusted average reimbursement for GI procedures dropped by 7% and 33%, respectively, according to a study published in the American Journal of Gastroenterology. Reimbursements for colonoscopy and biopsy decreased 38% during that period. 

"There is the well-known issue of decreasing reimbursement over time for procedures that already have existing CPT codes, and that too in the face of the post-pandemic increased demand, higher costs of doing business and staffing issues," Vivek Kaul, MD, gastroenterology professor at the University of Rochester (N.Y.) Medical Center, told Becker's last year. "In addition, a real challenge we are facing is the inability to get reimbursed for a host of relatively newer (but well-established) endoscopic procedures that have emerged in the last decade or so. Oftentimes, these are minimally invasive, transformational interventions for our patients that help reduce morbidity, length of stay and overall healthcare costs but are poorly reimbursed or not reimbursed at all, in some cases."

Prior authorizations can be another obstacle for gastroenterologists looking to secure reimbursements. 

"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," Eugenio Hernandez, MD, senior vice president of clinical affairs for Miami-based Gastro Health, told Becker's. "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."

While reimbursements are declining, demand for colonoscopies is on the rise. In 2021, an advisory panel lowered the recommended age for when people should begin colon cancer screenings from 50 to 45, and CMS said Nov. 1 it is expanding Medicare coverage for certain colorectal cancer screening tests by reducing the minimum age payment and coverage limitation from 50 to 45. 

Colon cancer diagnoses among people younger than 55 increased from 11% in 1995 to 20% in 2019, according to a report from the American Cancer Society. Additionally, colon and rectal cancer rates are expected to grow 8% among men and 7% among women in 2024. 

"Now, to see someone in their 20s and 30s [being diagnosed with cancer], it doesn't wow us anymore," Nancy You, MD, a professor of colon and rectal surgery at the University of Texas MD Anderson Cancer Center in Houston, told Becker's. "Even when I was a fellow in 2008 at Mayo Clinic, we were already seeing young patients with colorectal cancer, and even then we were writing about the increased rates." 

Omar Khokhar, MD, a gastroenterologist at Illinois GastroHealth in Bloomington, told Becker's he is holding out hope that 2024 might see more successful payer negotiations. 

"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," he said. "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."

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