The dangers of declining gastroenterology reimbursements

Colonoscopy demand is continuing to grow as gastroenterologists and GI practices face ever-declining reimbursements. 

Colon cancer diagnoses have been steadily growing for over a decade.There was a 15% increase in colon cancer diagnoses in people aged 18-50 from 2004 to 2023, according to hospital-based data from the National Cancer Database, and 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." 

Increased diagnoses have led to lowered recommended age for screenings. The U.S. Preventive Task Force lowered the recommended screening age from 50 to 45 in 2021. Additionally, 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. 

But the increase in demand is not met with a subsequent reimbursement increase. Gastroenterologists are instead facing declining reimbursement rates – gastroenterologists are expecting to see Medicare pay cuts for both facility and non-facility billing for the top 10 most common GI CPT codes in 2024. Additionally, 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. 

This has led to an increase in outpatient GI procedures, particularly at ASCs, because they can offer procedures at a lower cost than HOPDs.  

"ASCs and gastroenterologists should work to increase colorectal cancer screening rates in local communities to help prevent cancer," Benjamin Levy III, MD, gastroenterologist at University of Chicago Medicine, told Becker's. "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."

Lawmakers are working to change these reimbursement disparities. In January, 45 members of Congress wrote a letter to HHS urging federal agencies to expand access to colorectal cancer screenings by ensuring surveillance colonoscopies are covered as preventive services. States are also pushing to change this coverage. In February, a proposed bill in Nebraska regarding the expansion of colonoscopy coverage passed the first of three rounds of voting. If the bill passes, insured patients would not be charged additional fees for a medical service associated with colonoscopies.

"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," Omar Khokhar, MD, a gastroenterologist at Illinois GastroHealth in Bloomington, told Becker's. "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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