Where CMS policies are hurting gastroenterologists the most

From declining Medicare and Medicaid reimbursements to complex CPT code requirements, CMS policies present a major challenge to gastroenterology practices. Here, five of the specialists discuss the policies that are hitting them the hardest. 

Editor's note: These answers were edited lightly for clarity and brevity. 

Question: Which CMS policies are hurting gastroenterologists the most?

Curuchi Anand, MD. Gastroenterologist affiliated with UMass Memorial Health (Worcester, Mass.): The repeated reduction in reimbursement for procedures is making it unattractive to do colonoscopies for any Medicare or Medicaid patients. Especially if the procedure is complex and prolonged, we are left with a situation where it just about covers the overhead costs. I still continue to provide care as a service to the patients, but in the future may need to stop or limit access to these patients. There is enough volume of commercial patients to get by. I would rather work 40 hours instead of the 60 hours I work, as the 20 hours of my time is worth more than what I get paid by CMS.

Pankaj Vashi, MD. Chief of gastroenterology/nutrition department and vice chief of staff at CTCA Chicago: CMS has been instrumental in standardizing the practices of all specialties, and gastroenterology is not an exception. Complex CPT billing codes require the physicians to be familiar with the changes that are made every year. For instance, the use of modifier codes when two separate procedures are done during the same encounter. Also, it is crucial that we are aware of quality measures established by CMS, which impacts reimbursement. Such quality measures for colonoscopy include scope withdrawal time, cecal intubation and adenoma detection rates. The procedure report modules from electronic health records are very helpful in auto-populating the CPT codes for us.

Omar Khokhar, MD. Gastroenterologist in Bloomington, Ill.: Continued downward pressure on reimbursements while expenses are increasing across the board. CMS needs to realize that later endoscopy is valuable in preventing downstream morbidity to the patient and downstream cost to the overall healthcare system if diagnoses are made at later stages.

Joe Feurstein, MD. Gastroenterologist at Beth Israel Deaconess Medical Center (Boston): One of the biggest challenges that CMS policies have created is related to managing patients with inflammatory bowel disease. CMS rules do not allow for traditional copay assistance that is allowed with commercial insurance plans, regardless of patient’s income status to help pay for the high cost of biologic and small molecule medications. CMS rules do not allow for this to be used. As a result, the oral and subcutaneous self-injectable drugs can cost over $6,000 a year. In contrast, patients on commercial insurance typically will pay under $100 to $200 a year. The only fully covered drugs are infliximab and vedolizumab. This, unfortunately, limits our ability to manage our patients with inflammatory bowel disease on Medicare and creates unfortunate challenges in management and significant out-of-pocket costs to patients that many cannot afford. As a result, many patients are stopping drug therapy. Hopefully, CMS will reconsider how they cover non-infusion based biologics.

Adam Levy, MD. Gastroenterologist in Macon, Ga.: Without a doubt, skyrocketing costs are affecting GI private practices who utilize independent ASCs for endoscopy. Supply costs are at all-time highs, but Medicare ASC reimbursements do not adjust or offer any flexibility. Labor costs have also risen sharply. Before the inflation seen over the last two years, a typical ASC would hope to break even on a Medicare endoscopic procedure. This is now even more difficult due to cost raises on equipment. When ASCs are no longer profitable or lose money, private practice cannot sustain or recruit. This will only drive more physicians into hospital employment and shift more procedures to the hospital, therefore raising overall costs for Medicare. Medicare must improve ASC reimbursement in order to just sustain current ASC operations.

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