From pay declines to rising procedure demand, gastroenterology leaders are facing new and longstanding challenges.
Procedure demand is increasing as cancer cases rise
Colon cancer cases are on the rise — diagnoses among people younger than 55 increased from 11% in 1995 to 20% in 2019, according to a report from the American Cancer Society. 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."
With this comes rising demand for colonoscopies. In 2021, an advisory panel lowered the recommended age for when people should begin colon cancer screenings from 50 to 45. Colorectal screening among 45 to 49 year olds increased threefold following the 2021 guideline change.
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. This change is expected to further increase demand.
Reimbursements are on the decline
Gastroenterology was one of 13 specialties that saw declining reimbursement rates despite higher volumes per beneficiary. And cuts will likely continue next year, as CMS' proposed physician fee schedule for 2025 includes a 2.8% conversion factor decrease.
The Digestive Health Physicians Association released a statement July 16 opposing the proposal, saying it "follows years of negligible increases, freezes and a payment cut in 2024."
"This is unsustainable for our nation’s medical groups, physicians and other health care providers," the statement said. "The effects of these cuts will be exacerbated in rural and underserved areas, which continue to face significant healthcare access challenges."
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."
The GI workforce is becoming increasingly employed
Gastroenterologists, like all physicians, are increasingly moving to employed models. The proportion of Medicare-billing independent gastroenterologists declined from 31% to 13% between 2019 and 2022, according to a recent study by Avalere that was funded by the American Independent Medical Practice Association.
"Many young gastroenterologists are running away from private practice," Adam Levy, MD, a gastroenterologist in Macon, Ga., told Becker's in January. "This is due to the high cost of educational loans and an environment where hospitals are offering large salaries to graduates. It is difficult for private practice to compete upfront due to declining reimbursements."
This will likely have implications for procedure costs. According to a study published July 25 in Science Direct, vertical integration of physician groups and health systems is pushing colonoscopies to be performed in hospital outpatient departments over ASCs, ultimately driving Medicare and patient out-of-pocket costs up.
The report found that following vertical integration, there is a 6.8 percentage point increase in the use of HOPDs instead of ASCs for colonoscopies. For colonoscopies and arthroscopies, the report estimated that changing from "status quo to fully integrated relationships for all physicians" will lead to a $315.4 million increase in Medicare spending and a $63.1 million increase in patients' out-of-pocket costs.
Patients are paying unnecessarily for colonoscopy
Some patients pay out of pocket for colonoscopy prep, according to a recent study, and many leaders are concerned about how that could affect screening volumes. The study found that only 17% of patients pay nothing for their bowel preparation for screening colonoscopy and that almost half of patients are cost-shifted toward the use of non-FDA-approved over-the-counter regimens.
Study leader Eric Shah, MD, a gastroenterologist at Ann Arbor-based University of Michigan, told Becker's the study identified a loophole where prescription drugs are tied to screening costs, and Medicare patients end up paying more.
Only 36% of the prescription claims analyzed had no out-of-pocket costs. For Medicare Part D, only 25% of high-volume preps were free. This loophole is an added barrier to getting patients screened for colon cancer.
New industry standards are raising eyebrows
On July 29, FDA approved a screening test for colorectal cancer that requires only a blood sample, but some leaders are concerned about the standard it could set for care delivery.
Amol Akhade, MD, a medical oncologist, argued in an Aug. 27 commentary piece in Oncology News Central that the test is not accurate enough to surpass colonoscopies. While the noninvasive nature of these tests might mean that more people receive CRC screenings overall, Dr. Akhade questioned the tests' accuracy and ability to detect aggressive, precancerous lesions.
"Finding a blood-based test to screen for cancer is a dream for every oncology researcher. Imagine a simple blood test that can detect precancerous lesions or Stage 1 cancer in asymptomatic individuals," Dr. Akhade wrote. "This would greatly benefit both oncologists and patients, potentially reducing cancer-specific mortality in the long term. The catch is that the test needs to be highly sensitive and specific to be clinically useful. Unfortunately, the recent approval of a blood-based colorectal cancer screening test by the FDA sets the bar too low, opening a dangerous Pandora's box."
Other guidelines are also putting colonoscopy care in flux. In August, the American College of Gastroenterology and the American Society for Gastrointestinal Endoscopy published updated guidelines regarding the quality indicators surrounding colonoscopy, according to a report from the American Journal of Managed Care.
According to the journal, it remains unclear how the new recommendations will affect the ways endoscopists approach colonoscopies and how patients will receive colonoscopies in the future.
Prior authorizations are a huge burden
Prior authorization also puts a squeeze on gastroenterologists working with high demand for colonoscopies. In a recent AMA survey, around 88% of physicians reported that prior authorizations put a high or extremely high burden on their practice.
"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."