Becker's ASC Review

32 GASTROENTEROLOGY Consolidation pushing colonoscopies to HOPDs, driving Medicare cost surge: Study By Patsy Newitt T he 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, according to a study published July 25 in Science Direct. To determine how vertical integration changes services, the study analyzed data collected between 2013 and 2019 from 1 million arthroscopy and 10 million colonoscopy procedures in the U.S. Medicare population. e study used primary care physicians to measure patient's exposure to vertical integration, rather than specialist physicians, "due to the concern that health systems may influence patient referrals to these same specialists." Here are six key notes: 1. Scaling the change in Medicare payments by the increased use of ASCs equates to estimated 35% higher Medicare payments at HOPDs than ASCs for colonoscopy. 2. e report found that following vertical integration, there is a 6.8 percentage point increase in the use of HOPDs instead of ASCs for colonoscopies. 3. e report also estimated that vertical integration leads to an 8.1 percentage point higher probability of choosing an HOPD over an ASC for colonoscopies. 4. 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. 5. Medicare reimburses ASCs at roughly one-half to two-thirds the reimbursement rate for HOPDs, meaning that "vertical integration can create incentives to perform procedures" at HOPDs. 6. If all the primary groups were vertically integrated, 542,066 more colonoscopy procedures would be performed at HOPDs — a 20% increase — increasing patient payments by $56.9 million. n The uncertain future of colonoscopies By Francesca Mathewes R ecently, U.S cancer screening costs hit $43.2 billion annually. Screening colonoscopies accounted for $23.7 billion, or 55%, of that cost. All other colorectal cancer screening methods, such as stool and blood tests, accounted for only $3.8 billion. This recent data, alongside the development of non- invasive CRC screenings such as Cologuard and fecal immunochemical testing, have raised questions as to what the future of colonoscopies and CRC screenings may look like. Three physicians shared their perspectives on the future of colonoscopies with Becker's. Editor's note: Responses have been lightly edited for clarity and length. Tim Sowerby, MD. Gastroenterologist at MarinHealth Medical Center (Greenbrae, Calif.): Almost all colon cancers develop from benign polyps (adenoma). Removing adenoma prevents the development of colon cancers. Only colonoscopy [can] reliably screens for polyps. Consequently, colonoscopy is primarily a tool to prevent cancer. The role of colonoscopy in screening for colon cancer is actually a secondary benefit. The real value in colonoscopy is the prophylactic identification and removal of potentially premalignant polyps. In contrast, non-invasive tests detect most cancers but do not reliably detect potentially precancerous polyps. They are screening tests only and not cancer-preventing. Hitesh Chokshi, MD. Gastroenterologist at Atlanta (Ga.) Gastroenterology: Colonoscopy is still the gold standard and, compared to DNA based stool and blood tests at their current pricing, still most cost-effective. However, I believe there will be a shift to the noninvasive tests, especially if their costs come down. Also, they may be favored over screening colonoscopy based on patient, comorbidities and resource availability. If there is a shortage of anesthesia personnel, or of G.I. personnel, such that gastroenterologists are unable to provide care for patients with illnesses either as inpatient or outpatient due to the time burden of doing colonoscopies, non-invasive screening tests may be utilized in order to free up those resources to help take care of the general population. Jeffrey Fine, MD. Gastroenterologist at Fine Digestive Health (Irving, Texas): I think optical colonoscopy will still have a role as it has the highest level of sensitivity and specificity to identify polyps and cancers. Cologuard and other tests continue to be used, but they have lower sensitivity and specificity. Cologuard [costs] around $600. Recently, I've seen several patients with positive Cologuard and stool DNA which subsequently needed colonoscopies, which identified both polyps and one rectal cancer. Recently, I've also had two patients with negative Cologards and both ended up being diagnosed with colon cancer . Those are the patients I'm concerned about. I do recommend Cologuards for patients who decline colon cancer screening. Unfortunately, none of the noninvasive tests yet have [the same] sensitivity and specificity as cancer screening via colonoscopy. n

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