Good and Bad News for GI in 2023 CMS Physician Fee Schedule
Medicare expanded coverage of colorectal cancer (CRC) testing through the 2023 physician payment rule while also finalizing certain mandated budget cuts. Gastroenterologic medical societies praised the federal plan to increase access to screening but are among the groups now calling on Congress to prevent pay decreases.
The 2023 Medicare Physician Fee Schedule lowers the minimum age for CRC screening to 45 from 50 years, in keeping with the recommendation from the US Preventive Services Task Force. The physician payment rule, which was unveiled on November 1, also ends the co-pay for colonoscopies that follow a positive stool-based colon cancer test.
Both new policy moves had strong support from medical groups, including the American College of Gastroenterology (ACG) and the American Gastroenterological Association (AGA).
The current policy of requiring co-pays for follow-on colonoscopies has “a significant chilling effect on Medicare patients,” the Digestive Health Physicians Association (DHPA) wrote in a September comment letter on the draft version of the rule.
Eliminating co-pays also makes good financial sense for the federal government, DHPA argued, citing published research. The cost of increased colonoscopies due to the elimination of the co-pay would be more than exceeded by savings from earlier detection of cancers, the group said.
Favoring Stool Tests Over Colonoscopy?
But DHPA voiced concern about how Medicare officials seemed to advocate for stool-based tests over colonoscopy in the physician payment rule.
In the draft rule, Centers for Medicare & Medicaid Services (CMS) officials wrote that colonoscopy in many instances “is not the most appropriate first step in CRC screening and would represent an unnecessary burden and over-servicing for both the patient and healthcare system.”
In its comment letter, DHPA criticized CMS for basing its opinion on a 22-year-old study that wasn’t conducted in the Medicare population and was limited to asymptomatic adults.
Even though colonoscopy isn’t always the most appropriate first step in CRC screening, “it is equally true — and critical for Medicare beneficiaries, primary care physicians, and the medical community more broadly to understand — that screening colonoscopy is the right first-line screening option for a significant portion of Medicare-age patients and is the only CRC test option that screens, detects, treats, cures, and prevents colorectal cancer,” DHPA wrote.
In the final rule, CMS noted that it received complaints that the draft rule “inappropriately favors stool-based tests over colonoscopies” and thus could discourage their use as a first-line screening for CRC.
CMS also said in the final rule that it has not changed its coverage for colonoscopy as “an optional first step” in cancer screening. But the agency reiterated its call for patients and physicians to consider carefully the options for CRC screening.
“We recognized there are several advantages to choosing a non-invasive stool-based CRC screening test as a first step compared to a screening colonoscopy, including relative ease of administering the test and potentially reducing the experience of unnecessary burdensome preparation and invasive procedure,” CMS wrote.
‘Déjà Vu All Over Again’ on Pay Battles
CMS uses its annual updates of the Physician Fee Schedule to make myriad policy decisions, with the 2023 version of the rule running close to 3000 pages.
But the most controversial provisions in the rule involve federal mandates meant to control spending that CMS has no control over. These include a reduction in one of the variables used in determining payment, known as the conversion factor. This will fall by $1.55 from the current level of $34.61 to $33.06 next year.
There’s widespread agreement that Congress needs to reconsider its approach to setting Medicare payment for clinicians.
Between 2003 and April 2014, Congress passed 17 laws overriding the cuts to physician pay that were required under the old sustainable growth rate (SGR) formula.
The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) was supposed to end the annual battles over reimbursement cuts resulting from the SGR formula by changing the way physician payment is updated each year.
However, physicians face a 4.42% Medicare payment cut under the new payment system, as reflected in 2023 payment rule.
Two physicians serving in Congress, Rep Ami Bera, MD (D-CA) and Rep Larry Bucshon, MD (R-IN), have introduced legislation that would block next year’s cuts.
The current fight to stave off 2023 cuts seems like “déjà vu all over again,” said Kathleen Teixeira, AGA’s vice president of government affairs, in an interview with Medscape Medical News. Congress needs to shift away from the “Band-Aid approach” and concentrate on longer-term issues with physician payment, she said.
Bera and Buchson in September issued a letter seeking feedback on ways to “stabilize the Medicare payment system” without dramatically increasing the cost to taxpayers.
Louis Wilson, MD, chair of the ACG’s legislative and public policy council, told Medscape Medical News that Congress needs to revisit Medicare’s physician payment system, especially in terms of addressing inflation.
Lawmakers’ attempts to restrain growth in Medicare physician payments have had the unintended consequence of fueling the acquisition of practices by hospitals, said Wilson, the managing partner of a physician-owned single-specialty private practice in Wichita Falls, Texas. Once doctors are employed by hospitals, Medicare often pays higher rates for their services than it would pay to physicians for providing the same care in a private practice.
Indeed, the Federal Trade Commission (FTC) has said the US physician workplace is “undergoing a dramatic restructuring,” with traditional solo practices and small single-specialty group practices rapidly being replaced by large multispecialty physician group practices, or practices that are owned or employed by hospital systems. The FTC is in the midst of a major series of studies on the effects of this consolidation.
“There’s been so much market distortion, so much limitation in innovation by failing to adequately pay in the Physician Fee Schedule, that the consequence is the widespread consolidation,” said Wilson. “That’s recognized on both sides of the aisle as being essentially expensive and inefficient and not in patients’ best interest.”
Kerry Dooley Young is a freelance journalist based in Miami Beach. She earlier covered health policy and the federal budget for Congressional Quarterly/CQ Roll Call and the pharmaceutical industry and the Food and Drug Administration for Bloomberg. Follow her on Twitter @kdooleyyoung.
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