Here are my disclosures. Okay. Here's the outline. So today, you know, we'll go over colonoscopy, some specific policies that are relevant to colonoscopy, including the Affordable Care Act, cost sharing, and prior authorizations. I'll touch on MACRA, which is the Medicare Access and CHIP Reauthorization Act, including the two components, MIPS and APMs. And then I'll talk about the importance of advocacy. And I just want to highlight that, you know, most clinicians don't receive training on any of these topics in any part of our training, but yet these topics are really critically important to our day-to-day practice. And so I think it's really important that we have a basic understanding, perhaps even a more in-depth understanding of some of these topics. So let's start with the Affordable Care Act. So the Affordable Care Act, the Patient Protection and Affordable Care Act was signed into law in March 2010. And it requires screening for average risk adults be covered. And this includes for colon cancer screening as well, with no consumer cost sharing. However, despite this law now being present for over 13 years, there are still threats to the Affordable Care Act, and specifically colonoscopy and colon cancer screening. So cost sharing refers to the patient's portion of cost for healthcare services covered by their health insurance plan. And the ACA has actually limited this for most plans up to $9,100. But this does not include grandmothered or grandfathered plans, and these are plans that existed prior to ACA becoming into law. And then some other plans are not regulated under ACA, and so these limits don't apply. And then prior authorization is the process by which insurance companies use to determine if a prescribed product or service will be covered. So let's talk about cost sharing. And so in this study by Fendrick and colleagues, they looked at market scan data and Medicare data using claims, and found over 80,000 individuals from whom they had data on. And what they looked at was this 90-day period prior to when a colonoscopy was ordered, and then the 90 days afterwards. So looking at the cost of the bowel prep, anesthesia related to the services, as well as any pathology that might have been processed that patients might have been charged for. And what they found was that out-of-pocket costs were really quite common for colonoscopy. These were all individuals who had actually had a stool-based test, and so they were having this colonoscopy as part of that follow-up and completion of care. On about 80% of those who were under Medicare had out-of-pocket costs, and about 48% of those on commercial plans had out-of-pocket costs. This averaged to be over $100, and it was up to $500 for those who had had polypectomies completed. So they also found that cost sharing is allowed by many plans, including Medicare, Medicaid, and 12 different states, and commercial plans up until May of 2022. And the implications are really quite profound, including that individuals are less likely to complete screening. For those who have abnormal stool-based or non-invasive screening tests, that they're less likely to follow up, and that the cost that individuals pay as part of their screening process can lead to reduction in spending for other essential items, such as food and rent. So what about prior authorizations? So prior authorizations really came into the spotlight this year, and as many of you know, this was due to March 29th, specifically the UnitedHealthcare group initially announcing that they were going to cut back prior authorizations by about 20%. But then in that same week, then announced that they would actually require prior authorizations for surveillance colonoscopies, upper endoscopies, and capsule endoscopies starting in June of this year. You can imagine that there was massive uproar by patients, professional societies, and many others. And in May of this year, media coverage peaked with more than 4,000 stories on this topic, and many of our societies were advocating against this policy as well. On May 26th, UnitedHealthcare met with the GI societies and offered to delay the prior authorization policy in exchange for an advanced notification system. And really what that meant was that gastroenterologists had to provide UnitedHealthcare plan with information prior to being able to do colonoscopies. So yes, it wasn't a prior authorization, but it was still delaying care. And actually when the leaders had asked UnitedHealthcare why there was this push for this policy, they said it was due to overutilization of procedures, but we never really saw data to support that assertion. So the GI societies, as you can imagine, did not support this. UnitedHealthcare on June 2nd went ahead and announced this anyway and said that they'll be using this data to create a gold card prior authorization policy that for now is planned to go into effect in early 2024. And so you can imagine that it is still quite important that we continue to fight against this because of the possible implications for our patients. So this is a survey that was published in Gastro. It was a survey of over 200 gastroenterologists and they were asked what were their top priority concerns. And you can see here that close to 80% of respondents said that prior authorization burden was a significant issue and they believe the top priority concern for us as gastroenterologists and as GI societies when we engage in advocacy. And so this, you know, again, continues to remain a top priority and a top concern with a lot of practitioners saying that they spend the equivalent of up to two days of their week in practice dealing with prior authorizations. So there are several implications for prior authorization policies. We know that many of our gastrointestinal conditions already have disparate outcomes by race and ethnicity and socioeconomic status. And you can imagine that prior authorizations could further exacerbate those disparities. So when we think about colorectal cancer, how this could lead to higher mortality in black and Native American populations as you've already heard. This could also lead to individuals just not being able to access screening and treatment and that could further compound disparities as well. This could lead to delays in care. So for example, delays in surveillance colonoscopy for patients who have inflammatory bowel diseases and for those who have already survived colon cancer as well as could significantly contribute to abandonment of care in high risk patients who need the endoscopic procedures most. And then finally also increasing burnout and cost. You know, prior authorizations, I'm sure anyone in this room can talk about the amount of time it takes for themselves or their practice to complete these. It diverts time from caring for patients because of the burdensome paperwork. And if we were to pass this time charge along to health plans, then in turn that would drive up health care costs even more. So what can gastroenterologists do? So there are currently two bills in Congress and you should all let your state representatives and senators know to support these acts. So the first one is the Improving Seniors' Timely Access to Care Act. It's in the House as well as the Senate and it proposes to establish an electronic prior authorization program, would require Medicare Advantage plans to adopt it. It would standardize and streamline the prior authorization process for routinely approved items and services and it would increase transparency around prior authorization requirements in addition to some other factors as well. The second one is Getting Over Lengthy Delays in Care as Required by Doctors Act. And this was of 2022, has not yet been introduced into this Congress, but again, you know, here's an opportunity for you to advocate within your state elected officials to let them know to support this. This would create a rational approach for prior authorizations and Medicare Advantage plans by exempting physicians from prior authorizations for services that are approved over 90 percent of the time. And a lot of these begin with Medicare Advantage plans because once those are adopted, they are then adopted by commercial plans as well and then Medicaid plans. So next we're going to talk about MACRA. So MACRA is the Medicare Access and CHIP Reauthorization Act. This was signed into law in April 2015 and really it was meant to fulfill two goals. And so the first one was to repeal the sustainable growth rate formula. And what the SGR did was that it said that payment increases to physician really averaged about 0.3 percent annually, even though the cost of doing business was increasing by about 3 percent annually. So this was not sustainable. And MACRA replaced the SGR with the Quality Payment Program. And this had two components. And so the first one was MIPS, which is the Merit-Based Incentive Payment System. And the second one was to promote alternative payment models. And I'll get into details for this. So really the plan was to move from volume to value. And so instead of physicians, hospitals, and other entities receiving separate payments for all of the services provided, that all of this would be bundled into one payment that, you know, healthcare entities would receive and that payment would cover physician services, hospital services, as well as any post-acute services. And so the MACRA schedule, when it first came out, initially said that between 2016 and 2019 that physicians would receive about 0.5 percent of increases in payments over that four-year period, nothing for about a four-year period. And then for the groups that adopted these alternative payment models, that there were some additional incentives that they might benefit from. And then what happens with MIPS is essentially with MIPS you have four different components. So there is the quality, there is the resource use, clinical practice improvement, and then meaningful use of your electronic health records. And each of these is broken down into different components. So let's say for quality, meaning if you met, you know, the screening goal, 80 percent of your individuals are up-to-date for screening, then you would get 50 percent. And essentially you would have to get a really high proportion on each of those for your practice to be reimbursed for meeting those MIPS quality measures. And they said if you met those quality measures then in 2019 you'd get a 4 percent additional payment, in 2020 you get a 5 percent additional payment, and then in 2021 you get 7 percent, and then so on and so forth. The challenge with this is that you have to meet this really high bar in order to get those reimbursements. And so a lot of practices were not thrilled about it and didn't want to participate because it was really hard to get reimbursed for meeting these quality measures. So here comes the alternative payment models. And what these were supposed to do, and really this is where when, you know, the change to the SGR came, this is where they were trying to push physicians into. And the alternative payment models were supposed to really kind of make the quality part of reporting more streamlined, but the challenge was that you had to have really sophisticated electronic health records and other sort of built-in quality measures in order to be able to participate in the alternative payment models. And so a lot of groups were not really thrilled about participating in them. The other thing is that the alternative payment models have not really been designed for gastrointestinal practices. And so I'll give you an example of this shortly. So there are several different types of alternative payment models, and they include pay for performance, they include the medical home model, shared savings, bundled payments, and capitation. And groups can decide which ones that they want to participate in. Before I get into the example, I just want to highlight here that essentially this was a survey that was done by the American Medical Association, and they showed that over a 10-year period that the cost of providing medical care had actually increased by about 40%. But when you adjusted for inflation, reimbursements to physicians had actually decreased during that same period by 20%. And so if we just want to continue to deliver high-quality care and make sure that our patients have the greatest access, the greatest technologies, and all those great videos we were watching on ways to do, you know, really great endoscopic procedures that avoid surgeries, these two numbers really do not compute. And this is really the bottom line of why it is so important that we play a big role in advocating for changes in policy related to payment reimbursements. So I'm going to just go through a couple of the problems with MIPS and the APMs as well. So one problem in the MIPS under the new quality payment program is that there are unclear expectations around how CMS partners with professional societies in the development of these quality measures. So for example, I think everybody in this room can agree that adenoma detection rate is, you know, important. We all believe it works. There's data that demonstrates that it reduces mortality. It is, in fact, supported by the ASGE, the AGA, as well as ACG. However, this has not been adopted by CMS as a quality measure under MIPS. Currently, the quality measures that are adopted for GI measures are not GI-specific. So for example, closing the referral loop, which just means when a patient is referred from primary care to GI, that we have made contact with their primary care provider and said we have received that. That's important, but it does not reflect the quality of care that we provide to our patients. So what is a potential solution? I think we actually need legislation that mandates that CMS works with the specialty societies to develop or to identify quality measures for which we are then reimbursed for. What about the alternative payment models? So one current problem is that they don't reflect the complexity and the unpredictability in gastrointestinal conditions. So for example, for a patient that has GI bleeding, depending on if it's an upper source or lower source, if it's overt, if it's obscure, those patients may be in the hospital for a certain amount of time while we figure out what is causing their GI bleeding before they're eventually safe to go home. There are currently alternative payment models that might, say, give, you know, let's say $5,000 reimbursing for all GI bleeders when we know that for that patient that presents with obscure bleeding, they might be in the hospital much longer and their overall costs of care are much, much higher. So as a result, GI practices have not wanted to participate in these alternative payment models. We've been compared to other specialties, so for example, orthopedic surgery, and orthopedic surgery, so like knee replacements, hip replacements, used to be the most expensive procedures in this country. So there was a real focus on trying to reduce those costs in order to improve quality. And the way that the orthopedic surgeons achieved this was by really risk stratifying and reducing risk of individuals prior to their surgery. You can imagine that we can't do that for a GI bleeder. We can't predict who's going to bleed, so we can't risk stratify to reduce their length of stay prior to them hitting our door. So really the solution is that, you know, we again need legislation for alternative payment models that are specific to GI and other specialty societies, and we need more stable physician reimbursements. So Congress then, in response to this, expanded the scope of this Physician-Focused Payment Model Technical Advisory Committee, of which our GI societies participate. But to date, CMS has not taken any of the recommendations that come from this group that actually includes gastroenterologists. So I just want to show you a case example of advocacy, and again, why advocacy works. And so there was a Medicare loophole bill, and you all are familiar with this. It meant, like, for example, if somebody got a colonoscopy or if they had an abnormal fit and got a colonoscopy and a polyp was removed, that they could then be changed from a screening procedure to a diagnostic procedure, and then they could get this huge bill. So in 2015, there was a bill that was introduced to close this loophole for patients, and over a seven-year period, it slowly advanced through legislation with support from our GI societies. And in December of 2020, Medicare signed that bill into law. In January of 2022, commercial plans provided guidance that said that patients would not face those additional surprise bills from those procedures. And in July of that same year, CMS proposed a rule on follow-up colonoscopy to ensure that patients don't receive those bills, and again, that was followed up on the CMS final rule in November of 22. And so this tri-agency guidance, which comes from the Department of Treasury, Health and Human Services, and Labor, essentially released this guidance in January 2022, and they told commercial plans, and you have to really dig into this document, but they essentially said, you know, for any patient that has a follow-up after an abnormal noninvasive stool test, that those individuals are covered without cost-sharing because of this rule that passed, and it now has been implemented. And again, as I mentioned, usually whenever, you know, Medicare plans, you know, take action, commercial plans follow, and so this is just what happened, is that CMS also adopted this rule, and so now this applies to individuals who are commercially insured, as well as who are insured through Medicare and Medicaid. And right now, actually, Medicare, it's passed, and I think we're waiting for it to go into effect for Medicaid plans. So where are we now with this? So ACA-compliant plans now, there's no cost-sharing for follow-up colonoscopy. Medicare plans, this has been passed for Medicaid expansion populations. We're still waiting to see if traditional Medicaid programs will adopt this, and then right now, grandfathered and those who are uninsured, unfortunately, don't have the benefit of this new policies. So in conclusion, cost-sharing is very common, but new policies are promising. Prior authorizations remain a top priority, and I think if anybody in this room has an opportunity to speak out against the UnitedHealthcare prior authorization ruling that has been happening, that you should certainly speak up because I personally believe that it is a tipping point and other health plans will sort of follow suit if United is successful in moving this forward. We need legislation to ensure that CMS works with specialty societies to identify quality measures, and we need alternative payment models and reimbursements that really reflects the specialty care, high-quality care that we deliver. I want to impress that advocacy is really for everyone, and it's accessible through the GI societies, and to encourage your elected officials to support current legislation that is currently on the dockets to close some of these gaps. And last of all, I can't stress enough the importance of voting, because certainly if your elected officials don't support these, then it makes it, you know, really even hard for you to advocate for them as well. And finally, this is just a montage of opportunities that I have had to advocate for policies at the state level, in the state of Washington, as well as nationally, including recently when I got to meet Representative Donald Payne, Jr., who was really an advocate for pushing forward this closing the Medicare loophole bill. His father died of colon cancer, and really was because of his inability to access screening. And so, he has made it his job right now to make sure that this never happens to anyone again. So, thank you, and I look forward to any questions.

colonoscopy policies

Affordable Care Act

cost sharing

prior authorizations

patient outcomes

Medicare Access and CHIP Reauthorization Act (MACRA)