Many leaders say gastroenterology is getting hit harder by reimbursement cuts and payer behavior than other specialties.
Several leaders joined Becker's Nov. 1 on a panel at the 30th annual Business and Operations of ASCs Meeting in Chicago to discuss emerging issues in gastroenterology reimbursements.
One of the issues raised was the steady decline in reimbursements. Unadjusted and adjusted average reimbursement for GI procedures dropped by 7% and 33%, respectively from 2007 to 2022, according to a study published in The American Journal of Gastroenterology. Reimbursements for colonoscopies and biopsies decreased 38% during that period.
"The biggest pain is definitely the reimbursement cuts, and there's no Tylenol for it," said Emma Gimmel, BSN, RN, director of nursing at Manhattan Endoscopy Center in New York City.
In another study published in the Journal, researchers found reimbursements for an esophageal biopsy decreased 41% in hospitals and 32% in physicians' offices from 2006 to 2023.
Dr. Omar Khokhar, a gastroenterologist at Illinois GastroHealth in Bloomington, emphasized that while insurers may deny certain gastroenterology procedures, the need for patient care remains.
"I think we'd all agree that there's only so much juice you can squeeze out of the orange before quality and value are compromised," Dr. Khokhar said. "Reducing reimbursement doesn't make the patient disappear. If we can't provide that care, those patients end up in the ER with serious conditions like anemia or a colon mass. It just kicks the can down the road."
To counteract payer pushback, many GI leaders are focused on outcome data to strengthen relationships with insurers.
"Data speaks louder than words," Ms. Gimmel said. "Metrics like benchmarking and maintaining low complication rates can have a real impact. Every possible quality and risk assessment tool helps. Improvements in environment, equipment, staffing — all of it matters, because ultimately complications have a starting point."
However, many leaders still find this data is often disregarded by payers. Because gastroenterology care is generally lower cost and quick, some payers tend to downplay its value, Dean Lehmkuhler, administrator of Northside Gastroenterology Endoscopy Center in Indianapolis, said.
"The data on outcomes we share with insurers is the only evidence we can provide to demonstrate our quality of care. The frustrating part is that they don't listen," he said. "When I worked with multispecialty practices, I had more leverage. In GI, they just don't seem to see it as a priority because it's a smaller portion of their budget."
Prior authorizations and other administrative barriers also continue to be a significant issue.
"Prior authorization is a real pain point," Mr. Lehmkuhler said. "My solution has been to dedicate staff to handle these authorizations, ensuring they stay on top of things."
Obtaining timely information from payers adds another layer of complexity.
"Some payers are great to work with, but with others it's a struggle," Ms Gimmel said. "We're stuck on the phone with them because they don't respond to emails or texts."
Dr. Khokhar noted that clinicians can help by understanding what payers typically look for in authorizations and what leads to denials.
"When you ask insurers, they'll say prior authorizations are needed to control costs," he said. "But we need a better balance where patients can receive timely, appropriate care without worsening their conditions while still addressing payers' cost concerns."