As the US population ages, gastroenterologists will provide care for an increasing number of older patients. Many of these patients use Medicare, a federal health insurance program for Americans aged 65 years and older and certain people younger than 65 years with disabilities. Over the years, the program has grown in size and complexity. Medicare covers 65 million people and in 2020 represented 12 percent of total federal spending (1). Concurrently, concerns about healthcare costs have led to legislation targeted at reducing spending for physician services, including the 1997 Medicare Sustainable Growth Rate, and later, the 2015 Medicare Access and Children's Health Insurance Program (CHIP) Reauthorization Act, which have profoundly affected Medicare reimbursement (2). Despite these legislative efforts, Medicare's payment system for physician services is built on a budgetary rate-setting system that does not account for the rising cost of care (2).
Medicare primarily uses Current Procedural Terminology (CPT) codes for reimbursement. Given the changing political landscape and diversity of service types in gastroenterology, Medicare reimbursement trends not only elucidate the financial impact that gastroenterologists experience but also inform future political advocacy priorities and practice management trends. Centers for Medicare & Medicaid Services (CMS) reimbursement system provides a valuable tool to quantify and compare trends in Medicare reimbursement for services represented by CPT codes. Our study aims to analyze the trends in Medicare reimbursement of common gastrointestinal (GI) services including endoscopy, colonoscopy, and office/inpatient visits from 2007 to 2022.
The top 10 common GI procedures were identified through a joint list published by the American College of Gastroenterology, American Society of Gastrointestinal Endoscopy, and American Gastroenterological Association (3). These included various procedures such as colonoscopy, endoscopy, and gastrostomy tube placement. In addition, we identified the top 5 CPT codes from outpatient office and inpatient consult visits provided to Medicare Part B beneficiaries by gastroenterologists (4). Table 1 shows the selected services and their respective CPT codes.
The Physician Fee Schedule Look-Up Tool from CMS was queried for the selected CPT codes from 2007 to 2022 to determine the facility reimbursement rate by Medicare for each service. The reimbursement data were collected as national payments under the global modifier and adjusted to January 2022 US dollars using the Consumer Price Index inflation calculator from the US Department of Labor's Bureau of Labor Statistics (5). The compound annual growth rate and mean annual change for adjusted reimbursement were calculated.
The mean annual change was represented as the slope of an ordinary least squares regression of adjusted reimbursement rates by year. Continuous data were compared using the Welch t test. The mean growth rate for services for both adjusted and unadjusted reimbursement rates was calculated from 2007 to 2022.
Unadjusted physician reimbursement for GI procedures exhibited an average decrease of 7.0% (95% confidence interval [CI], −9.9% to −4.1%) from 2007 to 2022. After adjusting for inflation, the mean decrease in physician reimbursement for procedures was 33.0% (95% CI, −35.1% to −30.9%). The adjusted change in physician reimbursement ranged from a decrease of 28.8% for esophagus endoscopy to 37.9% for colonoscopy and biopsy. The mean annual growth rate in reimbursement was −2.6% (95% CI, −2.8% to −2.4%), which correlated with an average annual decrease in reimbursement of $6.88 (95% CI, −$8.38 to −$5.39).
From 2007 to 2014, the mean decrease in physician reimbursement was 6.7% (95% CI, −10.5% to 2.9%), and the annual growth rate in reimbursement was −1.0% (95% CI, −1.6% to 0.4%). In comparison, from 2015 to 2022, the mean decrease in physician reimbursement was 28.2% (95% CI, −31.6% to −24.8%), and the mean annual growth rate in reimbursement was −4.7% (95% CI, −5.3% to −4.0%). This indicates that the decline in reimbursement of GI procedures was significantly larger after 2015 (P < 0.001).
In contrast to the reimbursement trends for GI procedures, the unadjusted physician reimbursement for inpatient and outpatient visits showed an average increase of 32.1% (95% CI, 4.8%–59.3%). After adjusting for inflation, physician reimbursement for patient visits exhibited a mean decrease of 4.9%. Overall, reimbursement for outpatient visits increased by 4.3% while reimbursement for inpatient visits decreased by 18.8%.
To the best of our knowledge, this is the first study to examine Medicare reimbursement trends for GI procedures over time. The analysis revealed a steady decline in adjusted and nonadjusted reimbursement between 2007 and 2022. These findings are consistent with past studies that examined trends in other specialties, which all demonstrated a decrease in adjusted reimbursement (6–10).
Prior studies noted relative stabilization of Medicare reimbursement after 2015, likely because of the Medicare Access and CHIP Reauthorization Act, which aimed to prevent scheduled reimbursement cuts and to increase physician reimbursement by 0.5% every year until 2019 (7,8,10). Despite this legislation, the largest declines in reimbursement for GI services examined in this study were seen after 2015.
These findings are important because Medicare plays a crucial role in the establishment and implementation of billing practices. Less than 1% of gastroenterologists have opted out of Medicare, and the overwhelming majority see Medicare patients in their practices (11). Given the US aging population, Medicare participants will continue to make up a substantial portion of patients with GI. When Medicare reimbursements decrease, health outcomes, healthcare access, and patient satisfaction may be affected, particularly in light of high inflation and increased costs due to staffing shortages, increased staffing salaries, and additional equipment necessary for COVID-19 safety (Figures 1 and 2).
This study has several limitations. First, the trends in Medicare reimbursement may not be representative nor generalizable to other insurance markets. However, Medicare determinations significantly influence the reimbursement market as a whole, and private insurance compensation correlates strongly with CMS reimbursement rates (12). Second, this study examined the most common GI procedures although these may not be representative of all services provided by gastroenterologists. Third, this study is based on Medicare Fee-for-Service rates. While traditional Medicare is currently the dominant source of Medicare coverage, Medicare Advantage will likely be the dominant source by 2025 (13). Finally, our analysis used national payment amounts under the global modifier and did not account for geographic variations in reimbursement. However, the findings are nonetheless useful for understanding broad trends.
CONFLICTS OF INTEREST
Guarantor of the article: Samir A. Shah, MD, FACG.
Specific author contributions: All authors contributed substantially to the manuscript and approved the final manuscript. The study was conceived by M.K. and N.D., with input and supervision from S.A.S. Data collection was performed by M.K., N.D., and A.Z., and data analysis was done by M.K. and S.K. K.K. provided critical review, historical background information, and data interpretation. The bulk of the manuscript was written by M.K., N.D., A.Z., and S.A.S., with critical input from all the authors. Each author read and approved the final submitted manuscript.
Financial support: None to report.
Potential competing interests: None to report.
We thank Brad Conway, JD, for providing historical background information and manuscript feedback.
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