Medicare expanded coverage of colorectal cancer (CRC) testing through the 2023 physician payment rule while also finalizing certain mandated budget cuts.
The 2023 Medicare Physician Fee Schedule (MPFS) lowers the minimum age for CRC screening to 45 from 50 years, in keeping with the recommendation from the U.S. Preventive Services Task Force. The physician payment rule, which was unveiled on November 1, also ends the copay for colonoscopies that follow a positive stool-based colon cancer test. However, it is important to note that colonoscopies that involve polyp removal are still subject to Medicare coinsurance requirements, although the financial responsibility eventually diminishes to zero by 2030: From 2023 to 2026, patient responsibility is 15% of the cost; from 2027 to 2029 it falls to 10%; and by 2030 it will be covered 100% by Medicare.
These changes come after a year of intense advocacy led by AGA, including multiple meetings with senior officials at the Centers for Medicare and Medicaid Services and legislative pressure by members across the country. In the 2023 MPFS proposed rule, CMS attributed its decision to expand Medicare benefits to colonoscopy following a positive stool test to involvement from AGA, saying, “We consulted with and reviewed recommendations from a number of professional societies in developing this proposal, including supportive letters and communications with representatives from American Gastroenterological Association, American Cancer Society, and Fight Colorectal Cancer.”
“This is a win for all patients and should elevate our nation’s screening rates while lowering the overall cancer burden, saving lives. Importantly, the changes will lessen colorectal cancer disparities, eliminating a financial burden for many patients,” says AGA President John Carethers, MD, AGAF, who met with CMS earlier this year to advocate for the coverage of colonoscopy following a positive noninvasive colorectal cancer screening test.
David Lieberman, MD, AGAF, who met with CMS officials multiple times, offered, “Cost-sharing is a well-recognized barrier to screening and has resulted in disparities. Patients can now engage in a CRC screening program and be confident that they will not face unexpected cost-sharing for colonoscopy after a positive noninvasive screening test.”
‘Déjà vu all over again’
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 3,000 pages. AGA’s summary of the 2023 MPFS final rule highlights changes that impact gastroenterologists.
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 in 2023.
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 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 this news organization. Congress needs to shift away from the “Band-Aid approach” and concentrate on longer-term issues with physician payment, she said.
Rep. Bera and Rep. 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 American College of Gastroenterology’s legislative and public policy council, told this news organization 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 Dr. Wilson, the managing partner of a physician-owned single-specialty private practice in Wichita Falls, Tex. 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 has said the U.S. 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 Dr. Wilson. “That’s recognized on both sides of the aisle as being essentially expensive and inefficient and not in patients’ best interest.”
