A Productive Day in Washington, DC
Recently, I had an interesting and successful trip to Washington, DC, where I had an opportunity to update CMS and lawmakers on how gastroenterologists have made an enormous impact on colon cancer in America and how Washington policies can support these efforts. Throughout the morning of meetings, I was reminded that our lawmakers and regulators are willing to listen to constituents and how each of us can become involved and make our voices heard on a national level.
Meeting with CMS Administrator
I had the pleasure of joining the presidents of ACG and ASGE to meet with Marilyn Tavenner, administrator of CMS (pictured at left). Presidents Colleen Schmitt, MD, ASGE, Harry Sarles, MD, ACG, and I (with staff help and support) presented our specialty’s collective concern about the pending decisions about reimbursement and relative value units (RVUs) for colonoscopy.
Our meeting began with introductions during which the three presidents informed Administrator Tavenner that among us, we had close to 90 years of direct patient care experience in a community practice setting in practices ranging in size from small (Dr. Schmitt) to large GI practices (Minnesota Gastroenterology, where I practiced for over 20 years). We reminded her of the 30-year decline in colon cancer incidence and mortality resulting in large part from increased CRC screening. We thanked CMS for two key historical decisions: 1) deciding to credential free standing ambulatory surgery centers in the early 1980s, and 2) covering colonoscopy as a screening modality in 2000. We pledged to work with CMS to continue reducing barriers to CRC screening and exploring ways to increase the value of our services.
Our main purpose was to directly address continuing barriers to life-saving colon cancer prevention strategies, including the process of assigning RVUs to colonoscopy, which will be effective for 2015.
For background, as you may know, all of our endoscopy codes were analyzed recently at the request of CMS and through the Relative Value Update Committee (RUC) process. Upper endoscopy codes were surveyed in 2013 and RVU’s were decreased by the RUC. The RUC is an advisory committee to CMS and HHS (read more about the RUC process). After the RUC has determined their own recommended RVU assignment for CPT codes, CMS then has the option of accepting the recommendation of the RUC or altering codes further (either up or down). Usually, CMS publishes their recommendations in July in the Medicare Physician Fee Schedule proposed rule, but this failed to happen in 2013. Because of the government shutdown, the final rule was issued in late November and included deep cuts to the three upper endoscopy code families that would be implemented on Jan. 1, 2014. This left no time for GI practices to understand the dramatic impact of RVU cuts, which for some procedures amounted to a 36 percent reduction in reimbursement (EUS with FNA, for example). These cuts were implemented in January of this year for Medicare, and commercial payors usually follow suit in the ensuing year.
During our meeting with Administrator Tavenner, we asked that CMS be open and transparent in their further deliberations regarding the colonoscopy codes and listen not only to us, but to the letter signed by 47 members of Congress, spearheaded by Rep. Bill Cassidy, R-LA (who is a hepatologist and continues to practice while in Congress). We urged CMS to give physicians ample opportunity to participate in the regulatory process.
We then pointed out our continuing efforts to further reduce barriers to CRC preventive testing by asking CMS to recognize the “continuity of CRC screening.” When patients decide on a screening test for CRC (whether colonoscopy or other modality, such as stool testing), the entire episode of screening should be included as a preventive test (and covered fully). So when a stool test is positive or a polyp is found during a screening colonoscopy, preventive benefits (no co-pay or deductible) should remain available. We believe that CMS has the authority to lead in lowering this barrier to cancer prevention.
I found Administrator Tavenner to be open, forthcoming and welcoming. She, herself, began her career as a staff nurse in Richmond, VA, and she understands medical care. She stated that CMS welcomes data, opinion and feedback, and that everything sent to them is reviewed and included in their discussions. With her was Sean Cavanaugh, deputy director at CMS, who previously served as the deputy director of programs and policies for the Center for Medicare and Medicaid Innovation (CMMI) and was very aware of the important work AGA had done in developing alternative payment models, including the colonoscopy bundle.
Meeting with Rep. Bill Cassidy, R-LA
Prior to our meeting with Administrator Tavenner, I also met with Rep. Cassidy, who has been such a strong advocate and champion for the profession of gastroenterology in the U.S. Congress (pictured on the right). He is truly one of the few members of Congress who not only understands health policy, but also the clinical implications of such policies.
Dr. Cassidy has been working on legislation for shared savings models that small practices will be able to utilize since many of the shared savings models that have been developed are designed for larger practices or health systems. Rep. Cassidy spoke of his disappointment in working with the Congressional Budget Office, which did not score his proposal favorably. He was interested in hearing about my experience at Minnesota Gastroenterology and how we developed a price package for colonoscopy that made us competitive with other settings in the area and how the market made the procedures competitive and lowered the cost. He was very interested in learning more about this approach and how it could be translated to the Medicare program. We plan to collaborate on some shared-savings and shared-risk models.
All in all, it was a successful trip to Washington, DC, and it reiterated my belief in the importance of advocacy, especially in this critical time in the profession of gastroenterology. As president, I will continue to advocate on behalf of gastroenterology and think this will be the first of many trips to Washington.
Your involvement at the grassroots level is imperative to ensure success as we engage with lawmakers and regulators to protect the viability of GI practices and to protect Medicare beneficiary access to GI endoscopy services. To learn more about how you can get involved, please contact Navneet Buttar, AGA government and political affairs manager, at 240-482-3221 or Nbuttar@gastro.org.