The passage of the Patient Protection and Affordable Care Act (PPACA) in 2010 marked a major victory in the fight against cancer. The law waives the coinsurance and deductible for many cancer screening tests,¹ including colonoscopy, sigmoidoscopy, fecal immunochemical testing (FIT) and fecal occult blood testing (FOBT). However, due to the unique nature of colonoscopy as a diagnostic and therapeutic service, many patients wind up paying out of pocket. Since last year, the AGA, together with the American Cancer Society (ACS) and the ASGE, has worked to educate Congress and urge them to correct this “cost sharing” problem.

Under Medicare’s billing rules, performing a biopsy or removing a polyp reclassifies the screening colonoscopy as a therapeutic procedure for which patients must pay coinsurance. This means a patient can come for a colonoscopy assuming it’s free, only to receive a bill for the coinsurance from the facility and the doctor after the endoscopist finds and removes a suspicious polyp. 

In the 2011 Medicare physician fee schedule final rule, CMS stated that legislative action is necessary to waive the beneficiary coinsurance for colorectal cancer screenings that become therapeutic during the same clinical encounter. The Congressional Budget Office estimates this will cost $200 million over 10 years. The AGA worked tirelessly to include language in the PPACA to ensure that the waiver of deductible was waived for a screening colonoscopy regardless of the outcome; unfortunately, the law did not include similar language to address the coinsurance. 

The AGA, ACS and ASGE have spent countless hours on Capitol Hill educating members on this cost-sharing issue, and worked with Rep. Charlie Dent, R-PA, on crafting legislation to correct this problem for patients. Rep. Dent and Rep. Joe Courtney, D-CT, have introduced H.R. 4120, Removing Barriers to Colorectal Cancer Screening Act, which would waive the coinsurance for a screening colonoscopy regardless if a polyp or lesion is found and removed during the same clinical encounter. To date, 30 members of Congress have signed onto HR 4120. 

On May 11, Brian Jacobson, MD, MPH, Glenn Littenberg, MD, and I, along with representatives from AGA, ASGE, ACG, ACS, the National Colorectal Cancer Roundtable and Fight Colorectal Cancer, had the opportunity to meet with Jonathan Blum, the deputy administrator and director of CMS, on this issue. We explained the impact on Medicare beneficiaries, as well as how the impact on patients in the private insurance market. We described how commercial carriers are interpreting this policy very differently, causing concerns for patients and physicians. We emphasized that this cost-sharing policy has a detrimental impact on patients who are screened with FOBT or FIT and then require a colonoscopy because of a positive finding, as their colonoscopy is no longer considered by Medicare to be a screening service. We believe that when colonoscopy is performed in response to a positive FIT or FOBT, it should still be part of the screening continuum, and expressed our concern that, at present, the patient would have significant cost-sharing. 

We look forward to working with the administration on this issue and hope they can issue guidance to private insurers as there has been confusion from both patients and providers. We also hope to continue to work with the administration to help educate Medicare providers and patients on the CRC benefit so they are clear on what is covered and what a patient’s cost-sharing may be.   

Our goal is to continue to ensure that patients are screened for colorectal cancer since we know that screening saves lives. I look forward to continuing to advance this issue with the AGA and our colleagues to ensure that financial barriers are removed for patients seeking lifesaving screenings.    

The House also approved an amendment sponsored by Reps. Charlie Dent, R-PA, and Pete Sessions, R-TX, that would ensure medical services furnished by a hospital, emergency department, physician or on-call provider under contract with a hospital or emergency department pursuant to the Emergency Medical Treatment and Labor Act receive the same liability coverage currently extended to employees of community health centers and health professionals who provide Medicaid services at free clinics. The AGA supported this amendment along with several other medical specialty groups.

The fate of H.R. 5 now rests with the Senate, where they are not likely to bring the bill up for a vote. President Obama has also indicated that he would veto the measure.

The AGA is pleased that this legislation passed and will continue to work with our allies in the Alliance of Specialty Medicine to put pressure on the Senate to bring H.R. 5 up for a vote.

Look for more updates on the AGA Washington Insider.

The AGA is supportive of both of these provisions, and has long opposed IPAB and called for reforming our medical liability system.

Republican leadership decided to link the IPAB repeal with H.R. 5 given that medical liability reform saves the health-care system approximately $52 billion over ten years. However, many Democrats who support repealing IPAB have indicated that they will not support H.R. 5 since they do not support medical liability reform. Additionally, some Republican members who are supportive of states’ rights believe that medical liability reform should be handled by the states, and therefore may also be inclined to oppose H.R. 5.   

IPAB would be a panel of fifteen unelected and unaccountable individuals whose sole purpose would be to make recommendations on reducing Medicare spending. The panel’s recommendations would then need to be voted on by Congress in a fast-track manner, or Congress would need to come up with a similar amount of cuts before the recommendations would go into effect.

Given that hospitals and other Part A providers are exempt from the IPAB and that beneficiaries cannot have their care rationed or their premiums increased, physicians will undoubtedly be the recipients of these cuts. Physicians are already subject to a spending target with the broken sustainable growth rate formula and the IPAB will only further exacerbate these unsustainable cuts to physicians.

Look for more updates on this issue in the AGA Washington Insider.

AGA has drafted an op-ed that you can have sent directly to your local newspapers through our CapWiz system. In addition to educating your community about the importance of colorectal cancer screening, the op-ed will educate patients and local lawmakers about the barriers to screening under Medicare in using colonoscopy.  

AGA has been working to obtain support for a new bill introduced by Rep. Charlie Dent, R-PA — the Removing Barriers to Colorectal Cancer Screening Act of 2012 (H.R. 4120). This legislation ensures that screening colonoscopy is free to all Medicare beneficiaries, regardless of whether a polyp or other tissue is removed. Contact your representatives online and ask him or her to cosponsor H.R. 4120. Encourage your patients to contact their representatives as well using the AGA system. 

We know that colorectal cancer screening saves lives by preventing and detecting cancer early and we should be encouraging patients to be screened. This policy needs to be corrected since it not only causes confusion, but may also deter patients from getting lifesaving screenings.

The AGA, along with the Alliance of Specialty Medicine and the IPAB Repeal Coalition, has opposed IPAB since it was first introduced as part of the health-care reform debate. Physicians have long opposed IPAB since many Part A providers (hospitals and nursing homes) are exempt from IPAB until 2021 and IPAB cannot make any decisions that would increase Medicare beneficiaries’ premiums or limit care. Thus, IPAB would have more pressure to squeeze costs from physicians who are already living with a broken SGR formula. Repealing IPAB has also received the support of some Democrats, mostly in the House, who oppose relinquishing congressional authority to an independent, unelected board that would make budgetary decisions over Medicare. 

Depending on the margin of the vote in the House, the Senate could feel pressure to have an up or down vote on the IPAB repeal legislation.  As such, we continue to call on Congress, especially Democratic members, to support H.R. 452. 

Look for more updates on this important issue in AGA eDigest and the AGA Washington Insider.

As a result, the Supreme Court of the U.S. (SCOTUS) will hear arguments spanning three days in a case that will determine, in part, the fate of the PPACA. On March 26, the Court will hear arguments concerning their ability to rule prior to 2014 (when key provisions will be implemented and thus potentially create “damages”). On March 27, the constitutionality of the individual mandate will be reviewed, and on March 28, the court will review which parts of the PPACA are linked to the mandate and whether Medicaid expansion is constitutional. A decision is expected by June 30.

What does this mean for you? Lots. First, let’s deal with Medicaid expansion. We all worry that average patient reimbursement will be reduced to rates approximating Medicaid if employers decide to have their employees join a state health exchange or if a large number of previously uninsured patients become covered at Medicaid rates. Some states are counting on SCOTUS to strike Medicaid expansion as unconstitutional. They should read “All Heat, No Light — The States’ Medicaid Claims before the Supreme Court” by Sara Rosenbaum, JD, and Timothy Stoltzfus Jost, JD (N Engl J Med 2012; 366:487-489. Feb 9, 2012). It is unlikely that this portion of the PPACA will be overturned. An analysis by Thomson Reuter’s health-care division offers some comfort since 12 states plus DC will not see expansion of Medicaid because of the uninsured. Other states, however, will see a large number of uninsured become Medicaid-eligible through exchanges. You will need this information to anticipate changes in your payor mix.

Now, to SCOTUS and the impact on exchanges. David K. Jones writes a succinct article that you should read — The Fate of Health Care Reform – What to Expect in 2012 (N Engl J Med 2012; 366:e7. Jan. 26, 2012) — about four key events that could affect health-care reform this year.  Also, for those of you who attended the recent AGA Clinical Congress in Miami, you’ll remember that I discussed these issues during the keynote speech. Twenty-six states joined the current lawsuit and are betting that the individual mandate will be struck down. If that doesn’t occur, they hope that President Obama will be defeated and PPACA will be repealed or its implementation slowed. The deadline for states to apply for federal grants to support the creation of health exchanges is June 29. Therefore, if SCOTUS supports the constitutionality of the individual mandate, many states, whose legislatures meet January to June, will have insufficient time to pass legislation creating exchanges. Those states will likely have to accept a federal exchange, thus losing flexibility in designing their own. This is a dangerous gamble. Gastroenterologists need to understand their own states’ dynamics. Now is the time to become involved in a grassroots political effort.

As these events play out in rapid succession, I am committed, as is the AGA, to keeping you informed about implications for your practice. Your margin for error is diminishing, but the opportunity to provide critical health care for patients has not.

Do not make rash decisions. At the end of the day, if you have prepared for the future by implementing an electronic medical record, joining the outcomes registry, maintaining good relationships with your regional health-care systems, preparing to produce valid outcome (not process) measures about your colonoscopies and inflammatory bowel disease care, and conducted an internal lean analysis, you will be fine. AGA will help as it rolls out the Roadmap to the Future of GI (continue to read Clinical Gastroenterology and Hepatology for more information on the roadmap in July 2012).

We still have much to offer patients. They are counting on us to get this right.

Although AGA is pleased that physicians will not experience unsustainable cuts of 27.4 percent, we continue to advocate that Congress enact a permanent solution to the broken Medicare physician reimbursement formula and provide stability to physicians and their patients. Congress will once again need to address looming cuts, scheduled to go into effect on Jan. 1, 2013, which will continue to be challenging given the growing cost of the fix and the highly partisan election year climate. 

AGA continues to work with our partners in the Alliance of Specialty Medicine and the entire medical community in calling on Congress to repeal the SGR and enact meaningful payment reform for physicians and patients.

Through a lot of effort and a bit of luck, I was scheduled to meet with five Congressional Representatives and two Senators, and had several notable meetings. Each congressman was sympathetic to our desire to ensure that our patients have unrestricted access to screening colonoscopy, high quality generic injectable medications, the best biomedical research and a functioning Medicare program. However, others will come in at a later time and argue the other side. So, we need to have persuasive, defendable and fair requests, make these requests repeatedly and find our best advocates — and support them. 

The principal lessons I learned were that members of Congress are willing to spend time listening to us, but it is also clear that they hear many voices and have to find the consensus that satisfies the greatest number of their constituents, all while meeting the dictates of their own consciences. Most issues, however, are not issues of great moral gravity; they are simply “political” issues, in which two sides each want something. The best way for us, as GIs and AGA members, to get what we want, and to protect the strength of our profession, is to keep talking to them, and let them hear — over and over — our concerns and the rationale for our requests. 

Rep. Bill Cassidy, R-LA, a gastroenterologist, is perhaps the best advocate in the Congress for our field. He is well informed on the issues of interest to us, and has some good ideas about how we will move through the difficult years ahead of us. He provides a key link as we attempt to influence health reform legislation. He had commented in a previous meeting (in New Orleans) that most members of Congress are not entirely sure of the differences between Medicare and Medicaid; obviously, we need all the help we can get for a fair resolution to our current problems. 

Rep. Allyson Schwartz, D-PA, was both passionate and articulate regarding health issues, and is considered one of the leading figures in health care on the Hill. She understands the political challenges, and is prepared to help us ensure that our patients will have access to high quality health care in the future. Rep. Tom Price, R-GA, is an orthopedic surgeon who is ready to go to bat for our profession. He sits on the Ways and Means Committee and represents an important link between our interests and the halls of power. I had useful visits with Rep. Denny Rehberg, R-MT, and Kevin Brady, R-TX, and a whirlwind visit with Sen. Sherrod Brown, D-OH, in one of the Senate side chambers between votes on a contentious ethics bill (see picture above). The action in the Senate was sufficiently intense (with a number of repetitive procedural votes) and we were unable to meet with Sen. John Cornyn, R-TX, but I am going to try to catch up with him back in Dallas. 

Each congressman provided a generous amount of time (probably 20 min or more per visit) to discuss the issues of interest to the AGA. We raised our concerns about cost-sharing for colonoscopy (i.e., fixing the unfair co-payments patients are assessed when their screening colonoscopy reveals a polyp or cancer), shortages of injectable medications (a problem that has gotten worse over the past year), and adequate funding for the NIH. Of course, in each instance, the vexing sustainable growth rate problem came up, and all of them understood how essential it is to reach a permanent solution to ensure long-term access to Medicare. 

I encourage each of you to become more active in AGA’s outreach efforts to help ensure our voices are being heard so we can help protect our patients’ access to health care and our profession. Use AGA’s CapWiz system contact your legislators to educate them on the screening deductable issue and encourage them to support legislative efforts to waive the coinsurance for a screening colonoscopy that becomes therapeutic. 

If you are interested in becoming involved in AGA’s grassroots advocacy activities, please contact Lauren DePutter. From the AGA National Office, I’d like to thank Mike Roberts and Kathleen Teixeira who accompanied me on these visits, as well as two health legislation specialists who work as consultants for the AGA, Tim Yehl and Vicki Hart.

A recent New England Journal of Medicine article, “The Sources of the SGR ‘Hole’,” addresses many of the flaws of the SGR formula, such as how the behavior of a physician in Texas impacts the behavior of a physician in Minnesota. Under the SGR, all physicians are rewarded and punished the same way, which is why many policy makers have been advocating for a value-based system under which physicians are given more incentives to provide higher quality and efficient care. The authors state that a new physician payment model should emphasize bundled payments and episodes of care to “give provider organizations and physicians the incentives to capture gains from eliminating lower-value therapies and delivering higher-value health care.”

Despite many of the new payment model ideas that have been discussed over the past few years, there is still the issue of the SGR “debt” and how we dig out of this hole. The AMA and many Democrats have been arguing that Congress repeal the SGR and write off the debt with the unused overseas contingency operations funds — funds that would have been used in the wars in Iraq and Afghanistan. However, many House Republicans are not comfortable with using this approach since they believe it is an accounting gimmick. Physician groups have argued that the SGR debt is also an accounting gimmick since Congress would never allow a 27.5 percent cut to be implemented. The idea is still being floated, but at this juncture, it is a long shot at best that Congress would use some of these funds to offset the SGR debt.

As the conferees to the Middle Class Tax Cut Act (which included a two month “doc-fix” that expires Feb. 29) discuss the length of the next fix, the AGA and the Alliance of Specialty Medicine continue to call on Congress to provide physicians with a long term fix to the SGR.

Look for more updates on this critical issue on the AGA Washington Insider.

Although the AGA is pleased that the 27 percent cut did not go into effect and Congress enacted a temporary patch, we continue to call on Congress to reach an agreement on a long term solution to the broken reimbursement system and provide some stability to physicians and beneficiaries. AGA continues to meet with legislators to stress the importance of enacting a permanent solution.

The House had originally passed a package that would have given physicians a two year, 1 percent update and extended the payroll tax and unemployment insurance. However, the Senate rejected this proposal due to certain “pay-fors,” such as cuts to the Patient Protection and Affordable Care Act, and beginning movement on the Keystone XL pipeline, opposed by the president and the Democratic Senate. The Senate passed their own two month extension by a vote of 89-10, but House Republicans were demanding that the Senate return to negotiate the package. However, with time running out and increasing pressure to agree with the Senate, House Republicans relented and passed the legislation. This two month reprieve delays another showdown over taxes and the Medicare physician reimbursement fix until February.

Continue to read the AGA Washington Insider and AGA eDigest for more updates on this critical issue.