Defending Colonoscopy

ACG Responds with AGA & ASGE to Barrage of Negative Media Summer 2013
Inaccurate Articles Critical of Medicare Billing for Colonoscopy

In June and July there was a barrage of negative media that painted a scathing portrait of gastroenterologists and billing for colonoscopy under Medicare on the front pages of The New York Times and Washington Post and in the editorial pages of USA TODAY. The College has joined forces with AGA and ASGE in responding to media with letters to the editor and in October purchased advertising space in Becker’s ASC to publish an “Open Letter” to the GI Community.

The New York Times
The media onslaught started when The New York Times on June 2, 2013 published a front page above-the-fold expose by Elisabeth Rosenthal that featured colonoscopy as a case study for regional and national differentials in health care costs and cited the American College of Gastroenterology and its role in promoting colorectal cancer screening in a scathing story: The $2.7 Trillion Medical Bill: Colonoscopies Explain Why U.S. Leads the World in Health Expenditures. (Note: the Rosenthal series has also taken on child birth costs and hip replacement surgeries).

A letter to the Editor of the New York Times from ACG President Dr. Ronald Vender was published June 3rd in which Dr. Vender made the point that: “The roots of the problem of high medical costs are many, varied and complicated. The fact that the article focuses attention the one and only preventive cancer test that has been demonstrated to significantly reduce the incidence of colon cancer and death from the disease is disappointing. The evidence suggests that colonoscopy is a public health success story…This is the test we recommend for our friends and family, as well as our patients.”

The College issued a press release in the wake of the Times article and sent a e-blast to all members jointly with AGA and ASGE, “ACG Responds to Scathing New York Times Article on Colonoscopy.”

The Times also did a follow up editorial on the colonoscopy article: The Weird World of Colonoscopy Costs that explored the cost differentials for colonoscopy raised in the Rosenthal article and questioned: “What accounts for the big differences in colonoscopy costs?” 

Washington Post 
Then on Sunday July 21, 2013, the Washington Post published a front page investigation of a panel convened by the American Medical Association, known as the RUC (Relative Value Unit Update Committee), and its valuation of physician time under Medicare’s payment system and the formula used to derive physician payments which assumes a physician work effort equivalent to 75 minutes. (“Medical Panel uses data that distort doctors’ pay”)

Media scrutiny regarding the 75 minute value is important because the formula for colonoscopy reimbursement by Medicare is currently up for review by the RUC. In this front page story by business writer Peter Whoriskey, colonoscopy was again featured in a rather unflattering light. The story is ultimately about the flaws of the RUC system, not about gastroenterologists or colonoscopy, but again GI was used as an example of this complicated and opaque process.  

Nevertheless the article seemed targeted and somehow gratuitously harsh in its portrayal of gastroenterology. If one viewed the portrait painted by the article in the harshest possible light, the implication of the Post coverage is that GI physicians who bill Medicare are committing fraud, although the Post took pains not to go that far.  

The Post conducted an independent analysis of procedures by 115 physicians at an outpatient clinic in Florida as the basis for its reporting, and, according to the article, “If the time estimates are to be believed, some doctors would have to be averaging more than 24 hours a day to perform all of the procedures that they are reporting. This volume of work does not mean these doctors are doing anything wrong. They are just getting paid at the rates set by the government, under the guidance of the AMA.”

As follow up to the July 21st article, the Washington Post editorial board on July 24, 2013 released an opinion the topic, “Do doctors have too much sway over Medicare payouts?” The Post’s editors observed that “Medicare pays for a 15-minute colonoscopy as if it took 75 minutes,” and “… it’s hard to defend a system that, according to the Post story, pays gastroenterologists as if 41 percent of them are performing more than 12 hours’ worth of procedures a day.” Both of these figures indict the country’s 15,600 gastroenterologists based on the Post’s unrepresentative sample of 115.

ACG joined the AGA and the ASGE in a letter to the Post editors, “GI Societies Respond to Washington Post,” which did not get published, but the Post published a letter from the AMA.

On July 30, 2013, USA TODAY decided to cherry pick some of the reporting from the Washington Post, completely out of context, and featured it in an editorial on the Medicare payment issue and the RUC “When doctors set their pay: Our view.”

In an editorial that reprised many of the criticisms of the RUC from the Post article, the USA TODAY editors chose to feature a reference to a gastroenterologist, “For one doctor, 26 hours of pay for a 10-hour day,” as a pull-quote to accompany the editorial.

To their credit, at least USA TODAY invited the AMA to offer a counterpoint, “AMA: Physicians’ advice helps Medicare.” The AMA’s President, Dr. Ardis Dee Hoven, offered an overview of the RUC and the role of the AMA.

USA TODAY Publishes Joint Letter to Editor
The three GI societies joined on a letter to the Editorial Board of USA TODAY which was published August 5, 2013 over the signatures of ACG President, Dr. Ronald Vender; Dr. Anil Rustgi, AGA Institute President; and Dr. Kenneth Wang, ASGE President.

The three societies wrote: “We take issue with USA TODAY’s editorial creating the misleading impression that something is amiss when gastroenterologists bill Medicare…GI physicians in the U.S. are paid by Medicare for this complex and potentially lifesaving procedure $220 on average for their time, expertise and clinical care. This is not excessive.”

JAMA: Internal Medicine
JAMA Internal Medicine published a paper, “Medicare Payment for Cognitive vs. Procedural Care: Minding the Gap,” August 12, 2013 online in advance of print noting that Medicare reimbursement rates per hour for procedures (specifically screening colonoscopy and cataract extraction) are higher than reimbursement rates for cognitive care by primary care providers (E&M). 

The three GI societies sent a letter to the editor (not yet published) that noted, “We would argue for a different interpretation of this paper: valuable cognitive services provided by primary care providers are often underpaid. We fully understand the challenges of delivering care for complex medical illnesses, because gastroenterologists provide such services for many patients with chronic gastrointestinal illnesses, such as inflammatory bowel disease and hepatitis.”

Becker’s ASC Ads by Three Societies
The three GI societies teamed up to sponsor two full page ads in Becker’s ASC October issue to express their commitment to work together to defend the gastroenterology profession, “We’re Working Together to Set the Record Straight on Colonoscopy.” The ad takes the form of an “Open Letter to the GI Community.”