Patients want physicians to provide high-quality care and the health system requires good value for physician work. To help gastroenterologists achieve these goals, the American Gastroenterological Association (AGA) has developed a colonoscopy bundled payment model, which has been published in Gastroenterology 1, the official journal of the AGA.
By developing a framework and educating gastroenterologists about value-based reimbursement, the AGA hopes to inform physicians who wish to consider contracting with payors, purchasers and risk-bearing organizations around new payment models.
“Developing and negotiating bundled payments is one option in the transition to value-based care,” according to John I. Allen, MD, MBA, AGAF, AGA Institute president elect, and an author of the colonoscopy bundle. “Practices that perform procedures in high-quality, cost-efficient settings will be rewarded and can use a bundled payment mechanism for negotiation and alignment with health-care systems.”
The framework for the AGA bundled payment model is specifically for colonoscopy for colorectal cancer (CRC) screening, diagnosis and surveillance. The colonoscopy bundle model includes services and supplies provided in the pre-procedure period, the day of the colonoscopy, and the post-procedure period. The bundle provides a framework for physicians and facilities to consider scenarios when negotiating payment, such as poor preparation, incomplete procedures, and post-polypectomy bleeding. In creating the framework, the AGA had expert input from physicians, ASCs, and hospitals, as well as payors, McKesson, Brookings Institute, and the Health Care Incentives Improvement Institute. Humana, a national payor with commercial, Medicare, TRICARE and Medicaid lines of business, provided the AGA with a de-identified patient claims data set covering commercial and Medicare patients and provided technical and clinical assistance in analyzing the data regarding the post-procedure period.
There are significant regional variations in colonoscopy site of service, preparation agent, sedation method, and surveillance follow-up intervals. Inconsistent interpretation of what constitutes a preventive service under the Affordable Care Act means that asymptomatic patients who receive CRC screening at a primary care level and found to have an abnormality requiring referral for colonoscopy may have financial responsibility for the diagnostic colonoscopy. Some payors waive patient responsibility for anesthesia and pathology obtained during colonoscopy as a preventive service, while others do not. Variation presents an opportunity to improve the quality and value of care, and a bundled payment model is one method to achieve that. Through negotiating a bundled payment for colonoscopy services, physicians could demonstrate their commitment to patient-friendly CRC services in advance of potential future changes in reimbursement.
1 Brill JV et al. A Bundled Payment Framework for Colonoscopy Performed for Colorectal Cancer Screening or Surveillance. Gastroenterology 2014; 146(3): 849-853.