Colon cancer

Douglas Rex, MD, of Indiana University, Indianapolis, provided an array of highly clinically relevant tips to improve screening colonoscopy quality, which has been shown to reduce CRC mortality. Some of the basic concepts include using split-dose preparations and high-definition endoscopes, measuring and reporting adenoma detection rates, and using water immersion with carbon dioxide instead of air insufflation. Special attention was given to the diagnosis and removal of sessile lesions of the colon. Dr. Rex revealed many of his “tricks” to achieving high-quality colonoscopy, which include retroflexion to access polyps behind folds, using a stiff snare, and attaching a cap to the end of the colonoscope in order to facilitate visualization of polyps and assist in the mucosal resection of sessile lesions. Dr. Rex also presented data to support his recommendation to use “avulsion” with cold snare and forceps while limiting coagulative ablation for residual polyp tissue.

Finally, Rajeev Jain, MD, of Dallas presented the rapidly evolving area of reimbursement reform including the Medicare Access and CHIP Reauthorization Act (MACRA) that is driving payment away from fee-for-service and towards bundled payments, accountable care networks, and patient-centered medical homes. Key to this reform is the documentation and reporting of quality for procedural and cognitive patient encounters. There are limited performance measures specific to gastroenterology and hepatology, which currently include measures to both document appropriate CRC screening and reduce colonoscopy overuse, inflammatory bowel disease management, and hepatitis C management. However, there are many cost-cutting measures that can also be reported by gastroenterologists to fulfill these requirements. The Physician Quality Reporting System requires at least nine measures for at least 50% of Medicare patients in order to avoid penalties. It is not enough to track and document quality measures – results must also be reported through CMS-approved entities called qualified clinical data registries.

Dr. Jain described the movement toward payment bundles in which a single reimbursement is provided for services rendered by all providers and sites across a single episode of care. Screening colonoscopy was used as an example of how this could impact gastroenterology: a single payment would be provided for the preprocedure evaluation and education, the procedure itself (including endoscopy, anesthesia, pathology, facility), and postprocedure follow-up. Additional payments would not be provided for additional services such as repeating the colonoscopy because of a poor preparation or to treat postpolypectomy bleeding. Overall, health care reimbursement is moving to recognize value (quality/cost), reduce variation in care, and transfer more of the financial risk to health care providers and systems.

Dr. Inadomi, division of gastroenterology, department of medicine, University of Washington School of Medicine, department of health services, University of Washington School of Public Health, Seattle. He is on the clinical advisory committee for ChemImage and on the scientific advisory board for Epigenomics.