Nearly 1 in 8 patients receive unexpected out-of-network bills after colonoscopy

October 12, 2020

Below please find summaries of new articles that will be published in the next issue of Annals of Internal Medicine. The summaries are not intended to substitute for the full articles as a source of information. This information is under strict embargo and by taking it into possession, media representatives are committing to the terms of the embargo not only on their own behalf, but also on behalf of the organization they represent.


1. Nearly 1 in 8 patients receive unexpected out-of-network bills after colonoscopy

Abstract: https://www.acpjournals.org/doi/10.7326/M20-2928
URL goes live when the embargo lifts

Nearly 1 in 8 commercially insured patients nationwide who underwent an elective colonoscopy between 2012 and 2017 performed by an in-network provider received potential "surprise" bills for out-of-network expenses, often totaling hundreds of dollars or more. These findings are concerning, as federal regulations eliminate consumer cost-sharing when screening colonoscopies are performed in-network. A brief research report is published in Annals of Internal Medicine.

Colonoscopy is the most effective colorectal cancer prevention strategy. However, researchers suggest that surprise billing may deter patients from getting recommended screening.

Researchers from the University of Virginia and the University of Michigan reviewed 1.1 million claims from a large national insurer to estimate the prevalence, amount, and source of out-of-network claims for commercially insured patients having an elective colonoscopy when all of the endoscopists and facilities were in-network. The researchers found that 12.1 percent of cases received out-of-network claims, with an average surprise bill of $418. The bills often came because of the use of out-of-network anesthesiologists and out-of-network pathologists.

The researchers suggest that to spare patients surprise bills, endoscopists and hospitals should partner with anesthesia and pathology providers who are in-network, and they should consider cost-saving strategies such as endoscopist-provided sedation rather than use of deeper anesthesia. They also suggest that not all low-risk polyps need to be sent for pathological evaluation, which could offer further savings.

Media contacts: For an embargoed PDF, please contact Lauren Evans at laevans@acponline.org. To reach the corresponding author, James M. Scheiman, MD., please contact Joshua Barney at JDB9A@hscmail.mcc.virginia.edu.


2. Excess Days in Acute Care provide a more comprehensive picture of hospital performance compared to 30-day readmission rates
Using the EDAC measurement would change penalty status for about one-quarter of hospitals

Abstract: https://www.acpjournals.org/doi/10.7326/M19-3486
Editorial: https://www.acpjournals.org/doi/10.7326/M20-6254
URL goes live when the embargo lifts

The Excess Days in Acute Care (EDAC) measure provides a more comprehensive assessment of hospital performance compared to the 30-day readmission measure, which is currently used by the Centers for Medicare and Medicaid Services (CMS) to evaluate quality in the Hospital Readmissions Reduction Program (HRRP). Using the EDAC measure in the HRRP would change penalty status for about one-quarter of hospitals. These findings are published in Annals of Internal Medicine.

CMS currently uses 30-day readmission rates to evaluate hospital performance and to issue penalties to those that underperform. Hospitals have been penalized more than $3 billion to date under the HRRP. However, the 30-day readmission measure has increasingly been scrutinized because it provides an incomplete picture of hospital visits after discharge. In contrast, the EDAC measure captures all hospital encounters - inpatient, Emergency Department, and observation stays - that occur within 30-days of discharge and provides a more comprehensive picture of performance.

Researchers from Beth Israel Deaconess Medical Center studied more than 3,100 hospitals that participated in the HRRP in fiscal year 2019 to compare whether using the EDAC measure instead of readmissions would change hospitals' penalty status for three conditions targeted by the HRRP. They found that one-quarter of hospitals' penalty status would change if the EDAC measure were used instead of the readmission measure in the program. In addition, fewer small hospitals and rural hospitals would receive financial penalties if the EDAC measure were used. According to the study authors, these findings suggest that CMS should consider using the EDAC measure rather than the 30-day readmission measure to evaluate health care system performance under federal quality reporting and value-based programs.

Media contacts: For an embargoed PDF, please contact Lauren Evans at laevans@acponline.org. To speak with the corresponding author, Rishi K. Wadhera, MD, MPP, please contact Lindsey Diaz-MacInnis at ldiaz2@bidmc.harvard.edu.
-end-
Also in this issue:

New U.S. Law Mandates Access to Clinical Notes: Implications for
Patients and Clinicians
Charlotte Blease, PhD; Jan Walker, RN, MBA; Catherine M. DesRoches, DrPh; Tom Delbanco, MD

Ideas and Opinions
Abstract: https://www.acpjournals.org/doi/10.7326/M20-5370
Editorial: https://www.acpjournals.org/doi/10.7326/M20-6632

American College of Physicians

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