The Role Payors Play in Where Patients Seek Care

There are many factors to consider when deciding where to seek care for patients needing a routine or advanced endoscopic procedure. Perhaps it’s urgency for diagnostic or therapeutic care, the ability to travel, a desired physician to see, the convenience of available appointment times, or simply going to the first place found on Google.

But one influence is increasingly difficult to ignore: the bill.

Depending on type of coverage and whether benefits are from private or public sources, patients may unknowingly be directed to select certain locations for care. Increasingly, payors are favoring ambulatory service centers (ASCs) as a cost-effective alternative to hospitals.

“The ASC is usually more efficient, and the patient will benefit by having specialized care in a more efficient manner,” according to Dr. Adam Goodman, a gastroenterologist and professor at NYU Langone Hospital-Brooklyn. “The system benefits by less administrative costs, greater efficiency, and more procedures getting done in a similar amount of time.”

Ultimately, patients receive the same quality of care, but at a much-reduced cost, Goodman said.

It is estimated today that 90 percent of colonoscopies are performed in ASCs, hospital outpatient clinics, or in physician’s offices. Up to 32 percent of the ASC’s in the U.S. specialize in endoscopy alone, while 37 percent of the multi-specialty centers offer endoscopy services, including upper GI endoscopy, sigmoidoscopy, endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS).

Since ASCs typically offer specialized care, procedures can usually be performed more efficiently and quickly than at hospitals, resulting in lower costs. Patients seeking care at ASCs are likely also to have fewer complex conditions, requiring fewer resources for care. A recent study in California found colonoscopies cost an average $2,300 less when performed at an ASC rather than a hospital.

In fact, large payors have increasingly created policies that favor ASC care and may put continued pressure on physicians to perform non-urgent procedures in these settings. In some instances, insurance companies won’t pay for a routine colonoscopy in the hospital anymore. For example, United Healthcare now restricts sites available for non-emergent surgeries and Empire Blue Cross Blue Shield in New York began requiring proof of medical necessity for certain procedures to be performed outside of an ASC in 2021. The New York-based company argued procedures they were pushing to ASCs have been safely provided in such settings for many years. This is particularly true for GI endoscopy.

Studies have shown how care provided at ASCs is significantly cheaper than hospitals – with one report from Regent Surgical Health estimating healthcare cost savings up to $38 billion annually. Additionally, combined out-of-pocket expenses for patients could be reduced by roughly $5 million annually, according to the report. Even for advanced GI endoscopy procedures like ERCP or EUS, ASCs can offer a cost-effective alternative to a hospital.

ASCs are becoming increasingly popular throughout the country, and there are more than 5,000 operating nationwide today. If payors continue to drive future care to the centers, that number will only grow.

Adding EUS to your practice.  What are the benefits?

The first experimental endoscopies were performed on sword swallowers – those who had the skills to allow long tubes down their throats without causing harm to their bodies. Today, no such patient skills are required to undergo an endoscopy, thankfully. And with advancements in imaging technology, patients can wake up to view images directly from their digestive tract, lungs, urinary tract or uterus even immediately after their procedure.

Millions of patients undergo endoscopic procedures every year in the U.S. This minimally invasive option for treatment that sends long, thin tubes into hollow cavities of the body for diagnostic and therapeutic procedures. Several hundred years since those early sword swallowing days, those tubes can even facilitate ultrasound imaging.

Endoscopic ultrasound (EUS) has become increasingly attractive to patients and physicians. For gastroenterologists, these procedures allow physicians to diagnose severe digestive illnesses more efficiently. GI EUS is used to diagnose and evaluate a variety of conditions, including:

  • Mediastinal diseases
  • Pancreatic cysts and masses
  • Anorectal pathology
  • Subepithelial gastrointestinal lesions

Dr. Stephen Steinberg, co-founder and president of EndoSound, describes EUS as an incremental skill, meaning endoscopists don’t need to have mastered every advanced technique of the procedure in order to offer the benefits of EUS to their patients. There is still much to be gained from a “basic” EUS procedure, that could save patients time and money from having to travel to other medical centers for the kind of attention they need.

For example, EUS can provide endoscopists with more information than other imaging tests and evaluate lumps or lesions previously detected in other endoscopies. The ultrasound images can inform the origin of abnormalities and help inform treatment decisions. The procedure has proven successful in helping physicians diagnose diseases that couldn’t be confirmed with other testing options.

“While exciting diagnostic and therapeutic advances hold our attention, it may be important to highlight the one trend that could be the most important for patients – the increasing integration of EUS into general gastrointestinal (GI) training and practice,” wrote Anand V Sahai, in his 2018 Endoscopic Ultrasound journal article, “EUS is Trending!”

But, since EUS competency requires additional training, “it remains limited to a selected group of physicians willing to make this extra sacrifice, to allow them to include EUS in their GI practice,” according to Sahai’s article.

Challenges remain all over the world in establishing EUS in routine practice. These include the required physician competency and upfront equipment costs, specialized endoscopes, and accessories for EUS-guided fine-needle aspiration or EUS-guided fine-needle biopsy.

GI endoscopists need to complete close to 400 EUS procedures addressing multiple areas (mucosal tumors, pancreaticobiliary, etc.) over the course of 24 months to have full competency in EUS, according to guidance from the American Society for Gastrointestinal Endoscopy (ASGE). Training programs, even post-fellowship opportunities through the ASGE, are available and often at capacity. U.S. physicians may also find training opportunities abroad, where there are fewer restrictions for visiting endoscopists to perform procedures.

The benefits to seeking that additional training go beyond those for the patient and can outweigh time and revenue lost during training and acquiring necessary tools. If patients can undergo EUS at their local hospital or ambulatory surgery center (ASC), they can benefit from an advanced procedure that can assess damage to the digestive system, assist in diagnosing cancers, or potentially receive therapeutic procedures like cyst drainage, all without the added stress of travel to large medical centers were EUS is typically performed. For those that can receive EUS in an ASC, they avoid a potentially unnecessary hospital stay and may find more affordable care.

So, even for well-established GI endoscopists several years removed from fellowship training, pursuing mid-career training in EUS could open more possibilities for treatment and care in facilities and practice. There are initial steps, including time needed for training and upfront equipment costs, but the rewards for quality of care provided to patients just may be worth it in expanding a growing practice.

Exploring EUS Competency and Training Opportunities

It is estimated between 60 and 70 million people in the U.S. are affected by digestive diseases and gastrointestinal endoscopy has played an increasingly major role in management of those disorders.

While safer than, and often preferable to, invasive surgery, endoscopic procedures ranging from routine colonoscopy to more advanced procedures like endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) are not without risk. Physician competency is paramount to patient safety and can prevent misdiagnosis or poor treatment.

Competency in GI endoscopy is often measured by number of procedures completed in formal training programs, like post-residency fellowships. However, there is no formal specialized endoscopy board for the discipline, meaning training varies greatly across the nation and globe.

As the popularity of the discipline grows and endoscopic technology and techniques continue to evolve over time, it’s worth looking at what training opportunities are available, particularly for endoscopists who may choose later in their career to pursue more advanced endoscopic therapies in their practice.

Measuring Competency in EUS

EUS is an advanced endoscopic procedure used to assess and treat digestive and lung diseases (EBUS). Endoscopists use a specialized endoscope to take ultrasound images of the lining of walls of digestive system or lungs, or obtain images of organs like the pancreas and liver. These images can prove essential in the diagnosis of digestive or respiratory diseases. Additionally, endoscopists can perform therapies during more complex EUS procedures.

The American Society for Gastrointestinal Endoscopy (ASGE) recommends at least 24 months of GI or formal surgical training for GI endoscopists seeking competency in EUS. Further procedural requirements for competency, as outlined by the society, include:

  • Mucosal tumors: 75
  • Submucosal lesions only: 40
  • Mucosal and submucosal lesions: 100
  • Pancreaticobiliary: 75
  • EUS-guided FNA
    • Non-pancreatic: 25
    • Pancreatic: 25
  • Comprehensive competence: 50

The society also notes that competency in one type of advanced endoscopic procedure, such as EUS, does not guarantee competency in another like ERCP. Unique procedural requirements are set forth for each, as the skillsets required are quite different.

While EUS is typically performed at high-volume medical centers, especially given the procedural requirements for competency, there has been increased interest in smaller centers for physicians to take on the diagnostic and therapeutic practice.

Dr. Stephen Steinberg, co-founder and president of EndoSound, describes EUS as an “incremental skill.” There are less complex EUS procedures that can be performed competently with fewer training hours than the more advanced practices, he said. Still, beginning with these less complex procedures can be a pathway to improving skills and offer a way for  endoscopists to gather the imagery that will still be helpful in diagnoses and recommendations for care.

EUS Training Post-Medical School

There are currently 86 fellowship programs for advanced endoscopy, according to the American College of Gastroenterology (ACG). But, after fellowship, options become more limited.

“In the U.S., it’s really hard to get hands on experience,” Steinberg said, especially if the endoscopist is not part of a formal training program or fellowship. “Getting temporary privileges to work in another state for training isn’t typically available in the U.S.”

This leads many physicians to pursue advanced endoscopy training abroad.

In a 2014 op-ed penned by Dr. Todd Baron of the University of North Carolina, Dr. Baron explores the roadblocks he faced in pursuing EUS competency mid-career. Given how nationwide post-residency fellowship programs are geared to newly trained physicians, Dr. Baron said he did much of his training outside of the U.S. He said many physicians may find the same path challenging given the year needed to complete a fellowship and a medical center’s reluctance to losing a practicing physician for that length of time.

The COVID-19 pandemic has put even more pressure on developing new opportunities for EUS training that fall outside the realm of a traditional post-residency fellowship. During pandemic-era lockdowns, most non-emergency endoscopy procedures were delayed or postponed, greatly impacting the ability to train new endoscopists in the field. Thus, hands-on models and simulators, virtual conferences, and endoscopic video rounds were used more commonly.

Additionally, Steinberg said the availability of online videos or virtual training sessions and web streaming of live events can help those seeking new EUS skills learn techniques or see the latest available technologies.

Looking Forward

A recent article for the ACG Case Reports Journal outlined some avenues in which advanced endoscopy training could change to provide greater access to more physicians, including:

  • Incorporating EUS and ERCP training into the final year of residency
  • Standardizing advanced endoscopy training across fellowship programs
  • More exploration of non-traditional methods of training

GI endoscopy offers a safe and viable way for patients to receive preventative and therapeutic care without invasive surgery. More advanced procedures like EUS allow physicians to get a detailed look at the advancement of digestive and respiratory illnesses with minimal risk and discomfort to often quite ill patients.

Like most fields of medicine, endoscopy is ever evolving, making further opportunities for training increasingly important. There’s a real appetite for more training in EUS, especially as the procedure becomes more critical to endoscopic treatment, Steinberg said. This is especially noticeable as the ASGE training program for EUS is oversubscribed, he added.

New techniques and technologies are being developed all the time; to keep pace post fellowship training must accompany these advancements to continue to progress endoscopy.  Endoscopists and patients alike would benefit from more exposure to new techniques and advanced technologies.