Wrong Surgery Newsroom

In 2001, There Were About 4.8 Million Of These Gastroenterological Procedures Performed

Section 411 of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA) directed us to examine the practice of providing physician services that are ordinarily performed in health care facilities such as gastroenterological and urological endoscopic procedures--in physicians’ offices. We were directed to (1) review safety evidence regarding medical settings, (2) assess whether the practice expense site-of-service payment differential has served as an incentive for physicians to perform such  procedures in their offices rather than in other medical settings, and (3) assess whether access to care by Medicare beneficiaries would be affected if these procedures were no longer reimbursed by Medicare when conducted in physicians’ offices.For our study, we selected 12 gastroenterological and 8 urological procedures that are ordinarily performed in health care facilities for Medicare beneficiaries. In 2001, there were about 4.8 million of these gastroenterological procedures performed, of which about 156,000 (3.3 percent) were conducted in physicians’ offices. During this same year, there were about 306,000 of these urological procedures performed, of which about 12,000 (3.8 percent) were conducted in physicians’ offices. To determine the relative safety of these procedures conducted in different medical settings in the 50 states and the District of Columbia, we reviewed the scientific literature maintained by the National Library of Medicine and interviewed physicians; medical directors at Medicare carriers, which are the CMS contractors that process and review Medicare claims; and a representative of a trade association that represents the medical malpractice insurance industry. We also attempted to obtain Medicare claims data to determine whether patients who had endoscopic procedures later encountered medical complications. However, such data are not readily available. To assess whether the practice expense site-of-service differential has served as an incentive for physicians to conduct office-based procedures, we analyzed CMS data on the percentage of endoscopic procedures performed in physicians’ offices, hospitals, and ASCs from 1996 through 2001. To determine whether access to care by Medicare beneficiaries would be affected if these procedures were no longer reimbursed by Medicare when conducted in physicians’ offices, we analyzed CMS data on a geographic basis, leading to a focus on the New York City area, which has a high utilization rate of physician office based endoscopic procedures. For this metropolitan area, we analyzed CMS medical setting data and interviewed Medicare carrier directors and New York state officials. We conducted our work from February 2001 through October 2002 in accordance with generally accepted government auditing standards.