In more than one-third of cases, same-day bidirectional endoscopy is not performed in Medicare beneficiaries, despite the fact that so-called "bundled" endoscopies offer significant cost savings to Medicare, wrote Dr. Hashem B. El-Serag and colleagues in the January issue of Clinical Gastroenterology and Hepatology (doi:10.1016/j.cgh.2013.07.021).
Indeed, "Although in some instances the referral patterns and clinical indications may have precluded bundling, the persistence of the findings in analyses that adjusted for indications and the considerable geographic variation in practice suggest a component of physician discretion," they wrote.
Dr. El-Serag of Baylor College of Medicine, Houston, and colleagues looked at data from 12,982 Medicare beneficiaries with claims for colonoscopy and EGD within 180 days of each other captured by the Surveillance Epidemiology and End Results (SEER) Program.
Overall, 8,404 of these patients (64.7%) had "bundled" procedures, meaning that both upper and lower endoscopy occurred on the same day during the same session.
On the other hand, 2,359 patients (18.2%) did not have their procedures bundled, but rather had both procedures within 30 days of each other.
And an additional 2,219 patients (17.1%) underwent the procedures at an even greater interval, between 30 and 180 days of each other.
"Patients with bundled procedures were slightly younger, more likely to be white, more likely to reside in an urban area with a higher median educational level, and more likely to have low comorbidity scores," wrote the authors.
However, there was also a "strong and significant" geographic component to the frequency of bundling, whereby patients undergoing procedures in the Northeastern United States had the lowest rates, while patients in the Western portion of the country had the highest rates.
They also found that patients with GI bleeding were significantly more likely to have bundled procedures compared with patients undergoing screening or surveillance.
"This association between indications and bundling status persisted in a subgroup analysis of patients with a comorbidity score of 2 or greater (n = 2,961)," they wrote.
In an attempt to explain their findings, the researchers postulated that since Medicare reimburses bundled procedures at a rate that is less than the sum of each charged separately, physicians have a financial disincentive to bundle procedures.
To that end, "it is worth considering that insurers reimburse physicians fully for bundled procedures," they wrote, pending a formal cost-effectiveness analysis.
They conceded, however, that the data used in this study were collected primarily for billing purposes, such that clinical details – for example, procedural findings – were lacking.
"For example, in an open-access endoscopy system a patient may have been referred for only one procedure, and, based on the outcome, a second procedure may have been requested at a later time," they explained.
Nevertheless, "The missed opportunities related to nonbundled EGD and colonoscopy are likely to be associated with considerable increase in cost related to physician (gastroenterology, anesthesia, pathology) and facility fees," concluded the authors, as well as indirect costs of work days lost.
Dr. El-Serag and his colleagues stated that they had no conflicts of interest. They disclosed grants from the National Institute of Diabetes and Digestive and Kidney Diseases, the National Institutes of Health/National Cancer Institute, the Houston VA Health Services Research & Development Center of Excellence, and the Texas Digestive Disease Center National Institutes of Health, as well as the National Center for Advancing Translational Sciences.