Fiscal analysis of establishment of a double-balloon enteroscopy program and reimbursement

Revenue from single-balloon enteroscopy is driven by anesthesia: experience from a tertiary care facility

BACKGROUND/AIMS

Resource-intensive endoscopic procedures have shown to generate more costs than revenue under the current reimbursement system in the USA. Single-balloon enteroscopy (SBE), a resource-intensive procedure, has never been evaluated for its financial impact at tertiary care hospitals, and thus, our aim was to determine the sources of revenue that SBE procedures generate.

METHODS

Retrospective review of all procedures performed using the SBE system during the first year of implementation at a single tertiary referral center. Financial data from two subspecialties in the form of revenues for physician and facility fees were collected and analyzed. Revenues were analyzed in total and as a function of payer (insurance) and physician type.

RESULTS

Fifty-two procedures using the SBE system were identified during the first year of implementation at a single tertiary care center. Total revenue generated for all SBE procedures was $123,714 including $64,475 dollars from physician fees and $59,239 dollars from the facility fees. Revenue generated by anesthesia physician fees was higher from Medicare cases compared to private insurance cases (p < 0.01); however, revenues from facility fees were higher for private insurance cases compared to Medicare (p < 0.01). Revenues from anesthesiology physician fees were significantly more than revenues from GI physician fees (p < 0.01). Of the three referred cases, one generated additional downstream revenues from other non-SBE-related services totaling $4727.

CONCLUSION

A large proportion of revenues generated from SBE cases come in the form of ancillary services provided by anesthesia. Projected revenue generation (and it sources) should be considered when establishing a device-assisted enteroscopy program.

Changes in efficiency and resource utilization after increasing experience with double balloon enteroscopy

AIM: To investigate changes in efficiency and resource utilization as a single endoscopist’s experience increased with each subsequent 100 double balloon enteroscopy (DBE) procedures.

METHODS: We reviewed consecutive DBE procedures performed by a single endoscopist at our center over 4 years. DBE was employed when the clinician deemed the procedure was needed for disease management. The approach (oral, anal or both) was chosen based on suspected location of the target lesion. All DBE was performed in a standard endoscopy room with a portable fluoroscopy unit. Fluoroscopy was used to aid in shortening the small intestine and reducing bowel loops. For oral DBE, measurements were taken from the incisors. For anal DBE, measurements were taken from the anal verge. Enteroscopy continued until the target lesion was reached, until the entire small intestine was examined, or until no further progress was deemed possible. The length of small intestine examined (cm), procedure duration (min), and fluoroscopy time (s) were analyzed for sequential groups of 100 DBE. Sub-groups of diagnostic and therapeutic procedures were analyzed using multivariable linear regression.

RESULTS: 802 consecutive DBE procedures were analyzed. For oral DBE, median [interquartile range (IQR)] length of small bowel examined was 230.8 cm (range: 210-248 cm) and for anal DBE was 143.5 cm (range: 100-180 cm). No significant increase in length examined was noted for either the oral or anal approach with advancing position in series. In terms of duration of procedure, the median (IQR) for oral DBE was 86 min (range: 71-105 min) and for anal DBE was 81.3 min (range: 67-105 min). When comparing by the position in series, there was a significant (P value < 0.001) decrease in procedure duration for both upper and lower procedures with increasing experience. Median (IQR) time of exposure to fluoroscopy for oral DBE was 190 s (114-275) compared to anal DBE which was 196.4 s (312-128). This represented a significant (P value < 0.001) decrease in the amount of fluoroscopy used with increasing position in series. For both oral and anal DBE, fluoroscopy time was reduced by greater than 50% over the course of 802 total procedures performed. Sub-group analysis was conducted on therapeutic and diagnostic groups. Out of 802 procedures, a total of 434 were considered therapeutic. Argon plasma coagulation was by far the most common therapeutic intervention performed. There was no evidence of a difference in length examined or fluoroscopy exposure among oral DBE for diagnostic and therapeutic procedures, P = 0.91 and P = 0.32 respectively. The median (IQR) for length was 235 cm (range: 178-280 cm) for diagnostic vs 230 cm (range: 180-275 cm) for therapeutic procedures; additionally, fluoroscopy time median (IQR) was 180 s (range: 110-295 s) and 162 s (range: 102-263 s) for no intervention and intervention. However, there was a significant difference in procedure duration among oral DBE (P < 0.001). The median (IQR) was 80 min (range: 60-97 min) and 94 min (range: 77-110 min) for diagnostic and therapeutic interventions respectively.

CONCLUSION: For a single endoscopist, increased DBE experience with number of performed procedures is associated with increased efficiency and decreased resource utilization.