Reimbursement for artificial intelligence (AI) is being discussed at legislative, regulatory and commercial levels, with considerable concerns about how payment may impact AI utilization and, by extension, physician workflow and patient outcomes. AI in gastroenterology, whether assistive, augmentative or autonomous, offers the potential to enhance workflow efficiency and improve patient outcomes through improved disease detection and prediction of future events.
The largest U.S. health care payer, the Centers for Medicare and Medicaid Services (CMS), has established payment through different systems for outpatients (Medicare Physician Fee Schedule [MPFS]), inpatients (Inpatient Prospective Payment System) and hospital outpatients (Hospital Outpatient Prospective Payment System). The framework for establishing payments for traditional medical services for the MPFS is based on physician time, work intensity and practice expense, factors that are not easily translatable to AI technology. Furthermore, the rapidly changing landscape of AI technology does not lend itself to the collection of data used to establish these payments.
The American Society for Gastrointestinal Endoscopy (ASGE) has expressed concerns to CMS and other commercial payers about the risks of accumulating piecemeal information and has suggested a more comprehensive strategy for AI reimbursement. For example, the policy of adopting a “pay-per-use” strategy for AI does not align with CMS’s broader goal to move to value-based payment models and will likely evolve; however, as noted above, there is currently limited formal guidance on standards for CMS coverage of AI services. Commercial payers are even less transparent on how AI is being integrated and reimbursed.
Future reimbursement models will likely vary depending on the type of AI technology and expected outcome. For gastroenterology, the value proposition of AI is continuing to evolve. No truly autonomous AI technologies are currently available in gastroenterology; therefore, future payment models must see AI as an incremental and supplementary service. ASGE will continue to monitor and update members on the development of AI reimbursement pathways.