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GASTROENTEROLOGY & ENDOSCOPY NEWS • MAY 2013
these arcane differences, so it is unlikely that the new rule will increase screening colonoscopy rates above and beyond how the ACA provision was originally interpreted,” Dr. Dorn noted. “Still, the new rule will eliminate surprise costs that were a common source of frustration for both patients and their gastroenterologists alike.”
effectiveness in lowering the rates of both CRC and CRC-related mortality, the reluctance of the government and private insurers to do everything possible to reduce the barriers to CRC screening has raised some questions.
Medical Semantics
and prefer to undergo a noninvasive stool test. That’s a screen,
When the ACA was first passed, it included some positive measures in terms of CRC screening. First, the new state-based private health insurance exchanges were required to provide preventive services, including colonoscopy, at no additional cost to patients. Second, for Medicare patients, the deductible, as well as the 20% Medicare beneficiary coinsurance, were waived for any CRC screening recommended by the U.S. Preventive Services Task Force. Also, the deductible is waived for any Medicare beneficiary’s screening when a polyp is removed. However, due to the way procedures are coded, once a polyp is removed, a colonoscopy is no longer a screening exam, but a diagnostic or therapeutic one. Concerned about the wording of the ACA bill, representatives of the ACG, the American Society for Gastrointestinal Endoscopy (ASGE) and the American Gastroenterological Association (AGA) sought clarification from Congress and the Centers for Medicare & Medicaid Services (CMS). “CMS looked at the section in the law that states cost sharingg is waived for recommended screenings, and the next section that states the deductible is waived for a screening that turns therapeutic,” an ACG representative. “CMS then determined it did not have the regulatory authority to waive the Medicare beneficiary’s 20% coinsurance when a polyp is removed because Congress never used the word coinsurance, yet specifically chose the word deductiblee when a screening turns therapeutic,” the representative said, noting that this may have been an unintended quirk in the drafting of the statute. The ACG and others are currently advocating Congress to add the word “coinsurance” to the law. Dr. Seabrook said, “If I, as a gastroenterologist, was smart enough to know that a person being referred for a screening colonoscopy did not have any polyps or any lesions of concern, I would not do the colonoscopy. But we’re just not that smart yet. We might be, with other diagnostic tests in the future, but for now the single best test to detect and remove precancerous polyps is a colonoscopy.” Given colonoscopy’s established
treating advanced-stage CRC has risen dramatically in recent years. We’ve had a number of new drugs introduced that improve survival [rates], but those drugs come with a very high price tag.” In addition to the cost sharing still
‘Some people choose not to undergo a screening colonoscopy
but if it turns out positive, suddenly that patient’s colonoscopy would not be considered a screening test and they’d be faced with a full coinsurance and deductible.’ —Durado Brooks, MD, MPH
‘We view [having] a colonoscopy [as a follow up to] a positive stool test as part of the screening process. Hopefully over time we can get the insurance companies and federal agencies to share that view and consequently remove the barrier to full evaluation of an abnormal screening test.’ —Durado Brooks, MD, MPH
“Many of us in this field have wondered about it for a long time,” said Dr. Brooks. “It’s been shown for many years that CRC screening is highly costeffective compared with other cancer screening tests, like mammography, and also compared with other public health measures. Additionally, the cost of
faced by Medicare recipients who initially choose to undergo colonoscopy for CRC screening, Dr. Brooks pointed to other colonoscopy-related cost concerns. “Some people choose not to undergo a screening colonoscopy and prefer to undergo a noninvasive stool test. That’s a screen, but if it turns out positive,
suddenly that patient’s colonoscopy would not be considered a screening test and they’d be faced with a full coinsurance and deductible,” he said. “We view [having] a colonoscopy [as a follow up to] a positive stool test as part of the screening process. Hopefully over time we can get the insurance companies and federal agencies to share that view and consequently remove the barrier to full evaluation of an abnormal screening test.”
‘Lowering Barriers and Raising Quality’ In May 2012, members of the ACG, ASGE, AGA, the American Cancer Action Network, Fight Colorectal Cancer and the National Colorectal Cancer Roundtable met with HHS to discuss the problem of cost sharing as a barrier to CRC screening, and to advocate for the elimination of that barrier. The groups were pleased when HHS and the U.S. Department of Labor released the clarification in February 2013 in the form of a list of frequently asked questions specifying that non-grandfathered insurance companies and those participating in exchanges must waive cost sharing when a polyp is removed during screening. But it appears that a statutory fix is required to extend this provision to Medicare beneficiaries. In March, Rep. Charlie Dent (R-PA) introduced H.R. 1070, the Removing Barriers to Colorectal Cancer Screening Act of 2013, aimed at eliminating the unintended hidden costs of polyp removal during screening colonoscopy in Medicare beneficiaries. Also in March, Sen. Ben Cardin (D-MD) and Rep. Richard Neal (D-MA) introduced H.R. 1320, the Supporting ColoRectal Examination and Education Now (SCREEN) Act of 2013 into the House and Senate specifically to ensure that the waiving of cost sharing is extended to Medicare beneficiaries, and also to increase the quality of screening exams. For example, the SCREEN Act provides coverage for a prescreening visit, currently not covered by Medicare, and also provides an incentive for voluntary participation by health care professionals in one of the nationally recognized quality improvement registries. Gastroenterologists whose services do not measure up to the accepted standards of care as defined by their peers will be reimbursed at a lower rate. “As gastroenterologists in the ACG, we support the effort to lower the barriers to CRC screening as well as raise the quality of the examination,” Dr. Seabrook said. “That’s my new mantra: lowering barriers and raising quality.” ■