US costing rules anger Gastro specialists


An inadvertent ‘quirk’ in the US Medicare cost-sharing rules continues to vex gastroenterologists and their patients who need colonoscopies, and has deterred many patients from undergoing the potentially lifesaving procedure. Meanwhile, as gastroenterology and patient advocacy groups lobby to mend the coverage gap, clinicians worry that the current policy will continue to prevent Medicare beneficiaries from getting screened for colorectal cancer (CRC) just when they enter the age range when the risk for developing the disease rises substantially.

Colonoscopy is the preeminent screening tool for CRC in the United States and generally recognized as effective for reducing CRC mortality. It is one of only two cancer-screening tests with a grade “A” recommendation from the U.S. Preventive Services Task Force, yet it also is “woefully underutilized in the Medicare population,” according to the American College of Gastroenterology (ACG).

According to McMahon Publishing, ‘the trouble emerged and evolved through a series of well-intentioned Congressional actions meant to decrease the out-of-pocket liability for Medicare patients who receive a screening colonoscopy and to increase screening rates. First, the Deficit Reduction Act of 2005 waived the Medicare deductible expense for CRC screening—a change that the gastroenterology community had long advocated. However, the 20% to 25% coinsurance payment burden remained in place.’

In what would seem to be a trivial omission, the legislation failed to distinguish between screening and therapeutic colonoscopies. A colonoscopy was considered a “screening” procedure only until the endoscopist removed a polyp. Once removed, the procedure became a “therapeutic” procedure, and instantly the patient became liable for any remaining Medicare deductible plus a 20% copay for professional and facility fees. Some patients emerged from sedation to the unwelcome news that the procedure went well, but that they were now responsible for a hefty out-of-pocket expense.
There’s no way to know how many Medicare patients, fearing a sizable bill after the procedure, have delayed or have passed up a colonoscopy, but some clinicians are certain that the uneven policy hampers screening efforts.

“I have had patients who have scheduled a colonoscopy and not shown up for their procedure because of this policy,” said March Seabrook, MD, National Affairs Committee chair for the ACG, who practices in Columbia, S.C. “It does have an impact.” He also pointed out the irony that Medicare currently saves the relatively small outlay for therapeutic colonoscopies, but risks incurring the enormous cost of care for patients who develop CRC because they skipped a colonoscopy.
Dr. Seabrook also faults Medicare’s unwillingness to reimburse for precolonoscopy office visits, which it pays only when patients are symptomatic and referred for a colonoscopy to assess the problem. “I think it is critically important to establish a patient–physician relationship before having a sedated, invasive procedure,” he said. “That’s another roadblock that CMS has put up in terms of reimbursement.”

Lobbyists representing gastroenterologists and patients are pushing Congress to clearly and finally waive all colonoscopy-related cost burdens for Medicare patients. According to Mr. Roberts, during the 2010 lame-duck session there were “a lot of sympathetic ears on the Senate side, and a provision was prepared for inclusion in the so-called Doc Fix legislation” that temporarily staved off large cuts to physicians who treated Medicare patients. The rider didn’t make into the final version of the bill.