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MEDICARE: Colonoscopies and Evidence-Based Decision Making

Tom Emswiler - 
June 8, 2009 - 12:22pm

In my last post I discussed Medicare governance—specifically, why it makes sense to remove some of the more detailed and nuanced parts of CMS oversight from Congress in favor of a new institution similar to a board of trustees.  President Obama brought the issue of Medicare decisionmaking to the national stage with his letter to Senators Baucus and Kennedy. One challenge: how to insulate evidence-based medical decisionmaking from political pressures. 

This aspect of the health reform debate is timely because of CMS's decision last month to deny coverage for Computed Tomographic (CT) Colonography.  CT Colonography, or "virtual colonoscopy," uses advanced imaging technology to look for precancerous polyps.  Some patients prefer it; it is quicker, doesn't involve anesthesia and people don't miss a whole day's work (although they still have to do the unpleasant preparation.) But if abnormalities are found, a convention colonoscopy must be performed anyway.  Further, using CT Colonography runs the risk of false positives -seeing bad things that aren't really there.  

It appears that CMS made a sound decision after reviewing the evidence...but that's where the fun of Medicare governance comes in.  According to the livid Wall Street Journal editorial page, more than 50 members of Congress are demanding that this decision be overturned.  While these elected officials are more likely to have degrees in law than in science, they nonetheless have the power to make the ultimate rules about what medical services Medicare will cover or not cover.  Chairmen and other high-ranking committee members have the authority to insert language into important bills to render CMS's evidence-based decision useless.  Take the case of then-Senator Ted Stevens and PET scans.

Rhonda Rundle published stories in the WSJ in 2002 and 2003 describing how Medicare refused to cover PET scans in the early 1990s because they seemed duplicative to MRI and CT scans, cost twice as much, and required a then-unapproved radioactive tracing element.  Senators Stevens got the tracer approved, circumventing the regulatory process, and actively promoted its use to his colleagues and to HHS officials in the Clinton administration. 

As Robert Berenson, Len Nichols, and I write in our paper released this past spring:

The nature of this interference does not represent Congress exerting due diligence oversight to assure CMS accountability for the policies and operations of the Medicare Program, a function that rightfully belongs with Congress, but rather back-channel influence to undermine consistent and systematic, evidence-based decision-making.

 

Back to CT colonography, the New England Journal of Medicine recently published a thoughtful piece praising  the coverage rejection for this procedure.  It notes that the trial used to advocate for virtual colonscopy coverage did a poor job of including the population served by Medicare (the elderly) or African Americans, who are at high risk for colon cancer. 

As the WSJ Health Blog pointed out, the American College of Radiology, whose members are paid handsomely to use CT scanners, said this denial "may result in tens of thousands of unnecessary deaths each year from colorectal cancer."  But consider a recent statement from the America College of Gastroenterology reiterating their "longstanding position that colonoscopy remains the preferred colorectal cancer prevention test."

Instead of trying to find more expensive ways to perform colonoscopies, maybe we should consider how to perform them more effectively.  In 2006, researchers found that physicians who spend at least six minutes withdrawing the scope found 10 times more polyps than those who withdrew the scope quickly.  Do all physicians who perform colonoscopies know this?  If not, is that a more valid battle on behalf of patients than simply finding new technology?

I'm not against technology for technology's sake and I'm not cheap.  I'm really excited about the new Palm Pre.  I blogged last year on laparoscopic surgery to remove pancreatic tumors or cysts and discovered that it resulted in fewer complications, less blood loss, and shorter hospital stays.  If technology genuinely improves care, it should be covered by Medicare.  If it doesn't improve care and it's more expensive, it shouldn't be covered. It should be that simple. But in our current system for Medicare governance and decision-making, nothing is simple.

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Comments

Facts on Colon Cancer

Submitted by Emily5131 (not verified) on June 8, 2009 - 2:05pm.

It seems the recent decision by CMS to deny reimbursement of CT Colonoscopy for lack of evidence did not look at “ALL” of the facts, evidence, and costs related to colon cancer. It is easy to overlook some of the data out there and then claim lack of evidence.

Below are some pertinent facts relating to colon cancer that somehow did not appear in the 30 page decision by CMS to deny coverage:

Fact: 50,000 people are dying from colon cancer each year in the US.
Fact: Another 150,000 new cases are being reported each year.
Fact: Sadly, all of this is from a cancer that is more than 90% preventable by early screening.
Fact: CMS and other healthcare providers are paying billions of dollars for the treatment of colon cancer each year.
Fact: Optical colonoscopy is the only procedure where polyps (that can become a cancer) can be removed.
Fact: Any screening method is only effective when it is used.
Fact: More than 50% of the screening age population is simply not getting screened using the optical colonoscopy.
Fact: There is evidence that optical colonoscopy for screening is underutilized by CMS recipients – published papers.
Fact: The GI community currently does not have the capacity to meet the needs of the screening population (generally those over the age of 50).
Fact: CMS pays for screening tests with lower sensitivity, such as the barium enema or flexible sigmoidoscopy. The flexible sigmoidoscopy is equated to having a mammography test of one breast.
Fact: There is evidence that CTC is cost-effective for screening.
Fact: CTC screening programs over the past 5 years have shown as much as 70% increase in colon cancer screening compliance.

For those who use the argument that if you have a polyp you need to go for an optical colonoscopy to get it removed anyway: Yes, that is true for medically significant polyps. However, the fact remains that if people are not getting screened (by any method) then no one will find and remove the polyps that could prevent colon cancer to begin with.

On the topic of polyp removal, only 10%-20% of the general screening age population need polyps removed. However, without effective screening no one will know who falls into that 10%- 20% group.

CT Colonoscopy offers a proven, economical, and viable option for colon cancer screening. There is plenty of evidence in published clinical trials over the past 10 years to show that CTC is as good as OC for detecting clinically significant polyps. The commercial health insurance carriers see the light and are beginning to reimburse for CTC screening.

The problem is that CMS cites that all this supporting data is on patients with an average age of 58, not 65 (Medicare age). If 10-20% of those being screened (at 58) have polyps that can turn into cancer, imagine how many 65 and over will have polyps that turn into cancer because they are NOT screened! Did CMS make a truly medical decision or a financial one by taking the easy way? Reimbursement for CT Colonoscopy now may increase some Medicare costs in the short-term, but would save enormous amounts later by significantly reducing the cost of treating colon cancer. Is CMS “passing the buck” to control their spending now vs. investing in the future?

On one hand, our government talks about preventative health care, on the other, we are paying billions of dollars for treating colon cancer now but do nothing to improve prevention of the disease even when it is available. The reality is that optical colonoscopy is not working as it should for colon cancer prevention. Should we ignore this problem by choosing to accept it, or do something about it in a proactive manner? Maintaining status quo, as CMS has done, is really not the option to choose.

virtual colonoscopies

Submitted by w gaman md (not verified) on June 9, 2009 - 3:54pm.

What I don't get is how everyone says that virtuals are more expensive. Here in Irving Texas an optical colonosocpy with the facility fee and the anesthesiologiast costs about $4,000 while a virtual is $800 done in our office, not the expensive hospital! It seems that the opponents of ther virtual do not have the cost correct.

Colonoscopy

Submitted by Mike Jones (not verified) on June 11, 2009 - 4:37pm.

Hello,

Thanks for the interesting article on virtual colonoscopy coverage with medicare.

I have a friend that’s fighting stage 4 colon cancer so I know what a dreadful disease it is.

I had my first colonoscopy at age 50. A polyp was found and removed. I’m now 58 and I had my second colonoscopy a few weeks ago. Nothing was found this time.

I just want to remind and encourage everyone to get screened for colon cancer. The procedure itself (colonoscopy) is not painful, with the possible exception of the I.V. The preparation the day before is a little inconvenient. Plan to be close to a bathroom.

The ‘official’ guideline is to have a colonoscopy if you are older than 50 and every 10 years thereafter. That is, if you’re at average risk. Check with your physician. Schedule an appointment today!

I really agree with you, If

Submitted by Bakuri Software (not verified) on September 7, 2009 - 2:56am.

I really agree with you, If technology genuinely improves care, it should be covered by Medicare. If it doesn't improve care and it's more expensive, it shouldn't be covered.

Virtual colonoscopy

Submitted by Virtual colonoscopy (not verified) on September 17, 2009 - 1:35am.

A study states that virtual colonoscopy can be a satisfactory diagnostic option to conventional colonoscopy, but only in some patients and not all. It includes X-rays and computers to created three dimensional imaging of the colon. But it is not suitable for those patients with IBS or irritable bowel disease or those people with a past of flat lesions. So one has to be careful while going for this.