In a dreary replay of last year's battle over coronary CT angiography scans, the Centers for Medicare and Medicaid Services has proposed not covering a valuable and rapidly evolving screening exam: CT colonography.
CMS eventually backed down on its plans for coronary CTA, and reimbursement remains the province of individual Medicare carriers. A decision on CT colonography reimbursement is due out this month, and we still hope CMS reverses its recommendation. If it does not, we can anticipate that screening for colon cancer will remain at lackluster levels and that death rates for colon cancer will remain unacceptably high.
CMS outlined its proposed decision in a Feb. 11 memorandum. The agency's analysis turned heavily on a few points. One was that CT colonography is considerably less effective at spotting polyps in the 6 to 10-mm range than is optical colonoscopy, something that has been challenged in studies not cited by CMS.
The other was an argument about the cost-effectiveness of CT colonography. Although no studies look at this issue in the Medicare population, CMS contends that a higher incidence of polyps and a resulting higher referral rate for optical colonoscopy to remove them would limit the value of an “intermediate” test like CT colonography. That argument may have some validity, but there is a question whether CMS can use it. In comments to CMS, the Advanced Medical Technology Association contends that CMS is preempted from considering cost in this issue by a decision in Congress in 1997 to create a colorectal cancer screening benefit under Medicare.
More serious is what CMS didn't address in its coverage proposal, the fact that screening rates for colorectal cancer are still relatively low and that limiting screening payments to optical: colon scans combined with fecal occult blood testing will not help boost them. There just aren't enough gastroenterologists to do the job.
Studies from New Hampshire (Am J Prev Med 2007;32:25-31), Montana (Am J Prev Med 2009;36:329-32), and New Mexico (Prev Chronic Dis 2005;2:A07) all conclude that current capacity is a barrier to increasing screening rates. The New Mexico study notes that achieving more universal screening would require additional testing modalities.
Another study looking at the national picture concluded that meeting the demand for screening would require that the number of endoscopists be increased by about a third (J Gastroenterol Hepatol 2008;23[Suppl 2]:S198-204).
“Our studies of capacity to deliver screening colonoscopy to average-risk people illustrate a clear deficit in manpower,” the author wrote.
Although the study did not endorse a multimodality strategy, saying it may confound the screening message, it seems this problem is more easily overcome than a serious staffing shortage.
We have a promising technology that is improving rapidly and will eventually rival, if it has not already, optical screening in effectiveness. The new technology offers the opportunity to greatly expand screening options and capabilities and can lead to earlier detection and a reduction in deaths from colon cancer. CMS should not stand in the way.