Does CMS coverage decision signal a change of policy?

May 29, 2009

The recent decision by CMS to deny coverage for CT colonography in colorectal cancer screening has been seen by some as a favorable trend toward using evidence-based medicine to make more cost-effective coverage decisions. With the Medicare hospital insurance trust fund projected to become insolvent by 2017, perhaps the agency is responding to the impending fiscal realities.

As previously reported on this blog, despite a wave of lobbying from the medical imaging industry and policy-makers on Capitol Hill, CMS has decided to deny Medicare beneficiaries coverage for CT colonography in colorectal cancer screening. With Medicare expenditures increasing at an unsustainable pace, this decision could signal a subtle shift toward cost-effective analyses when the agency is determining a coverage issue. 

However, the agency emphasized that the "pivotal, overarching concern," was the fact that the findings of the trials showing benefit were not generalizable from the study populations to other groups of patients--there were no studies evaluation this technology in those aged 65-years and older.

Proponents of CTC claim that the less invasive nature of the test enhances regular screening adherence. In a public statement, James H. Thrall, MD, FACR, chair of the American College of Radiology's board of chancellors said, "For CMS to turn its back to a technology that can attract more patients to be screened and save countless lives is deeply concerning."

It is important to note that CMS does not, as a rule, consider costs in its coverage decisions. However, CMS has authority to use costs only when evaluating coverage for colorectal cancer and prostate cancer screening. A recent editorial in the New England Journal of Medicine applauds CMS, and hopes that this evidence-based decision on CTC heralds the beginning of a proactive trend toward cost-effectiveness analyses. "In our view, given the economic realities facing Medicare, health care reform must include authority for CMS to consider costs in all its coverage decisions in order to assess the true value of a given procedure," stated the authors.

Interesting times lie ahead...