Making the Most of Medicare

A recent study of Medicare coverage for colon cancer screenings has demonstrated the power of policy in the fight against cancer. The research revealed almost a sevenfold increase in the rate of colonoscopy use after expansion of Medicare coverage in 2001, with a corresponding increase in the likelihood of a colon cancer diagnosis coming at an early, curable stage.

This is especially good news, says Wendy Selig, vice president for legislative affairs at the American Cancer Society, because screening for colon cancer, the second leading cause of cancer death in the United States, is so effective. “We could prevent colon cancer outright if we screened more people. If a colonoscopy finds a polyp, it can be eliminated, which can prevent that person from developing colon cancer. Screening is a good investment in saving lives, money, and resources.”

Before 2001, Medicare’s coverage of colon cancer screenings included just the fecal occult blood test, barium enema, and sigmoidoscopy methods; coverage for colonoscopy was extended only to high-risk individuals. ACS guidelines, however, recommend that everyone age 50 and older be screened, so the organization worked to enact legislation to bring Medicare coverage in line with that.

The Medicare colonoscopy study, led by Cary P. Gross, MD, associate professor of medicine at Yale University School of Medicine, assessed whether the changes in Medicare coverage increased use of screening procedures and how the health of beneficiaries was affected. During the study period, 44,924 Medicare patients received a diagnosis of colorectal cancer. Early on, 22.5 percent of the cancers were caught in the early stage; later, 26.3 percent were—an increase of almost four percentage points in early diagnosis.

With 60,000 diagnoses of colorectal cancer a year among those 65 and older, an increase in early diagnosis of even a few percentage points can have a substantial effect at the general population level, the study noted.

What we really want is for people to sit down with their doctor and make an informed decision about what is best. To do that, we need all the options on the table.

Evidence shows, however, that while coverage of a procedure is a key component, it is not the only one determining whether people get screened. So while the revised reimbursement policies were a great step forward, Gross says, other barriers to use of screening procedures need to be removed as well.

Selig agrees. “Step one is making sure people have coverage. Medicare coverage of screening for major cancers now meets or exceeds ACS guidelines. Step two is making sure people avail themselves of the opportunities. More people are getting screened for colon cancer now than before, but we aren’t doing as well as we could.”

The ACS therefore is now focusing on educating providers and patients, encouraging more people to go to their doctor, and removing or reducing disincentives such as co-payments. Colonoscopy in particular, Gross acknowledges, is a tough sell to the public.

“We have to do a better job of showing how beneficial it is,” he says, “perhaps by making people who have had the procedure available to describe the experience.”

Those who have survived colon cancer thanks to early diagnosis can also be very effective spokespeople to friends and family about the importance of screening, says Selig. “With early diagnosis of colon cancer, you’re looking at a 90 percent survival rate, versus 10 percent at later stages.”

The ACS recommendations include any colon cancer screening modality, not just colonoscopy. “What we really want is for people to sit down with their doctor and make an informed decision about what is best. To do that, we needed all the options on the table.”

ACS believes that expanding another benefit, the Welcome to Medicare visit (which provides an overview of your health and the services you need), has the potential to increase use of screenings. “This is an initial visit for new Medicare beneficiaries, to get them started off right with what to do to stay healthy,” Selig says. “One of the things physicians are to do at this visit is talk about screening. Right now people have to use or lose the welcome visit within six months, and we want to give them more time.

“We want individuals to know what coverage is available, to talk to their doctor and be sure they are doing recommended things, and to advocate to friends and family to follow the guidelines.”