To uphold the established standard of care for colorectal cancer screening, commercial insurers regulated by the Affordable Care Act (ACA) must cover follow-up surveillance colonoscopies that take place after the removal of precancerous polyps or lesions in initial screening tests.
That’s the message the Texas Medical Association delivered in a December letter co-signed with others in organized medicine to U.S. Department of Health and Human Services Secretary Xavier Becerra; Acting Secretary of the U.S. Department of Labor Julie Su; and Secretary of the Treasury Janet Yellen.
The U.S. Preventive Services Task Force (USPSTF) and the U.S. Multi-Society Task Force (USMSTF) on Colorectal Cancer both recommend that, after initial screening, asymptomatic individuals receive repeat colonoscopy exams to look for new polyps. As the principle of this practice is to detect and remove polyps in asymptomatic individuals, it falls in the screening continuum of care.
Such coverage is already part of Medicare policy, but “commercial insurers regulated by the ACA treat a surveillance exam as a ‘diagnostic’ service despite the patient having no signs or symptoms, thus triggering patient cost-sharing for a preventive service,” TMA and other signatories wrote.
This is not just a barrier to care, but also one that disregards the USPSTF’s 2022 guidelines, which recommend earlier colorectal cancer screenings, says Mammen Sam, MD, chair of TMA’s Committee on Cancer.
“If screening tests begin at age 45, and most patients between 45 and 65 will be on private insurance, private insurance payers also need to be on board with the same cancer screening guidelines,” he said. “Our physicians are already employing these guidelines. We want to make sure that it's accessible to patients who might not otherwise utilize the health care system because of cost.”
Additionally, the reduced age for screening means more opportunities for intervention, Dr. Sam says.
“Once we reduced [the recommended age for screening] to 45, we realized, well, if we screen patients at 45, they're going to live another 25, 30 years at the minimum. And so, we'll need to screen them again.”
Follow-up surveillance colonoscopies are crucial to the screening continuum, medicine wrote. According to the USMSTF guidelines, undergoing one or two surveillance examinations reduces the risk of colorectal cancer by 43% to 48%, and patients who did not have a colonoscopy after a non-invasive colorectal cancer screening test had a 103% higher risk of death from colorectal cancer, compared with those who had a colonoscopy.
The American Cancer Society estimates that when detected and treated early, the five-year survival rate for colorectal cancer is 90%.
“What we want to be able to do is make sure that we treat patients earlier, so we have to do less,” Dr. Sam said. “If you wait, and it's spread into the lymph nodes, you might have to have a larger piece of the colon removed. You may then have to have chemotherapy with that. Those things reduce life.”
But to intervene early requires commercial insurance providers to remove the financial burden of a co-pay for surveillance exams.
“What we do in medicine is complicated, but it's simpler than what insurance makes us do,” Dr. Sam said. “A physician might make a recommendation, but hurdles through which a patient has to jump through to get that recommendation or to act on that make it prohibitive sometimes. And a lot of times that's related to payment.”
Learn more about TMA’s work to effect policy change on the TMA Federal Advocacy page.