The new year has already marked major progress for colorectal cancer (CRC) screening with the implementation of the Removing Barriers to Colorectal Cancer Screening Act by the Centers for Medicare & Medicaid Services, which will protect Medicare beneficiaries from an unexpected bill if a polyp is detected and removed during a screening colonoscopy, as well as new guidance from the federal government requiring private insurers to cover colonoscopy as a follow-up to a noninvasive CRC screening test without imposing cost sharing for patients.
The American Gastroenterological Association is strongly committed to reducing the incidence of and mortality from colorectal cancer. There is strong evidence that CRC screening is effective, but only 65% of eligible individuals have been screened. A. Mark Fendrick, MD, and colleagues recently found that cost sharing for CRC screening occurred in 48.2% of patients with commercial insurance and 77.9% of patients with Medicare coverage. The elimination of these barriers to CRC screening should improve adherence and reduce the burden of CRC.
Dr. Joel V. Brill
As one of AGA President John M. Inadomi’s initiatives, the AGA created the CRC Screening Continuum Executive Committee in 2021 to develop AGA Position Statements that highlight the continuum of CRC screening and identify barriers, as well as work with stakeholders to eliminate known barriers. Chaired by former AGA President, David Lieberman, MD, AGAF, and with public policy guidance from Kathleen Teixeira, AGA Vice President of Public Policy and Government Affairs at the AGA, the committee identified that, at that time, colonoscopies after positive stool tests had often been considered “diagnostic” and, therefore, were not covered in full the way a preventive screening is required to be covered by the Affordable Care Act (ACA). The committee recognized that copays and deductibles are barriers to CRC screening and contribute to health inequity and socio-economic disparities. Noninvasive screening should be considered a part of programs with multiple steps, all of which – including follow-up colonoscopy if the test is positive – should be covered by payers without cost sharing as part of the screening continuum. Further, screening with high-quality colonoscopy should be covered by payers without cost sharing, consistent with the aims of the ACA. The committee recommended that the full cost of screening, including the bowel prep, facility and professional fees, anesthesia, and pathology, should be covered by payers without cost sharing.
Dr. David Lieberman
Over the past decade, the AGA and other organizations have spent countless hours advocating for closing the gap. In September 2021, Dr. Inadomi and Dr. Lieberman, along with the American Cancer Society Cancer Action Network and Fight CRC, met with Assistant Secretary of Labor, Ali Khawar, and representatives from the U.S. Department of Health & Human Services and U.S. Department of Treasury to request they direct private health plans to cover colonoscopy after a positive noninvasive CRC screening. In January 2022, guidance from the United States Department of Labor, HHS, and the USDT clarified that private insurance plans must cover follow-up colonoscopies after a positive noninvasive stool test. In the Frequently Asked Questions (FAQs) about the Affordable Care Act Implementation, Part 51, the departments affirmed that a plan or issuer must cover and may not impose cost sharing with respect to a colonoscopy conducted after a positive noninvasive stool-based screening test or direct visualization screening test for colorectal cancer for individuals described in a U.S. Preventive Services Task Force (USPSTF) recommendation from May 18, 2021. As stated in that USPSTF recommendation, the follow-up colonoscopy is an integral part of the preventive screening without which the screening would not be complete . The follow-up colonoscopy after a positive noninvasive stool-based screening test or direct visualization screening test is therefore required to be covered without cost sharing in accordance with the requirements of Public Health Service Act section 2713 and its implementing regulations.
