Could LDCT screening for lung cancer move decision out of the primary care office?

A counseling requirement included in Medicare’s proposed decision to cover screening for lung cancer with low-dose computed tomography could pull primary care physicians out of the decision loop.

The proposed national coverage decision from the Centers for Medicare & Medicaid Services, announced Nov. 10, includes a requirement that patients “receive a written order for [low-dose computed tomography screening] during a lung cancer screening counseling and shared decision making visit, furnished by a physician ... or qualified nonphysician practitioner.” CMS has proposed covering low-dose computed tomography (LDCT) screening only for certain high-risk patients, with strict limitations on eligibility.

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A proposed CMS decision memo suggesting LDCT use in lung cancer screening may remove primary care physicians from the decision making.

But the time requirement and questions on how this counseling would be covered could make it challenging for patients to make this decision alongside their primary care physician.

“One of the most interesting things in the Medicare requirement for payment focuses on the counseling visit,” said Steven Zeliadt, Ph.D., core investigator at Veterans Affairs Health Services Research & Development Services and professor at the University of Washington, Seattle. “That’s very different than other cancer screening tests, and for Medicare to really be encouraging that and requiring that is something providers and systems are going to have to figure out how to offer and make sure that [this] actually happens.”

Dr. Zeliadt said that he expects to see specialized screening centers similar to those related to pulmonary or mammography screening to gain traction. These will be the places that integrate both parts of the screening by conducting the LDCT test as well as providing the prescreen counseling. This differs from the model used for colon cancer and prostate cancer screening, where the consultation and decision to conduct screening tests are typically done with the primary care physician.

“The Medicare guidelines encourages that [counseling] as well, to make sure that that’s a visit that gets built in,” Dr. Zeliadt said.