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Colon Cancer Screening -
Webinar Agenda
Statistics
Quality metrics
Types of screening procedures
Pros and cons
Medicare coverage options
Private insurance coverage options
Questions to consider when selecting a screening method
Colon Cancer National Statistics
The estimated direct medical cost of colorectal cancer care in 2010 was $14 billion
Median age at diagnosis = 67
Median age at death = 73
Approximately 4.3% of men & women will be diagnosed with colon and rectum cancer in their lifetime
Colorectal Cancer Screening
UHC Initiatives
BioIQ - iFOBT kits
mailed to patients
LabCorp - FOBT kits
mailed to providers
Patient Reward ~ $10
PHP InitiativesBonus measure; highly
weighted
GIC report cleanup and
patient outreach
Nov-14 Dec-15 Dec-16PPP 48% 52% 71%SMPC 56% 61% 71%
4 Star Goal2016 Projected 201771% 76%
You have historical data on pts. use these codes when patients have had total colectomy or colorectal cancer
Z85.038, Z85.048
Colonoscopy Overview
Studies show:
● A colonoscopy reduces deaths from colorectal cancer by about 60 to 70%
Any abnormal growths in the colon and the rectum can be removed
● Includes growths in the upper parts of the colon that are not reached by sigmoidoscopy
Colonoscopy
Pros
● Can usually look at the entire colon
● Can biopsy and remove polyps
● Done every 10 years
● Can help find some other diseases
Cons
● Can miss small polyps
● Full bowel prep needed
● Costs more on a one-time basis than other forms of testing
● Sedation is usually needed
● Small risk of bleeding, bowel tears, or infection
Fecal Immunochemical Test (FIT)
Overview
Uses antibodies to detect human hemoglobin protein specifically.
● Dietary restrictions are typically not required for FIT
Fecal Immunochemical Test (FIT)
Pros
● No direct risk to the colon
● No bowel prep
● No pre-test diet changes
● Sampling done at home
● Fairly inexpensive
Cons
● Can miss many polyps and some cancers
● Can produce false-positive test results
● Needs to be done every year
● Colonoscopy will be needed if abnormal
Flexible Sigmoidoscopy Overview
Studies show:
● People who have regular screening with sigmoidoscopy after age 50 have a 60% to 70% lower risk of death due to cancer of the rectum and lower colon than people who do not have screening
During sigmoidoscopy, abnormal growths in the rectum and sigmoid colon can be removed for analysis (biopsied)
Flexible Sigmoidoscopy
Pros
● Fairly quick and safe
● Usually doesn’t require full bowel prep
● Sedation usually not used
● Does not require a specialist
● Done every 5 years
Cons
● Looks at only about a third of the colon
● Can miss small polyps
● Can’t remove all polyps
● May be some discomfort
● Very small risk of bleeding, infection, or bowel tear
● Colonoscopy will be needed if abnormal
CT Colonography (virtual
colonoscopy) Overview
Studies are ongoing to compare virtual colonoscopy with other screening methods
The accuracy of virtual colonoscopy is similar to that of standard colonoscopy with a lowered risk of complications
● If polyps or other abnormal growths are found during a virtual colonoscopy, a standard colonoscopy is usually performed to remove them
CT Colonography (virtual
colonoscopy)
Pros
● Fairly quick and safe
● Can usually see the entire colon
● Done every 5 years
● No sedation needed
Cons
● Not covered by Medicare or UHC for screening
● Can miss small polyps
● Full bowel prep needed
● Some false positive test results
● Can’t remove polyps during testing
● Colonoscopy will be needed if abnormal
Guaiac-Based Fecal Occult Blood
Test (gFOBT) Overview
Studies show:
● Guaiac FOBT, when performed every 1 to 2 years in people aged 50 to 80 years, can help reduce the number of deaths due to colorectal cancer by 15 to 33%
Uses a chemical to detect heme, a component of the blood protein hemoglobin
Guaiac-Based Fecal Occult Blood
Test (gFOBT)
Pros
● No direct risk to the colon
● No bowel prep
● Sampling done at home
● Inexpensive
Cons
● Can miss many polyps and some cancers
● Can produce false-positive test results
● Pre-test diet changes are needed
● Needs to be done every year
● Colonoscopy will be needed if abnormal
Stool DNA Test Overview
More sensitive than FIT
Cologuard is the only stool DNA test approved by the FDA to date
The DNA comes from cells in the lining of the colon and rectum that are shed and collect in stool as it passes through the large intestine and rectum
Stool DNA Test
Pros
● No direct risk to the colon
● No bowel prep
● No pre-test diet changes
● Sampling done at home
Cons
● Can miss many polyps and some cancers
● Can produce false-positive test results
● Should be done every 3 years
● Colonoscopy will be needed if abnormal
● Still fairly new – may be insurance issues
Medicare Coverage
Fecal occult blood test (FOBT) or fecal immunochemical test (FIT) every year for all Medicare beneficiaries 50 years and older
● Covered at no cost to the patient
Stool DNA test (Cologuard) every 3 years for Medicare beneficiaries 50 to 85 years old who do not have symptoms of colorectal cancer and who do not have an increased risk of colorectal cancer
● Covered at no cost to the patient
Medicare Coverage cont.
Colonoscopy● Every 2 years for those at high risk (regardless of age)
● Every 10 years for those who are at average risk
● 4 years after a flexible sigmoidoscopy for those who are at average risk
● Covered at no cost* at any age (no co-insurance, co-payment, or Part B deductible) when the test is done for screening. If the test results in the biopsy or removal of a growth it’s no longer a “screening” test, and patient will be charged co-insurance and/or a co-pay Patients may need to pay for surprise costs such as bowel prep kit, anesthesia,
facility fees, etc.
Virtual Colonoscopy● At this time, Medicare does not cover the cost of virtual
colonoscopy (CT colonography)
Medicare Coverage cont.
Flexible sigmoidoscopy every 4 years for those 50 years and older, but not within 10 years of a previous colonoscopy● Covered at no cost to the patient
Insurance Coverage for Colon
Cancer ScreeningACA requires the coverage of colorectal cancer screening tests
● Patients may need to pay for surprise costs such as bowel prep kit, anesthesia, facility fees, etc.
Colonoscopies that are done to evaluate specific problems, such as belly (abdominal) pain, intestinal bleeding, or low red blood cell counts (anemia), are classified as diagnostic– and not screening – procedures
● This may cause patient to pay deductible or co-pay
Colonoscopies may be considered diagnostic if performed after any other positive exam which suggests the presence of an abnormality. However, there is some room for interpretation and the benefit allows for screening FIT test and screening colonoscopy to be done in the same year at the discretion of the ordering provider.
Some insurance plans also consider a colonoscopy diagnostic if something is found (like a polyp) during the procedure that needs to be removed or biopsied
Questions to Consider when
Selected a Screening Tool
The patients age, medical history, family history, and general health
The potential harms of the test
The preparation required for the test
Whether sedation may be needed for the test
The follow-up care needed after the test
The convenience of the test
The cost of the test and the availability of insurance coverage
IPA Recommendations
Patients should be screened as per HEDIS guideline and bonus criteria recommendation
Best test: Colonoscopy
2nd best: FIT
Other acceptable testing:
● Cologuard; consider pros and cons including cost
● Stool Guaiac, sigmoidoscopy
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