William R Stern MD ConC2012 Presentation


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Program Manager, Gastroenterologist at Associates in Gastroenterology in Rockville Maryland & the American College of Gastroenterology (ACG) Governor for Maryland

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  • Important new medical evidence proves that removing polyps during a colonoscopy protects against death from colorectal cancer. Physicians know that colonoscopy is one of the most powerful preventive screening tests because we can see and remove pre-cancerous growths in the colon called polyps. Stopping colorectal cancer before it can start. Now a study by Ann Zauber and Sid Winawer published last week in The New England Journal of Medicine proves that when polyps are removed during colonoscopy, deaths from colorectal cancer are reduced by 53 percent.  Widespread media coverage of this landmark study, including the New York Times.
  • Deaths from colorectal cancer may exceed 50,000 U.S. citizens again this year.  The CDC recently concluded that 2,000 deaths would be prevented if screening rates rose just 10%. (CDC Colorectal Cancer Vital Signs; July 2011).
  • Screening RatesIn 2008,The American Cancer Society estimated that about 60% of all U.S. adults over 50 got recommended colorectal screening. In Maryland, it’s almost 70 percentIn March 2011, the American Cancer Society (ACS) reported that only 58% of Medicare-aged Americans 65 and older are receiving some sort of colorectal screening. This is tragic because colorectal cancer is largely preventable with appropriate screening.  SOURCES: American Cancer Society, 2010 Cancer Facts & Figures and 2011-2013 Colorectal Cancer Facts & Figures; U.S. Dept. of Health & Human Services, “Enhancing Use of Clinical Preventive Services Among Older Adults: Closing the Gap”; Centers for Disease Control, Vital Signs: Colorectal Cancer Screening in Adults Aged 50-75 Years- United States, 2008.
  • Unlike other screenings where early detection is the goal, colorectal cancer screening actually prevents cancer by removing pre-cancerous polyps during the same encounter.  That is why colorectal cancer screening is one of only two cancer screenings with an “A” recommendation by the US Preventive Services Task Force (USPSTF). NOTE:Cervical cancer screening is another preventive service with an “A” recommendation.
  • Since the implementation of Medicare preventive screening for colorectal cancer in 1998, deaths from colorectal cancer continue to decline. We are catching cancer at an early stage – and preventing cancer – much more than ever before. 
  • Mortality from colorectal cancer is declining, however, we are very concerned that lifesaving colorectal screening tests remain radically under-utilized in Medicare.Much still needs to be done as screening rates remain low and screening barriers remain high, including the patient out-of-pocket costs
  • The Problem: A “Good News-Bad News” Situation The recent health reform law creates an unintended cost barrier for colorectal screening in Medicare  Good NewsAs of January 2011, under ACA, Medicare beneficiaries have no cost sharing (deductible and coinsurance) for preventive services rated “A” or “B” by the U.S. Preventive Services Task Force such as screening colonoscopyAlso as of January 2011, Medicare beneficiaries will have no deductible for colorectal cancer screening regardless of whether or not the screening turns into a therapeutic procedure Bad NewsIf a physician detects a polyp and removes it during a screening colonoscopy, the procedure is coded as a diagnostic procedure.  It becomes a “therapeutic intervention” – polypectomy and different patient cost sharing applies.This means that a beneficiary may go into a screening expecting to have neither a deductible nor co-pay, but if a polyp is found, would have to pay the co-pay (the 20% Medicare coinsurance). 
  • Under the new health reform law, the deductible and co-insurance are waived for preventive screening. However, colonoscopy is unique in that a physician can identify and remove a potentially precancerous polyp during the procedure, in which case the examination is no longer a preventive screening, but becomes a therapeutic procedure (polypectomy.) Once an intervention moves from pure prevention to therapeutic – which is the goal of the test in the first place, only the deductible is waived for colorectal cancer screenings.    Medicare patients run the risk that they go into a procedure assuming that all cost sharing is waived, only to wake up from sedation to realize that they owe a 20 percent co-pay if a polyp is removed – depending on site of service this amount is between $138 and $193. The Congressional Budget Office estimates the cost to correct this oversight as $200 million over 10 years.
  •  Here’s what happens:The patient goes for Screening Colonoscopy so it’s a preventive service and gets Code G0121But, if I find a polyp and excise it, now it’s Code 45385The good news is that I may have prevented colorectal cancer. The bad news is here is a bill for what the patient previously thought was a free service. In effect, this “post polypectomy” surprise penalizes Medicare patients financially for getting screened.
  • This chart outlines the cost-sharing changes for colonoscopy. As you can see, the health reform waived certain cost-sharing but did not go far enough to completely remove this barrier to screening. Cost sharing still applies.It is important to note that beginning 2014 this cost-sharing quirk will also impact privately insured patients and not just Medicare beneficiaries. Conservative estimates in the medical literature suggest that these cost-sharing quirks may impact 25% of men undergoing screening colonoscopy and 15% of women.
  • As physicians, we work every day to remove some screening barriers, such as addressing patient fear through education, but Congress needs to step in to remove this financial barrier. According to Medicare, a legislative fix is necessary to waive all patient cost sharing for these screenings that turn into a polyp removal.  The irony here is that this is the reason why the USPSTF rates colonoscopy an ‘A’ recommended preventive service in the first place: because the “screening” and the polyp removal occur at the same time or patient encounter, thereby preventing cancer from occurring. This is precisely why we need Congress to fix this coverage quirk in order to increase screening rates. ACG supports Rep. Dent’s bill. We are glad you will be on Capitol Hill asking for support. What have I and physicians been doing? ACG members and friends, including Marylou Stinson here today from South Carolina, have also been on Capitol Hill advocating on behalf of the SCREEN Act, a bill which incorporates the same cost-sharing provision as Rep. Dent’s bill among other provisions relating to providing the screening. ACG appreciates the opportunity to join grassroots efforts with Fight Colorectal Cancer in getting this cost-sharing barrier resolved once and for all.
  • William R Stern MD ConC2012 Presentation

    1. 1. The Affordable Care Act’sImpact on Preventive Services William R. Stern, MD, FACGAssociates in Gastroenterology Rockville, MD Governor for Maryland American College of Gastroenterology
    2. 2. Colonoscopy inthe NewsZauber, Winawer study provescolonoscopy with polypectomyreduces colorectal cancerdeaths by 53 percentFeb. 22, 2012 Denise Grady“Report Affirms LifesavingRole of Colonoscopy”
    3. 3. Colorectal Cancer Incidence & Mortality Maryland United States Estimated Colorectal 2,630 142,570 Cancer Incidence (2010) Estimated Colorectal 950 51,370 Cancer Deaths (2010)
    4. 4. Colorectal Cancer Screening Rates Maryland United States Screening Rates of U.S. 69% 63% Adults Aged 50+ (2008) Screening Rates of NA 58.1% Medicare-aged Adults, (American Cancer Society 2011)
    5. 5. Colorectal Screening –The Power of Prevention Screening by colonoscopy can prevent colorectal cancer by identifying and removing pre-cancerous polyps during the same encounter U.S. Preventive Services Task Force (USPSTF) gives colorectal cancer screening an “A” – one of only two screenings
    6. 6. History of Medicare’s ColorectalScreening Benefit ACG lead the efforts to get Medicare to cover colorectal cancer preventive screening as a benefit in 1998 working with patient advocates and other professional organizations Colonoscopy for high risk only in 1998 In 2000, the law changed to cover colonoscopy for average risk individuals
    7. 7. A Barrier to Medicare Screening:Out-of-Pocket Costs Colorectal mortality is declining, but screening rates remain low for Medicare patients Barriers to screening remain high – Including patient out-of-pocket costs
    8. 8. What is the problem? Good news: The health reform law eliminates all Medicare beneficiary cost sharing for colorectal cancer screenings Bad news: Cost sharing still applies for any colonoscopy screening that turns into a therapeutic procedure to remove a polyp
    9. 9. A “quirk” in the health reform law The Patient Protection and Affordable Care Act (known as the “ACA”) creates an unintended problem for patients: Under the health reform law, cost sharing still applies for a screening colonoscopy that turns into a therapeutic procedure! This means that a beneficiary may go into a screening exam expecting no deductible or co-pay, but if a polyp is found and removed, the patient becomes responsible for the co-pay (20% Medicare coinsurance)
    10. 10. Coding for Colonoscopy:“Screening” vs. “Therapeutic”Physicians are required to code a preventive“screening” exam differently from the screeningthat ultimately turns into a procedure thatremoves polyps Screening Colonoscopy (Code G0121) Colonoscopy w/ Polyp Removal (Code 45385)“Post polypectomy surprise”
    11. 11. Colonoscopy:“Screening” vs. “Therapeutic”Colonoscopy Medicare Current Private Insurance Before Health Medicare Beginning 2014 Reform Law PolicyScreening: Coinsurance (20%) Applies Waived Waived Deductible Waived Waived WaivedTherapeutic: Coinsurance (20-25%) Applies Applies Will Apply Deductible Applies Waived Will Apply
    12. 12. Legislative Fix Representative Dent’s bill SCREEN Act (HR 3198) ACG appreciates the opportunity to join grassroots efforts with Fight Colorectal Cancer to get this cost-sharing barrier resolved once and for all