New Report Finds Patients Pay for Confusion Over Colonoscopy Screening

Today, the Kaiser Family Foundation—in partnership with CHIR, the American Cancer Society, and the National Colorectal Cancer Roundtable—released a new report exploring how private insurers are applying cost-sharing for colorectal cancer screening. Although the Affordable Care Act (ACA) aimed to remove barriers for accessing important preventive services, we found that consumers, insurers, and providers are confused about how and whether to apply cost-sharing for colorectal cancer screening.  We also encountered stories from consumers who faced unexpected cost-sharing and regulators who reported that they have received more complaints from consumers about this issue than any of the other new ACA protections.

What does the ACA cover? Under the ACA, private health insurers are required to cover certain recommended preventive services without cost-sharing, such as copays and deductibles. Among others, insurers must cover services with an “A” or “B” recommendation from the United States Preventive Services Task Force (USPSTF). These services include screening for diabetes, obesity, cholesterol, and cancers such as breast cancer, as well as drug and tobacco counseling, among others.

This requirement went into effect in September 2010 and is considered one of the ACA’s “early market reforms.” CHIR faculty recently found that nearly all 50 states and the District of Columbia have required or encouraged compliance with these new reforms, including the coverage of preventive services without cost-sharing. An estimated 54 million Americans received expanded coverage of preventive services under the ACA in 2011.

What did the report find? We studied how insurers are approaching cost-sharing for colorectal cancer screening in three different clinical circumstances: 1) when a polyp is detected and removed during a screening colonoscopy; 2) when a colonoscopy is performed following a positive stool blood test; and 3) when the individual is at increased risk for colorectal cancer and may receive earlier or more frequent screening compared with average risk adults.

Drawing from interviews with state regulators, consumer assistance programs, medical directors of major insurance companies, medical providers, billing experts, and patients, we found variation in how cost-sharing is applied and how providers code procedures in all three scenarios. We also found that state regulators were looking to the federal government for guidance on how to address this variation.

What do the findings mean? Colorectal cancer is one of the most common cancers and causes of death from cancer in men and women in the United States. It is estimated that almost 52,000 will die from the disease in 2012. Thus, screening for colorectal cancer—and the removal of precancerous polyps from the lining of the colon—is as important as ever to reducing premature death.

Colorectal cancer screening, however, is one of the more expensive preventive services covered under the ACA and charges can range from $1,000 to $2,000, or more. If consumers fear that their screening colonoscopy will not be covered, it could deter them from seeking screening. This concern was voiced by 70 percent of respondents in a recent survey of professionals from the National Colorectal Cancer Screening Network, which represents public health and health care professionals who deliver such services.

The findings suggest that additional clarification from the federal government could reduce coverage inconsistencies and help ensure that consumers have access to screening colonoscopies without cost-sharing. Guidance could be particularly helpful regarding the distinction between “preventive services” and “treatment” which may occur in the context of other screening benefits under the ACA, such as mammograms.

For information on reports like these—and much more—be sure to check in with CHIRblog‘s series on “Implementing the ACA.”