A new CBS story (hat tip crittermom) does a public service by alerting consumers to the financial, as opposed to health risks, of using a heavily-promoted at home colon cancer screen, Cologuard. The wee problem with this account is that it doesn’t being to explain the fact that colonoscopies are overprescribed in the US, and that even in normal circumstances, they represent a financial minefield.
Let’s first turn to the CBS story:
A popular home test to screen for colon cancer has come with an unexpected bill for some people — leading to fears they may put off life-saving treatment. Americans may be used to seeing commercials for Cologuard, an at-home test advertised as a way to screen for colon cancer at home instead of the much-more involved process of colonoscopy. Experts say it is a good screening tool, but some users have said they were faced with a high bill.
CBS then turns to the sad tale of Lianne Bryant from Missouri, who saw a Cologuard commercial and called her insurer to confirm that the test would be free. She sent in the test and got a positive result. That’s when things got messy:
Bryant ended up needing a colonoscopy after all, but was relieved to get a negative result.
Then the bills began arriving.
“I start getting statements from my hospital saying that I have a balance of $1,900,” Bryant said. “I’m thinking, well, I certainly don’t owe that much. I mean, that’s not possible.”…
Colonoscopies are provided at no cost to most people over age 45.
Under the Affordable Care Act, only routine screening tests are covered, and because Bryant’s Cologuard result was positive, her colonoscopy was coded as a “diagnostic” test, which was not fully covered by her insurance.
She would have been fully covered if she had not used Cologuard first.
“I am mad because I pay so much every month for this insurance,” Bryant said. “I just feel like I’m really getting raked over.”
CBS News surveyed 11 of the largest health insurers in the U.S. to see what they would do in situations like Bryant’s. Seven did not respond. The four who did said coverage decisions vary, and how much a consumer will pay depends on how doctors code the colonoscopy procedure.
The trap for Bryant is that under the Affordable Care Act, a list of preventive care services, including colonoscopies for older patients, are covered at zero patient cost.1 However, what this article misses is those supposedly free colonoscopies often aren’t. What is free is the doctor having a look and seeing if anything appears amiss. But clipping polyps isn’t covered and that part will lead to a bill. So it isn’t clear if the $1900 was just for the inspection or whether it included specimen removal. The median cost for a colonoscopy in St. Louis is $1600, so it’s not possible to make an informed guess either way based on price alone.
The Des Moines Register gave a similar warning in 2019, again based on a patient having been burned by an unexpected colonoscopy bill after using Cologuard. This story adds:
In the medical community, Cologuard has generally been considered a good thing: It detects genetic mutations commonly seen in colon cancer and detects blood in the stool. Medicare and many private insurance plans cover the test if it’s performed once every three years.
But agreeing to that cheaper, easier DNA screening for colorectal cancer can cost consumers much more in the end. Because if that test comes back positive, as mine did, some insurers and Medicare will no longer cover as a preventive service the colonoscopy that your doctor will inevitably order next….
Under my company’s Blue Cross Blue Shield plan, an in-network colonoscopy is supposed to be fully covered as a “preventive” benefit once every 10 years. But that same procedure is coded as “diagnostic” for insurance purposes after a positive Cologuard test….
My doctor didn’t tell me having the test could put my colonoscopy coverage at risk because she didn’t know. Nor did the administrator at the UnityPoint clinic I’ve gone to for years near Highland Park. She told me my case was a wake-up call for those who work there…
In reading up on Cologuard, I learned that some gastroenterologists are concerned that people already are being prescribed the tests who shouldn’t be.
Naresh Gunaratnam, research director at Huron Gastroenterology in Ypsilanti, Michigan, said in a Stat medical news article last year that he’s concerned physicians aren’t giving enough weight to the test’s limitations because of “an outsized focus on convenience.”
According to Becker’s Healthcare, a medical industry publication, a large study involving almost 10,000 subjects showed Cologuard detects 92% of colorectal cancer. But it’s not so good at detecting precancerous polyps, the article said.
The test also has a significant false-positive rate of 6% for those 50 to 65. Over 65, that rate goes up to 13%, according to Becker’s GI & Endoscopy.
A second issue is why colonoscopies being pushed so aggressively in the first place. The US is an outlier among advanced economies in recommending them for everyone over 50; most countries encourage them only for high risk groups.
Canada provides a striking contrast. Not only do Canadian experts deem colonoscopies to be not warranted as a first-line colon cancer screening tool for most patients, they find it to be less reliable for that application than other, less costly and intrusive methods. From Health News Review:
Generating numerous headlines in major Canadian papers such as the National Post, The Toronto Star, Globe and Mail and Reuters, the Canadian Task Force on Preventive Health Care came out this week with new recommendations on colon cancer screening, essentially saying that routine colonoscopies were not justified. By contrast, in the United States, the U.S. Preventive Services Task Force (USPSTF) 2015 guidelines say that adults aged 50–75, should have a colonoscopy every 10 years; FIT (fecal immunochemical testing) or gFOBT (guaiac fecal occult blood testing ) annually or flexible sigmoidoscopy every 10 years plus FIT annually.
For this age group the Canadian Task Force says there is insufficient evidence to justify using colonoscopy for routine screening for colorectal cancer. They recommend patients should undergo the fecal occult blood testing every two years or flexible sigmoidoscopy – a procedure which examines the lower part of the colon and rectum every 10 years. These colon cancer screening guidelines, published in the Canadian Medical Association Journal, are for low-risk people: asymptomatic adults, aged 50 to 74 who have no prior history of the disease, no family history or symptoms such as blood in the stool, or a genetic disposition to the disease…..
For this age group the Canadian Task Force says there is insufficient evidence to justify using colonoscopy for routine screening for colorectal cancer. They recommend patients should undergo the fecal occult blood testing every two years or flexible sigmoidoscopy – a procedure which examines the lower part of the colon and rectum every 10 years. These colon cancer screening guidelines, published in the Canadian Medical Association Journal, are for low-risk people: asymptomatic adults, aged 50 to 74 who have no prior history of the disease, no family history or symptoms such as blood in the stool, or a genetic disposition to the disease….
The Canadian approach is supported by other experts in the US such as Dr. Richard Hoffman, one of our medical editors whose opinion has not wavered from an article he wrote five years ago saying that “from a public-health perspective, emphasizing colonoscopy is problematic.” His article succinctly outlined the problems: “the efficacy of colonoscopy has not been supported with randomized trial data, accuracy is imperfect, procedural quality is variable, complications are not uncommon, endoscopic capacity is limited, procedure costs are high, and many patients prefer alternative tests.”
My PCP hasn’t objected to my refusing a colonoscopy and Cologuard and relying on other tests instead. But she’s also a solo practitioner. I suspect doctors in big corporate practices would get a service quality demerit for not hectoring colonoscopy conscientious objectors.
1 Under my grandfathered health plan, my situation is the reverse of Bryant. Preventive services save an annual physical and eye exam, are not covered, while treatment following a positive colon test would have been.