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.
When I refused it was clear from her face that I was ‘difficult’. To my objection that I was low risk I was
told ‘it doesn’t work that way’. For that and other reasons I will be replacing the Weill Cornell docs.
Yes. Anyone turning down these tests is a pariah.
Not to be crude, but the Health care system is so used to shoving everything and the kitchen sink up our proverbial asses that when we decline consent for access to our rear ends, they act like a spurned rapist.
Ive heard that mammograms are similarly unnecessary.
I have “discussions” with my generally very good doctor about this stuff. I’m reasonable, but tend to do all the tests they want about 1/2 as often as they want them (pap smears, mammograms, physicals with blood work etc.). I just had my first colonoscopy (and probably my last) at age 54. BUT, I look at my family history and in 3 generations including many aunts and uncles, there is exactly 1 case of cancer and that was my grandfather’s lung cancer after smoking for 40 years. My family runs to allergies, asthma, auto immune disease (I wonder if over active immune systems lead to less cancer?), a smattering of neurological issues and heart disease, but almost no cancer.
It is very informative to look at the recommendations for “screenings’ and “preventative care” in places where medical care isn’t a profit center.
There is some evidence that having allergies is associated with less cancer.
I believe there is also some evidence that constant irritation can cause cancer, so YMMV.
Chronic low-level inflammation is known to cause heart disease, and may also cause senility.
Floss your teeth- gum disease is a common cause of low-level inflamation.
There’s more crap in the food supply than in past generations. Family history may be part of the picture, but what you eat may also play a role. If you eat a lot of fast food or processed food, maybe getting regular colonoscopies is a good idea.
‘Yes. Anyone turning down these tests is a pariah.”
One-size-fits-all Medicine has been mentioned here before and that is how the Covid treatment is going. I see all Medicine going that way with the treatments dictated by the corporations. Don’t like it—you are a pariah and will be treated as such. “We do not have time for your opinion, you, the non-expert.”
About eight years ago, in a cardio situation, I turned down the Industrial Medicine recommended treatment having read numerous, well qualified experts who said the treatment was a corporate sham. Glad I did as in the subsequent years those contrarian experts have been proven to be correct. I also remember that the Doctor who discharged me was quite miffed by my refusal as was a nurse who indicated I might soon die.
Not too shocking, given our great and wonderful US healthcare. As to the consistent recommendation to have the colonoscopy once every 10 years, is there reasonable data to support not doing so? Risk reward scenarios for equity or fixed income is something to run through an IRR or monte carlo simulation. This is much different
Cancer runs in my family, so I plan on this next two years. Important to get aware of the potential costs and cumbersome nature of health coverage, so this post is very helpful.
Yes, and colon cancer has been increasing among people under 50 for a few years now. Colonoscopies are notoriously unpleasant, but I don’t know that I would avoid getting one if my doctor advised me to do so.
Well, to be precise, colonoscopies themselves are not unpleasant; I’ve had 5 of them. The preparation is very unpleasant and to me that’s quite different.
Also, how does one know what risk level they have? As far as I can tell, the way this occurs is by looking at large amounts of data amassed by medical people who use, among other things, information gleaned from colonoscopies.
“colonoscopies themselves are not unpleasant; I’ve had 5 of them. The preparation is very unpleasant”
I had been told this dozens of times, so I dreaded the prep but not the procedure. To my surprise, I found the prep to be relatively easy, once I was psyched for it. I was not prepared to repeatedly awaken from “twilight sleep” in terrible pain during the colonoscopy. They kept putting me under, only for me to start awake with a stab of intense pain. This happened four times.
I will not have another colonoscopy unless given a compelling reason to do so. It’s an invasive procedure, and there is no colon cancer in my immediate family.
hm, sounds like doctor used a low grade sedative, or possibly you are very resistant to it, my wife had a similar experience, only her’s didnt include pain, she just heard the doctors and nurses talking during the surgery
I’ve had three. For the first one, at age 55, I asked the dr to leave me (semi-)conscious, so I could observe. He woke me up and, after seeing my insides on the monitor I promptly passed-out. None were painful, but the prep isn’t particularly fun. I get them every 5 years since my father had colon cancer, surgery and had to wear an ostomy bag for over 20 years (he never complained once, he was happy to be alive; the treatment for the throat cancer he got later was brutal).
For my procedures, they’ve always removed a few pre-cancerous polyps. My OD said the average time for a polyp to progress to a tumor is 7 years, and if I continued to get a colonoscopy every five years I was all but guaranteed to not get colon cancer. That’s a fair tradeoff with the hassle and expense IMO. The first three were on private insurance, the next one will be on Medicare; anyone know how Medicare handles these?
ps. My OD did colonoscopies two days a week, all day; he basically had an assembly line going.
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.
There are about a billion things wrong with health care in this country, but just one thing is the justification of the “market” for pricing, when it is obvious that at least in a market there is transparency of prices.
Nobody has any idea of what anything costs. That is the way the people COLLECTING the money want it.
Every day, this story occurs thousands, tens of thounsands, maybe a million times.
And strangely (well, not so strangely) the political system is a perfect mirror of the medical system – so many people not getting what they want….
As a cash payer for healthcare, it’s a different process. It’s like calling around to find the cheapest price on a refrigerator.
This is all bs.
I, having had to go the “cash payer” route several times out of necessity, can testify that there are medicine adjacent people and organizations who will not give out the ‘real’ price to a non-professional.
Then we get to the phenomenon of multiple price levels for a device or procedure depending on who is doing the paying.
My favourite analogy here is that of buying a new car at a dealership. Rule number one is: Never say that you are paying cash. When you say this, the price always goes up, automatically. Why? Most dealerships make their “big” money on their cut from the finance charges for the auto loan. All cash buyers don’t pay loan fees and interest. The dealership makes up the “difference” by raising the price.
The lesson here is that “The Market” itself is an exercise in bs.
Welcome to the Neo-liberal Dispensation.
Most of the recommendations for preventative care involve some way for the medical-hospital-pharma complex to make money. The colonoscopy is “free” but if they find polyps, they will remove them and you’ll be charged $$$ for that.
There’s so much pressure from these PCP’s to have you undergo tests; yet they have no clue as to what they cost!
none of the doctors or other providers know any thing about the costs of any thing. and even billing department has no idea
Yes. I reduced the number of epi-pens I got this year. We normally do 2 boxes (4 pens), but I reduced to 1 this year since my son doesn’t lose them anymore. My son’s pediatrician asked me if they charge by the prescription or by the box. It is by the box. Over $500 for 1 box this year since I haven’t met my deductible this year.
He had no idea.
Canadian pharmacy or la farmacia if you’re closer to the border
Self-licking ice cream cone ( SLICC) tied to the most terrifying part of our lives: our health, the health of loved ones, and the fear-laden specter of suffering through our immortality and not having a way to pay for it all.
Predatory immoral abuse of fellow humans. We are some animal, Homo sapiens…
Let’s not forget that invasive tests such as a colonoscopy have risk. What if the doctor makes a mistake and you are left holding the bag so to speak…not funny I know but truly you are at the mercy of the skill of the doctor. Anyone who has ever had the test knows how awful it is just prepping for it. Anyway, aside from researching any particular advised test, not an easy task as a lay person, to try to ascertain if it’s really necessary or not, this issue and many others of over-testing people in the U.S. can presumably be mitigated in some cases if we eat better, keep weight down and exercise. We’ve been conditioned to ignore habits and just rely on the medical establishment to keep us healthy. For example, if you take cholesterol meds, do you care if you eat eggs or not? I know health for each individual is not that simple but I think based on the U.S. penchant for lousy and unnecessary healthcare that we pay through the nose for, we need to take control of our health as much as possible. It’s mind-boggling to have any idea what is really necessary and how often – the recommendations change all the time. Mammograms, pap smears, colonoscopy…even teeth cleaning and other procedures – how often is necessary and what about the radiation from tests that are supposed to be routine? It’s a long list of complicated decisions unless you are very trusting and just assume doctors are gods and never make a mistake.
I think it’s a good idea to get at least one. My brother-in-law had a huge polyp that was supposedly pre-cancerous. It was discovered when he had his first colonoscopy. I also know someone whose sister died in her forties of colon cancer.
The Big issue with Colon cancer screening is unnecessary screening colonoscopies. The recommendation for colonoscopy every 10 years in low risk patient is based on inadequate science. It’s based on the natural history of polyp transformation. The problem is low risk patients with no family history are unlikely to develop polyps after a negative colonoscopy. Even considering sampling error 90% of polyps never transform into malignancy. When you consider the number of people that have had two negative studies getting a 3rd screening colonoscopy at 70 is a BIG problem. Beside tying up limited resources the risk of a procedural misadventure is far greater than finding cancer or premalignancy on the 3rd study. But Medicine won’t address the inadequate data they aren’t interested in knowing. Unfortunately colonoscopies are done on individuals that have an ability to pay.
My doctors and the health insurer hounded me for 5 years. We also were hounded by my husbands employer wellness plan. His employer forced us to be in wellness plan in order to get insurance for dependents. That free preventative cost me 2200.00 out of pocket. The polyp they found was lower and could have been done by sigmoidoscopy. When I brought up that I would prefer this less invasive method, and had no colon cancer in my family? I could barely even get them to acknowledge that this other procedure existed.
Like everything else it’s a racket.
What’s this “health insurance” malarkey? Sounds like a scam to me.
A. Smug-Brit, Esq.
Thank you for this post. It makes sense that at 60 your cells aren’t as coherent as they were even at 50. To diagnose cancer cells (my experience) is never easy – you have to look at the state of proliferation, accelerated growth, of cells in a smear sample. If some cells have characteristics of rapid growth, like there are too many of them and they are smaller (simple things) then there’s a calculated probability of cancer. And the lab will inform the PCP what your probability is. At 60 all cells get goofy, not just cancer cells. That colonoscopy could definitely be a waste of time and money. So this makes me feel much saner at 75. My new doc (whom I like) just handed me the at-home sampler and asked why I had not done the last one? “You do still poop, don’t you?” she said. I could only smile thinking of all the answers I could give her. And politely took the little package home and threw it away.
Why would you buy a cancer test when the NHS does them for nowt? Oh, you’re Americans.
I’m fending off the ‘tender ministrations’ of my generally reasonable medica concerning this exact item now. The thinking seems to be that since I am now Medicare “enabled,” cost is not a factor. That last is an argiment without merit.
Medicare is a fully dysfunctional neo-liberal mare’s nest today. Part A, in hospital costs, has one annual ‘deductable.’ Part B, outpatient care, not only comes with an monthly fee, ($149 USD for most,) but also an annual, even if reasonably small, deductable charge. Then there is the 80/20 cost sharing formula. Medicare sets basic prices and then proceeds to only pat 80% of that. The “customer” is left to pay the other 20%. Enter Medigap Insurance, a federally ‘managed’ but private insurance scheme to cover that ‘last’ 20%. Basically, the Federal Government establishes guidelines concerning the services covered by Medigap policies. There are now eight (8) types of Medigap plan available, along with some “High Deductable” versions of same. Each type of plan covers the same ‘benefits’ across all providers.
Here is the kicker, to provide Medigap plans, an insurance company must offer Plan A, and then is allowed to chose which of the other plan types to offer alongside it. Plan A, as one may surmise, is near the top of the price field. (I refer to it as the “Medicare Mine Field.”) Also complicating matters is that insurers can tailor their offerings and prices to each zip code. The basic plans stay the same across the country, just which plans offered per zip code can change, (again, A is the standard requirement.)
I coundn’t imagine a more “criminogenic environment” if I tried.
“I coundn’t imagine a more “criminogenic environment” if I tried.”
And unless you live in one of the few states that allow you to switch each year from one Medigap insurance company to another without underwriting, you can get stuck with the Medigap plan you initially choose (unless, of course, you wish to move to an Advantage plan or undergo underwriting.)
The insurance companies are always touting “choice”, yet you do not always have a choice once you choose a Medigap plan.
Back in 2009, my aunt and I went to a Bernie Sanders town hall in Peacham, Vermont (pop. 600). It was in the village’s Congregational Church and attracted an overflow crowd. Total attendance was around 600.
Now, if you’ve been to a Bernie Sanders rally, a lot of them are called town halls. Well, let me tell you, they’re mostly about listening to speakers.
At his town hall in Peacham, Bernie listened to the people, and, oh, did they have a lot to say. Health care was on many people’s minds, and I’ll never forget the young man who shared the story of his father’s colonoscopy. The procedure was botched, and in the aftermath, Dad lost the family farm.
What is the difference between a cologuard test and a FIT test? I do one of those every year, recommended by a doctor. The idea of a colonoscopy in a hospital – a surgical procedure- rightfully makes me uneasy for a number of reasons
There is a difference, apparently. I do a FIT test every year since I am uneasy about colonoscopies, and so far mine have been negative (knock on wood). I get the FIT test from my doctor and he is fine with this approach. I have also been giving a DIY FIT test (which I order online) to my 96 year old father in law for each of the five years since he moved in with us (since I know several very old people who got colon cancer that wasn’t found early). His last DIY FIT test tested positive. So, his doctor did a FIT test; that was positive, too.
Of course a follow up colonoscopy would be problematic for my FIL, since he is 96; he is incredibly frail and his skin is very thin (so he could be perforated). So the doctor recommended Cologuard. Apparently it tests for more things than the FIT test does; it could tell us if the positive FIT test result really was due to cancer. Unfortunately right now the Cologuard test is sitting on our table since his recent compression fractures make it hard to use safely until we get him treated with Reclast. The Cologuard will cost $600 out of pocket.
Colon cancer ought to be among the least of your father-in-law’s concerns. Why bother doing any of the screenings? If they turn out to be positive, then what? A colonoscopy to confirm? Then what? Surgery for a very frail 96 year old? That would make zero sense and would be cruel to say the least.
I’ve had a few, the earlier ones were simple, a sedative, one Doc, one nurse. The last one had a larger room, two nurses and an anesthesiologist, who counted me down until I no longer knew what was happening. Unnecessary, a risk in itself, and doubled the bill, which was the real reason for it. The enema solution is not good for you either.
Thanks so very much for this post. I was given the Cologard package, read up on it that involves yet more DNA collection and threw it out. Because I run on constant suspicion of the medical establishment, I figure it’s a big moneymaker for someone. I never thought of diagnostic coding! But went through that nonsense before.. I had to fight to avoid paying for, get this, mammograms after cancer! Yes! All mammograms after cancer were coded “diagnostic” and therefore not covered. Go figure.
Colonoscopies! Yes, I’m high risk, family history of colon cancer and Crohn’s. Last colonoscopy? Well over 10 years ago. You can’t pay me to do another one. I have a testy autoimmune digestive disorder so I’m not willing to go through the prep. I’ll take my chances, thanks.
Yes for me the DNA was the issue. I did some superficial poking and saw no reassurance that they didn’t keep it. You’d think they’d broadcast that if they didn’t.
I’m 69.5 yo. I’ve had three colonoscopies in the past four years. Noncancerous polyps were found, clipped, and removed, on all occasions.
I’ve refused anesthesia on all occasions. No pain. Mild discomfort like the sensation of diarrhea is all.
I refused anesthesia because several acquaintances have died from the procedure (perforation). There are usually a half-dozen students around each patient. The medical staff is more alert when the patient is conscious and alert to medical malpractice (less of a party atmosphere).
Interesting – my husband was pushed hard to have the colonoscopy and said only without anesthesia and the practice refused. Thanks for your posting. Makes a lot of sense that if the patient is awake, all are on their toes. I am very sorry to hear you knew people who died from malpractice during the procedure. That is really awful and a warning to all.
It’s important as you age to distinguish things you die with from things you die of. Much screening after 70 is finding things you end up dying with not of. Most people struggle to understand risk. It’s always a ratio of risk to benefit. The older you get the risk of testing out ways benefit.
If you consider the natural history of the 10% of polyps transforming into cancer takes 10 years.
Most colon cancer advance over 5 years. This time line should instruct ones decision on colorectal cancer screening. I haven’t mentioned the stress of false positives and
finding benign polyps at advancing age.