When the Affordable Care Act was signed in 2010, patients became eligible for coverage of screening examinations, which was good news for gastroenterologists and their patients in the fight to prevent colorectal cancer.
But there was a problem: While noninvasive stool tests – measuring microscopic amounts of blood or key DNA mutations, both tip-offs to increased colorectal cancer risk – were considered a screen, the necessary follow-up colonoscopy was not, leaving patients with expensive copays or other payment responsibility.
That interpretation prompted a years-long effort to have the federal agencies who oversee the health insurance sector reinterpret their policy, which finally changed in May 2022. Medicare, which is not covered by the ACA and is administered by a different agency, announced a change to its policy in July 2022, and the change went into effect in January 2023.
Dr. David Lieberman
“It’s a major victory for patients, and I couldn’t be more delighted,” said David Lieberman, MD, AGAF, professor of medicine in gastroenterology at Oregon Health & Science University, Portland, and former American Gastroenterological Association president, who participated in the effort.
AGA Regulatory Affairs Director Leslie Narramore said AGA Vice President of Public Policy and Advocacy Kathleen Teixeira worked for 10 years, alongside other GI societies and patient advocacy groups, to close the “colonoscopy loophole.” In 2022, the AGA, Fight Colorectal Cancer, and the American Cancer Society–Cancer Action Network met with White House officials and senior officials with the Department of Health & Human Services about expanding the coverage. They also lobbied to eliminate cost-sharing, another way in which preventive colonoscopy is discouraged.
“The COVID-19 public health emergency highlighted health disparities and barriers to access to care,” said Ms. Narramore, who gave input about the effort along with Ms. Teixeira and AGA Director of Government Affairs Sarah Ankney. “The temporary suspension of elective procedures, including screening colonoscopies, exacerbated the existing low colorectal screening rates and created momentum and willingness in agency officials to create positive change.”
Without coverage of the colonoscopy, patients have needed to cover at least part of the cost of the procedure, which could be $1,000 or more with private insurance, or $100 or more with Medicare, Dr. Lieberman said. So, he noted, unsuspecting patients might receive a positive result on a noninvasive test and have a colonoscopy, only to get a “surprise bill.” Or they would know about the lack of coverage and not get the colonoscopy.
“Prior to the policy change, gastroenterologists and their staff had to explain to patients that their insurer would not fully pay for a colonoscopy following a positive noninvasive stool test, and field questions from upset patients who weren’t aware of their insurance plan’s cost-sharing requirements for a cancer screening procedure they thought was free,” Ms. Narramore said.
There’s little doubt the change will help save lives and improve quality of life, Dr. Lieberman said.
“We don’t know the full impact of this new ruling, but we know that financial barriers are important for some patients,” he said. “And so by removing these barriers we hope that we’re going to see improved adherence to follow-up with colonoscopy after a positive stool test, and that would result in reductions in incidence, mortality, and increased life-years gained.”
Ms. Narramore said the changes show the importance of pushing for policy change.
“Our physician advocates were effective in educating policy makers on the need for coverage of the full colorectal cancer screening continuum, and how colorectal cancer needs to be viewed as a program given the various steps necessary for a complete screening,” she said. “These successful efforts demonstrate to our members that advocacy works and that they can be a voice for their patients in improving their access to care.”
