Report: More cancer screening reimbursement leads to more usage, earlier diagnosis

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Back in 1998,Medicare raised the amount it pays for colon cancer screening. A study was conducted to evaluate the impact the change had and found a rise in the number of colonoscopies by Medicare beneficiaries as well as a jump in the number of patients being diagnosed with the disease at an earlier stage. The study is published in the December 20 issue of JAMA ( Journal of the American Medical Association). 

Widespread screening has actually not been at what experts consider optimal levels, according to background information in the article. The 2000 survey found that 42.5 percent of respondents 50 years of age and older were up to date with colon cancer screening, while persons 65 years of age and up were 48.7 percent up to date. Prior to 1998 a lack of insurance reimbursement could have been a likely cause.

To determine whether expanded Medicare reimbursement policies after 1998 were directly associated with changes in the use of colonoscopy researchers analyzed data from the Surveillance Epidemiology and End Results (SEER) -Medicare linked database of individuals who were 67 years of age and older and had a primary diagnosis of colon cancer during 1992-2002, as well as a group of Medicare beneficiaries who were not diagnosed with cancer, according to a release of the results.

"Our finding that new Medicare policies may have facilitated early diagnosis is encouraging and supports the institution and evaluation of other efforts to broaden the access to and use of screening tests in the older population. Given that there are approximately 60,000 cases of colorectal cancer diagnosed annually among patients 65 years of age and older in the United States, even a 4 percent increase in the percentage of patients whose cancer is diagnosed at an early stage can have a substantial impact at the population level," the authors wrote. "Increasing the use of screening tests further has the potential to diagnose many more beneficiaries at an early stage."

Patients with cancer were classified in stages, early (stage I) vs. all other (stages II-IV). Additionally, time was categorized as in periods 1-3:  period 1 (no screening coverage, 1992-1997), period 2 (limited coverage, January 1998-June 2001), and period 3 (universal coverage, July 2001-December 2002).

The researchers found that among the sample of Medicare beneficiaries who did not have cancer, there was an increase in colonoscopy use during the study period. The average colonoscopy rate per 100,000 beneficiaries per quarter tripled from period 1 to 2, and went up 6.5 times, comparing period 1 to period 3.

The final sample of patients with colorectal cancer consisted of 44,924 patients (average age, 77.4 years; 56 percent were women and 8 percent were black). The time period was significantly related to stage at diagnosis. Nearly 22.5 percent of patients were diagnosed at an early stage in period 1 (1992-1997), with 25.5 percent in period 2 and even more (26.3 percent) in period 3. In further analysis, patients diagnosed in periods 2 and 3 were much more likely to have early-stage illness than patients diagnosed in period 1, according to a release of the results.

In an editorial accompanying the report, Arden M. Morris, MD, MPH, of the University of Michigan, Ann Arbor commented that the findings “demonstrate that the change in Medicare policy was effective: a target population received screening at a higher rate and this resulted in an increase in the detection of early stage and right-sided cancers. It remains to be seen if future screening will continue to increase the rates of early identification of colorectal cancer. Given the costs of universal screening, if rates of colonoscopy continue to increase without additional benefit in overall diagnosis of early stage disease, policy makers, health care organizations, and physicians may have to devise a feasible rationing plan for broader colon screening. While increasing access to care and improving compliance with recommended care is an undeniable good, providing screening colonoscopy to all is not realistic.