An opinion piece in the September issue of the Journal of the American College of Radiology lambasted the Centers for Medicare & Medicaid Services (CMS) for its decision denying coverage of CT colonography (CTC) for colorectal cancer screening.
One of the reasons given by CMS for its decision was its “pivotal, overarching concern” that the data from clinical trials on the benefits of CTC colorectal cancer screening might not be applicable to the average Medicare beneficiary because the age of the average beneficiary is higher than that of the patient cohorts in these trials.
The editorial, written by Bibb Allen Jr., MD, of Trinity Medical Center’s department of radiology in Birmingham, Ala., noted that “in the past, CMS has inferred applicability to the Medicare population for many new technologies and treatments.”
For example, wrote Allen, clinical evidence regarding technical innovations in cardiovascular disease “has been generalized to the Medicare population, despite age discrepancies in the cohorts in the clinical trials and the Medicare population similar to the age discrepancies in the clinical trials of CTC.”
Yet, he pointed out, CMS has reached the opposite conclusion regarding coverage for CTC.
“The reasons for requiring clinical trials specifically designed to study screening CTC in the subset of the Medicare population aged 65 to 75 years are not clear,” wrote Allen. “Perhaps CMS is merely using the lack of Medicare-specific studies as a convenient reason for not covering CTC for screening. Given the current pressure to reduce Medicare spending, this is certainly a plausible if not likely consideration.”
Allen also responded to an “unusual editorial” in the New England Journal of Medicine, in which, wrote Allen, CMS medical officers “praised their own ‘landmark decision’ as an unprecedented endorsement of evidence-based medicine while deriding those who disagree with their decision by characterizing the efforts of ‘radiologist groups’ and other proponents of CTC, including the American Gastroenterological Association and the American Cancer Society, as political pressure.”
Allen called the editorial “unusual” because two of the authors were CMS medical officers responsible for writing the colorectal cancer coverage decision who were “opining as if they were disinterested observers of the process,” while ignoring opinions that do not share their views regarding the benefits of CTC screening for colorectal cancer.
“Instead, the editorial's authors publically derided the efforts of the ACR and other medical societies, electing to characterize efforts to educate members of Congress about the benefits of CTC for Medicare patients as financially motivated advocacy,” wrote Allen. “Sarcastically criticizing specialty societies for using their right of freedom of speech to advocate for a technology that they believe is likely to save lives is highly inappropriate. So, too, is the derision of the coverage decision comment process that condemned the supporting comments by interested physicians and members of the public as ‘powerful pressure’ from ‘interest groups.’”
The ramifications of withholding diagnostic testing, surgery and care on the basis of age, wrote Allen “are almost unimaginable.”
The overall health of a patient, and not his age, should determine the best course of treatment, Allen concluded, and CMS’ decision to use age as a basis of coverage could “become a slippery slope” as the country strives for healthcare reform.