Why Aren’t More Americans Getting the Test that Could Save Their Lives? Capitol Hill Briefing on Colorectal Cancer Prevention March 20, 2013 Tom Deas, MD President, American Society for Gastrointestinal Endoscopy

Tragic Costs of Colorectal Cancer (CRC) Pain, suffering, and death Lost grandparents, parents, children, aunts, uncles, friends, colleagues... Economic impact Cost of care Lost productive minds Research funding

Cost of Cancer Care National Institutes of Health Cancer Trends Progress Report 2011/2012 Update

National Expenditures for Cancer Care National Cancer Institute

Value of CRC Prevention $29,000 average 1 st year Medicare cost for CRC diagnosis $300,000 for late stage CRC $600-$800 screening colonoscopy cost in ASC

Value of CRC Prevention $10.7 billion in lost productivity in 2005 due to CRC. 1/3 rd of CRC occurs pre-Medicare Screening colonoscopy in the age population has potential to save Medicare $15 billion annually (’08 NCRCRT/Lewin study)

Ambulatory Surgery Centers High quality—Low cost Sites of service for screening colonoscopy ASC Hospital outpatient department (HOPD) Office About 41% of Medicare patients receive colonoscopy in an ASC Safe, effective, patient-centered, timely, efficient, equitable

ASC payment = 56% of HOPD (CMS) = 33-50% (Commercial) Case migration ASC = $$$$ Ambulatory Surgery Centers High quality—Low cost

“Get your butt to the doctor!” - Katie Couric, March 5, – Medicare coverage of screening colonoscopy for average-risk patients – Deficit Reduction Act eliminated Medicare patient deductible for CRC screening.

Screening Recommendations U.S. Preventive Services Task Force 2008 – The USPSTF gives an “A” recommendation, to screening for colorectal cancer using fecal occult blood testing, sigmoidoscopy, or colonoscopy, in adults, beginning at age 50 years and continuing until age 75 years.

Affordable Care Act Provisions ACA waives Medicare beneficiary cost sharing (deductible and coinsurance) for USPSTF-rated “A” and “B” services. ACA also requires private insurers to provide benefits for “A” and “B” services without cost sharing. ACA corrects DRA to exclude Medicare deductible for screening colonoscopy with polyp removal.

ACA-Implementation “Hiccup” Medicare patients still liable for coinsurance when polyps are removed during screening colonoscopy. Inconsistent cost-sharing practices by private payers.

Cost-Sharing Creates a Screening Barrier Cost sharing is a deterrent to screening Cost sharing = $100-$300 coinsurance when a polyp is removed Cost-sharing is higher for privately insured patients.

Clarifying Guidance for Private Payers Departments of Labor, HHS, Treasury February 20, 2013 – If a colonoscopy is scheduled and performed as a screening procedure and a polyp is removed during the screening, the plan or issuer cannot impose cost sharing. Why? Because “polyp removal is an integral part of a colonoscopy.”

Medicare CRC Screening Cost Sharing ColonoscopyEffective January 2011 Screening: CoinsuranceWaived DeductibleWaived Screening that includes polyp removal: Coinsurance Applies (20% of the Medicare-approved amount with no Part B deductible. If the test is done in a hospital outpatient department or an ambulatory surgical center, 25% of the Medicare-approved amount.) DeductibleWaived

Medicare Solution H.R. 1070, the “Removing Barriers to Colorectal Cancer Screening Act” Congressmen Charlie Dent (R-PA) Michael Fitzpatrick (R-PA) Joe Courtney (D-CT) Donald Payne, Jr. (D-NJ)