NCA (national coverage analyses) Tracking Sheet for Screening Computed Tomography Colonography (CTC) for Colorectal Cancer

Centers for Medicare and Medicaid Services (CMS)
Issue
CMS covers colorectal cancer screening for average risk individuals age 50 and older using fecal occult blood testing, sigmoidoscopy, colonoscopy, and barium enema (42 CFR 410.37). On March 5, 2008, the American Cancer Society, the US Multi Society Task Force on Colorectal Cancer, and the American College of Radiology issued new cancer screening guidelines, including a recommendation that computed tomography colonography (CTC) be considered an acceptable option for colorectal cancer screening for such individuals. CTC, also referred to as virtual colonoscopy, uses computed tomography (CT) to acquire images and advanced 2-dimensional (3D) -image display techniques for interpretation. Neither the Medicare law nor the regulations identify the CTC test as a possible coverage option under the colorectal cancer screening benefit. However, under 42 CFR 410.37(a)(1), CMS is allowed to use the NCD process to determine coverage of other types of colorectal cancer screening tests that are not specifically identified in the law or regulations as it determines to be appropriate, in consultation with appropriate organizations.
Actions Taken
February 11, 2009:
CMS posts a proposed decision memo indicating our intent not to expand the colorectal cancer screening benefit to include coverage of this test. We are also posting a technology assessment, including a cost effectiveness analysis for use of this test as a screening test which was requested from the Agency for Healthcare Research and Quality. As with all national coverage analyses, the public may submit comments or additional evidence that cause us to reassess our evidentiary review and arrive at different conclusions.
Tracking Sheet:
http://www.cms.hhs.gov/mcd/viewtrackingsheet.asp?id=220
Technology Assessment Report: Cost-Effectiveness of CT Colonography to Screen for Colorectal Cancer (92 pages):
http://www.cms.hhs.gov/determinationprocess/downloads/id58TA.pdf
Links to other documents:
http://www.cms.hhs.gov/mcd/viewnca.asp?where=whatsnew&nca_id=220&basket=nca:00396N:220:Screening+Computed+Tomography+Colonography+%28CTC%29+for+Colorectal+Cancer:Open:New:8

This CMS decision to not pay for computed tomography colonography (CTC or “virtual colonoscopy”) when used as a screening test for colorectal cancer has already caused considerable controversy even before the final public comment period has closed. Before we start deciding who is right and who is wrong, we should look at the issues. (What? Make decisions based on facts!?)
Medicare, as a public health insurance program, has an obligation to finance health care for which the benefit to patients more than offsets any potential risks. Also, as a steward of taxpayer funds, Medicare has an obligation to see that those funds, which are finite, are used optimally to benefit the public good. Ah ha! Rationing! But is it?
Rationing is generally defined as distributing restricted allotments of a scarce resource. Current debates on rationing stem from concerns about the escalating costs of health care, creating an excessive demand on our limited resource of… dollars! So are dollars becoming so scarce that we have to cut back on beneficial health care services?
Let’s look at how Medicare approaches this problem. Medicare does not make treatment decisions, but rather makes decisions about whether or not to pay for certain services. These decisions are important not only for Medicare patients, but for other patients as well, since the commercial insurance industry often follows Medicare’s lead on whether or not to pay for these selected services.
Virtual colonoscopy (CTC) used as a colorectal cancer screening test serves as a good proxy for this decision process.
First, does CTC screening benefit the patient? No attempt will be made to summarize the massive amount of studies and documentation that has been used to answer this question, but only a couple of points will be made here. If a CTC test is positive, it then is followed up with colonoscopy, which has already been approved as a screening test for colorectal cancer. Thus the patient has received two uncomfortable, expensive screening tests when only one has sufficient data to confirm its unquestionable value in screening. Further, over one out of one thousand patients receiving CTC screening at age 50 will likely develop cancer as a result of the radiation exposure from this test, resulting in a negative impact on the benefit/risk ratio.
Second, is CTC screening a responsible use of taxpayer funds? The Technology Assessment Report indicates that, based on cost effectiveness, it would not be in our interests, as taxpayers, for our public stewards to pay for CTC screening.
Consequently Medicare has made a decision to not pay for CTC screening for CRC, unless new important information is provided during the pubic comment period, or if new studies in the future would warrant readdressing this issue. It is likely that several commercial insurers will follow Medicare’s lead on this.
So what is the controversy? It comes from two sources: 1) dedicated professionals who have legitimate disputes over the interpretation and weighting of the evidence, and 2) right-wing ideologues who see this as a golden opportunity to attack “government medicine.”
Innumerable studies confirm that a significant portion of wasteful spending stems from non-beneficial, high-tech excesses. Defining those excesses will always be controversial, but the process used by Medicare is precisely what we need, especially with the inevitable improved refinements in the process that we will see in the future. Those dedicated professionals who will be denied payment by these decisions will always have doubts about the process, but they will always have the opportunity to provide more data that would warrant reconsideration of the payment decisions.
What will we see from the right-wing non-think tanks? The government rations care. Government medicine kills people over 65 who have colon cancer. Government deprives patients of their health care decisions. Patients should own their own health care and get the government out of their lives.
Refuting their position, it is important to understand that this is not rationing. The government is not declining to pay for CTC testing in individuals for whom it is clinically indicated. They have merely made a decision to not pay for CTC screening when the clinical data and costs have not demonstrated that it has advantages that would warrant it being included as a screening option. The conservatives/libertarians would substitute for rational decision making by our public stewards, a chaotic health-business marketplace that would prevent the majority of us from receiving the care that we need merely because it isn’t affordable.
Medicare has shown that we can address wasteful, excess costs. The easiest measure would be to recover the costs of the administrative excesses – a process that would be made possible by providing everyone with Medicare. Reducing the waste of high-tech excesses is more difficult, but the national coverage determinations process (NCD) has shown us that it is not only possible, but that we must expand this important government function since it will help to guarantee that high-quality, affordable care will always be there for all of us.

Centers for Medicare and Medicaid Services (CMS)

Issue

CMS covers colorectal cancer screening for average risk individuals age 50 and older using fecal occult blood testing, sigmoidoscopy, colonoscopy, and barium enema (42 CFR 410.37). On March 5, 2008, the American Cancer Society, the US Multi Society Task Force on Colorectal Cancer, and the American College of Radiology issued new cancer screening guidelines, including a recommendation that computed tomography colonography (CTC) be considered an acceptable option for colorectal cancer screening for such individuals. CTC, also referred to as virtual colonoscopy, uses computed tomography (CT) to acquire images and advanced 2-dimensional (3D) -image display techniques for interpretation. Neither the Medicare law nor the regulations identify the CTC test as a possible coverage option under the colorectal cancer screening benefit. However, under 42 CFR 410.37(a)(1), CMS is allowed to use the NCD process to determine coverage of other types of colorectal cancer screening tests that are not specifically identified in the law or regulations as it determines to be appropriate, in consultation with appropriate organizations.

Actions Taken

February 11, 2009:
CMS posts a proposed decision memo indicating our intent not to expand the colorectal cancer screening benefit to include coverage of this test. We are also posting a technology assessment, including a cost effectiveness analysis for use of this test as a screening test which was requested from the Agency for Healthcare Research and Quality. As with all national coverage analyses, the public may submit comments or additional evidence that cause us to reassess our evidentiary review and arrive at different conclusions.

Tracking Sheet:
http://www.cms.hhs.gov/mcd/viewtrackingsheet.asp?id=220

Technology Assessment Report: Cost-Effectiveness of CT Colonography to Screen for Colorectal Cancer (92 pages):
http://www.cms.hhs.gov/determinationprocess/downloads/id58TA.pdf

Links to other documents:
http://www.cms.hhs.gov/mcd/viewnca.asp?where=whatsnew&nca_id=220&basket=nca:00396N:220:Screening+Computed+Tomography+Colonography+%28CTC%29+for+Colorectal+Cancer:Open:New:8

Comment:

By Don McCanne, MD

This CMS decision to not pay for computed tomography colonography (CTC or “virtual colonoscopy”) when used as a screening test for colorectal cancer has already caused considerable controversy even before the final public comment period has closed. Before we start deciding who is right and who is wrong, we should look at the issues. (What? Make decisions based on facts!?)

Medicare, as a public health insurance program, has an obligation to finance health care for which the benefit to patients more than offsets any potential risks. Also, as a steward of taxpayer funds, Medicare has an obligation to see that those funds, which are finite, are used optimally to benefit the public good. Ah ha! Rationing! But is it?

Rationing is generally defined as distributing restricted allotments of a scarce resource. Current debates on rationing stem from concerns about the escalating costs of health care, creating an excessive demand on our limited resource of… dollars! So are dollars becoming so scarce that we have to cut back on beneficial health care services?

Let’s look at how Medicare approaches this problem. Medicare does not make treatment decisions, but rather makes decisions about whether or not to pay for certain services. These decisions are important not only for Medicare patients, but for other patients as well, since the commercial insurance industry often follows Medicare’s lead on whether or not to pay for these selected services.

Virtual colonoscopy (CTC) used as a colorectal cancer screening test serves as a good proxy for this decision process.

First, does CTC screening benefit the patient? No attempt will be made to summarize the massive amount of studies and documentation that has been used to answer this question, but only a couple of points will be made here. If a CTC test is positive, it then is followed up with colonoscopy, which has already been approved as a screening test for colorectal cancer. Thus the patient has received two uncomfortable, expensive screening tests when only one has sufficient data to confirm its unquestionable value in screening. Further, over one out of one thousand patients receiving CTC screening at age 50 will likely develop cancer as a result of the radiation exposure from this test, resulting in a negative impact on the benefit/risk ratio.

Second, is CTC screening a responsible use of taxpayer funds? The Technology Assessment Report indicates that, based on cost effectiveness, it would not be in our interests, as taxpayers, for our public stewards to pay for CTC screening.

Consequently Medicare has made a decision to not pay for CTC screening for CRC, unless new important information is provided during the pubic comment period, or if new studies in the future would warrant readdressing this issue. It is likely that several commercial insurers will follow Medicare’s lead on this.

So what is the controversy? It comes from two sources: 1) dedicated professionals who have legitimate disputes over the interpretation and weighting of the evidence, and 2) right-wing ideologues who see this as a golden opportunity to attack “government medicine.”

Innumerable studies confirm that a significant portion of wasteful spending stems from non-beneficial, high-tech excesses. Defining those excesses will always be controversial, but the process used by Medicare is precisely what we need, especially with the inevitable improved refinements in the process that we will see in the future. Those dedicated professionals who will be denied payment by these decisions will always have doubts about the process, but they will always have the opportunity to provide more data that would warrant reconsideration of the payment decisions.

What will we see from the right-wing non-think tanks? The government rations care. Government medicine kills people over 65 who have colon cancer. Government deprives patients of their health care decisions. Patients should own their own health care and get the government out of their lives.

Refuting their position, it is important to understand that this is not rationing. The government is not declining to pay for CTC testing in individuals for whom it is clinically indicated. They have merely made a decision to not pay for CTC screening when the clinical data and costs have not demonstrated that it has advantages that would warrant it being included as a screening option. The conservatives/libertarians would substitute for rational decision making by our public stewards, a chaotic health-business marketplace that would prevent the majority of us from receiving the care that we need merely because it isn’t affordable.

Medicare has shown that we can address wasteful, excess costs. The easiest measure would be to recover the costs of the administrative excesses – a process that would be made possible by providing everyone with Medicare. Reducing the waste of high-tech excesses is more difficult, but the national coverage determinations process (NCD) has shown us that it is not only possible, but that we must expand this important government function since it will help to guarantee that high-quality, affordable care will always be there for all of us.