Category Archives: Colonoscopy

Higher-risk patients paying more for colonoscopies

Posted on by • Posted in Colonoscopy, Colonoscopy Diagnostic, Colonoscopy Screening, Health Insurance Coverage Adequacy, Health Insurance Industry, High Deductible Health Plans, High Prices, High Risk Patients, Out of Pocket Expenses, Surprise Bills • Leave a comment

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Published this week in Stat, this article explores the confusing payment landscape patients must navigate when receiving colonoscopies. While the Affordable Care Act requires that preventative care services be covered without cost-sharing, this only applies to the “screening” colonoscopies that low-risk patients are recommended to get every ten years.

But when procedures are performed at more frequent intervals for higher-risk patients, they are called “surveillance” or “diagnostic” colonoscopies, for which patients have no guarantees of cost-sharing protections, despite being essentially the same procedure, done for the same purpose.

If a gastroenterologist finds and excises one or more precancerous polyps during a screening colonoscopy, the procedure can leave the patient—especially one with a high deductible health plan—with a large, unexpected bill. 

The Gist: Against the backdrop of a sharp rise in colorectal cancer rates among US adults under 65, articles like this are a frustrating demonstration of how insurance incentive structures can work against optimal care delivery. 

Incentives should be carefully designed such that proven, preventative screenings—at the discretion of their doctor—are widely available to patients with minimal financial barriers. Surely, no one is “choosing” to have an “unnecessary” colonoscopy—as the procedure is notoriously disliked by patients. 

UnitedHealthcare to require prior authorization for some colonoscopies

Posted on by • Posted in Colonoscopy, Delayed Approval, Delayed Care, Denial, Health Insurance Industry, Physician, Prior Authorization, Profit Motive, Unnecessary Care • Leave a comment

https://mailchi.mp/73102bc1514d/the-weekly-gist-may-19-2023?e=d1e747d2d8

Starting June 1, UnitedHealthcare will require physicians to submit prior authorization requests for certain types of colonoscopies. While routine screening colonoscopies will remain exempt, United beneficiaries requiring surveillance or diagnostic colonoscopies—which are performed on patients at greater risk of developing colon cancer or those already exhibiting worrisome symptoms—will need advance approval for the procedures to be covered by the payer. A UnitedHealthcare spokesperson said that this policy change is due to concerns that colonoscopy overutilization generates unnecessary medical risks and higher healthcare spending for patients.

The American College of Gastroenterology released a statement criticizing the new policy on the grounds that prior authorization requirements create harmful delays for patients and are a significant source of provider burnout.

The Gist: So much for the planned rollback of prior authorizations that UnitedHealthcare recently touted. 

While the insurer is not wrong in saying that some studies have documented overutilization of colonoscopies, 

prior authorization is a blunt tool that takes care decision making out of practicing providers’ hands, redirecting that power (along with more profit) to the payer. 

To process prior authorization requests in a timely manner, insurers now commonly rely on AI algorithms, which are an imperfect solution. For patients exhibiting signs of colon cancer, improper denials and delayed approvals for colonoscopies could have life-threatening implications.

The concerning rise in colorectal cancer

Posted on by • Posted in Colonoscopy, Colorectal Cancer, Home Screenings, Home-Based Care, Screenings • Leave a comment

https://mailchi.mp/c6914989575d/the-weekly-gist-march-31-2023?e=d1e747d2d8

A new study from the American Cancer Society revealed a startling phenomenon in colorectal cancer: cases are trending younger while the severity of diagnoses is increasing. As shown in the graphic above, despite an overall reduction in the incidence of colorectal cancer—thanks to an emphasis on earlier detection and treatment—more severe diagnoses of colorectal cancer (termed “regional” and “distant”) each grew by over 30 percent in adults under age 50 from 2010 to 2019.

While researchers are still exploring the causes for the increase in younger people, it underscores the importance of new guidance from May 2021 which lowered the recommended colorectal cancer screening age from 50 to 45. One bright spot: unlike most other cancer screenings, screenings for colorectal cancer actually increased during the pandemic, thanks to the rise of at-home stool testing. Stool testing was especially common among lower income and minority populations who often struggle to access colonoscopies.

However, there is evidence that flagged patients are not scheduling critical follow-up colonoscopies. Better connection between at-home assessments and more thorough diagnostic services is a critical next step in the broader home-based care movement.   

Colonoscopies fail to reduce colon cancer deaths in landmark study

Posted on by • Posted in Clinical Research, Colonoscopy, Preventable Disease, Preventative Care, Preventive Screening, Unnecessary Care, Value, Value-Based Healthcare • Leave a comment

https://mailchi.mp/4587dc321337/the-weekly-gist-october-14-2022?e=d1e747d2d8

In a randomized controlled trial (RCT) study of 85K Europeans, published this week in the New England Journal of Medicine, colonoscopies were found to reduce incidence of colorectal cancer by only 18 percent—much less than earlier large studies—and have no impact on ten-year colorectal cancer mortality rates. This is the first study to directly compare individuals invited to receive colonoscopies with a control group receiving no cancer screening.

While the study’s findings surprised many researchers, an important caveat to the headline takeaways is that a secondary analysis of study participants who actually completed their colonoscopies found a 50 percent reduction in death, though the decision to accept the invitation likely correlates with other factors that improve mortality outcomes. 

The Gist: We were surprised to learn this was the first RCT to assess the effectiveness of colonoscopies—15M of which are performed in the US each year—and which comprise a $36B market. While the study’s results need careful interpretation, it reminds us that much of established medical consensus has yet to be “proven” by rigorous scientific research. 

While we don’t expect this study’s results to significantly change colonoscopy recommendations, it does place greater emphasis on the question of value generated by widespread preventative screenings. Colonoscopy will almost certainly remain the gold standard for colon cancer screening in the US, but if these results bear out, other less invasive types of screening, like home-based fecal immunochemical testing, could be viewed as equivalent options and receive more traction.