Insufficient Evidence?

I found this newsletter to be interesting. In the first article, the discussion is about how great it is that CMS denied coverage for CTC (see earlier posts to learn what this is). The very next article on the very same day shows that through Early Detection (read: screening), we show declines in cancer rates. Yet there was insufficient evidence to support the CMS decision. Some days it is absolutely fascinating to see our government in action.

Virtual Colonoscopy; A Three Part Series - The Facility

After a short absense while I attended the Abdominal Radiology Course (great content for a future blog or two), I wanted to wrap up my discussion on the series of virtual colonoscopy by looking at the facility.

CTC should offer facilities a unique way to differentiate themselves from everyone else. There are many different places that could offer the procedure including hospitals and diagnostic imaging centers. But, the place that I want to focus is the physician's office, namely the GI office.

Right now, it seems that many gastroenterologists are fighting the idea of CTC. They don't want to take the scope out of their hands. But, they are missing a golden opportunity to market to the communities they serve, grow their business, and even make their work more enjoyable.

Here's an ideal scenario. As a practice they structure themselves to offer both VC and OC. They structure the facility so that the patient comes in and goes through the VC screening. If there are any questions or lesions, they are sent over to OC for a procedure. For the 88% that are clean, they are done, and they go home (the 88% is from the ACRIN trial where it was concluded that 88% of participants would not have had to undergo an optical colonoscopy based on the CTC findings).

As a facility, you can then market this concept to the physicians and patients in the area. Non-invasive screening, but the option for same day removal. One single prep. Go about your day, and feel good. What are the chances that the number of patients increases? Initial studies indicate it will be better than good.

Next, market this to insurance companies as a package. Say they pay one flat rate regardless of outcome. This means you win on VC, lose a little on OC, but end up ahead because you are doing far more VC than OC. Plus by covering screening, they are less likely to have to pay on the back end for the treatment of cancer.

Lastly, market to the physicians. To the GI guys, it's not about taking the scope out of their hands. Rather, it's allowing them to forego the mundane, basic, non-polyp colons and focus on more challenging cases and polypectomies, thus being more stimulating for them (the same thing is occuring with the cardiologists as they realize it's more "fun" to deal with the challenging cases and leave the basic, routine ones to CT). For radiologists, this allows them an opportunity to do some additional reading, or it allows teleradiology practices the opportunity to increase their workload.

All-in-all, if this is properly positioned, it should be a win-win for everyone. It is going to take some education of the parties involved, but in the end, I think the advent of VC is going to lead to increased screening, which will lead to increased survival rates and increased revenues for the GI facilities. Because, when we get right down to it, it's not about taking the scope out of their hands, it's the fear of taking the dollars out of their pockets.

Virtual Colonoscopy; A Three Part Series - Healthcare Reform

If you had asked me a year ago what my thoughts were about colonoscopies, I may have given you a blank look and quickly turned my attention to something sports related.  Now however, colonoscopies, specifically virtual colonoscopies (also known as CTC) occupy a good part of my thoughts throughout the day.  As such, I thought it would be an interesting topic to try and get this little blog up and running.

I wanted to look at the idea of virtual colonoscopy, and the recent memo issued by CMS stating that they would not reimburse for the procedure, from three different aspects.  The first is general health care reform as some state this is the beginning of changing times (more on this in a moment).  The second is through the perspective of the patient.  The third is through the perspective of the provider.  The latter two will have a much more marketing perspective to them.

Last month the Centers for Medicare and Medicaid Services (CMS) issued a memo stating that they would not be reimbursing for Virtual Colonoscopy as a screening method for Colorectal Cancer.  Many different articles and editorials, such as this one from the New York Times, suggest that these type of decisions are "fundamental to any successful health care reform effort".  The author goes on to say that "Eliminating unproven procedures and reducing needless costs is necessary if the nation is to improve the quality and lower the cost of care over all."

Now, I don't disagree with this sentiment, per se.  However, are we really going about this the right way?  Currently there are other "screening" tests that are reimbursed by CMS, such as Fecal Occult Blood Test, that have been proven to be far less effective than CTC.  Wouldn't it make more sense to review current procedures that are reimbursed as to their efficacy?  Or do we leave them because at one point they were the gold standard, but as technology has advanced, it would be too much of a hassle to reevaluate these antiquated methods?  

Taking this a step further, shouldn't it also be important to look at the types of procedures that are being reimbursed?  By this I mean screening, diagnostic, treatment, monitoring, etc.  When looking at it from this perspective, preventative medicine is far less expensive than treatment of a disease.  Just ask anyone that has had an overnight stay in a hospital, or a surgical procedure.  And how much of that is paid for by Medicare and Medicaid?  By simply preventing the disease in the first place, how much money would be saved?  I don't have the answer to this, but I would assume it is quite a bit. 

So, let's return to the case for Virtual Colonoscopy.  Why is this become a hot topic?  Colorectal cancer is the second leading cause of cancer death in the U.S. annually (nearly 50,000 deaths per year), but is one of the most treatable if caught early.  Unfortunately, less than 50% of the at-risk population (adults over the age of 50) are screened using any method including those that are less effective.  Not only do there exist numerous studies that indicate that this procedure is as effect as optical colonoscopy (the current gold standard) at identifying lesions of 10 mm and greater, but there are additional studies that show the at-risk population is more likely to be screened using this method.  On top of this, the numbers indicate that 80% of those that are screened do not have lesions that need to be removed, thus saving additional time and money (no anesthesia and CTC costs less per procedure than optical).

In my opinion, this decision by CMS concerning Virtual Colonoscopy is a short-sighted view that could affect access to an proven procedure, and is at best a veiled attempt at reform without really digging deep and asking some tough questions about the entire system.  Are all currently reimbursable procedures still adequate?  Can money be saved by removing older, less effective, but still reimbursable procedures?  What types of procedures are being reimbursed?  Can money be saved in the long-term by putting more emphasis on screening procedures?  It won't be until CMS begins looking at things from this perspective that we will see actual reform begin to take place.