Obese people on Medicare  now have the opportunity to have regular weight loss counseling paid for when offered by a primary care provider.  Since this is considered prevention, there is no co-pay.

On November 29, the Centers for Medicare and Medicaid Services announced that there was enough evidence that intensive behavioral counseling was reasonable and necessary to prevent disease or disability and that Medicare beneficiaries were entitled to coverage as a preventive service.

This is particularly good news for people trying to prevent colon or rectal cancer since studies have consistently found a link between body mass index (fatness) and colorectal cancer, including the World  Cancer Research Foundation which included BMI and colorectal cancer in their 2007 comprehensive analysis reported in  Food, Nutrition, Physical Activity and the Prevention of Cancer.

This year the WCRF updated their analysis for colorectal cancer looking at new studies published since 2007 as part of the Continuous Update Project.  They wrote,

The CUP Panel agreed that the recent evidence was consistent with the conclusion of the Second Expert Report; the evidence that greater body fatness is a cause of colorectal cancer is convincing.

With the latest CMS coverage decision, Medicare patients with a BMI of 30 or over  can get:

• One face-to-face visit every week for the first month
• One face-to-face visit every other week for months 2-6
• One face-to-face visit every month for months 7-12, if the individual has lost at least 6.6 pounds.

The benefit is limited to counseling delivered in primary care settings by primary care doctors or primary care nurse practitioners, clinical nurse specialists, or physician assistants.

Benefits are also provided for screening to determine BMI and nutritional assessment.

CMS defines intensive behavioral counseling as providing the 5-As:

• Assess: Ask about/assess behavioral health risk(s) and factors affecting choice of behavior change goals/methods.
• Advise: Give clear, specific, and personalized behavior change advice, including information about personal health harms and benefits.
• Agree: Collaboratively select appropriate treatment goals and methods based on the patient’s interest in and willingness to change the behavior.
• Assist: Using behavior change techniques (self-help and/or counseling), aid the patient in achieving agreed-upon goals by acquiring the skills, confidence, and social/environmental supports for behavior change, supplemented with adjunctive medical treatments when appropriate.
• Arrange: Schedule follow-up contacts (in person or by telephone) to provide ongoing assistance/support and to adjust the treatment plan as needed, including referral to more intensive or specialized treatment.

CMS estimates that 1 in 3 people receiving Medicare are obese.

Patrick Conway, MD, MSc, CMS Chief Medical Officer and Director of the Agency’s Office of Clinical Standards and Quality said,

This decision is an important step in aligning Medicare’s portfolio of preventive services with evidence and addressing risk factors for disease. We at CMS are carefully and systematically reviewing the best available medical evidence to identify those preventive services that can keep Medicare beneficiaries as healthy as possible for as long as possible.

Body Mass Index (BMI) is calculated using weight and height. It doesn’t measure “fatness” directly but correlates well to overall amount of body fat. You can use this CDC calculator to find out your own BMI.

American Cancer Society Chief Medical Officer Otis W. Brawley, M.D., says that he is disappointed in the decision by the Centers of Medicare and Medicaid Services not to cover CT colonography screening for elderly Americans on Medicare.

Dr. Brawley points out that randomized clinical trials have shown the CTC option as effective as traditional optical colonoscopy in finding early cancers and precancerous polyps.  He also concerned that there is not a sufficient supply of trained specialists providing colonoscopy to meet the need for screening and that new options are needed.

The American Cancer Society believes, Brawley says, that a full battery of testing for colorectal cancer screening should be available, particularly to the Medicare population who are at higher risk of developing and dying from colorectal cancer.

Dr. Brawley’s statement:

I am disappointed in this decision, as randomized clinical trials clearly show CT colonography (CTC) is as effective as optical colonoscopy for the early detection of early cancers and pre-malignant lesions. Medicare coverage for CTC, also known as virtual colonoscopy, would have provided an additional option for colorectal cancer screening. Additional options are absolutely necessary as the supply of gastroenterologists and other trained specialists is currently inadequate to supply optical colonoscopy to all of those who need it, and many people are unwilling to undergo colonoscopy or other currently reimbursed tests. It is our belief that by increasing the proportion of Americans 50 and over who get colorectal cancer screening, we could increase the number of lives saved from this devastating disease and decrease long term medical costs. Providing access to all proven screening options is even more important for those in the Medicare population, most of whom are at even greater risk of developing and dying from colorectal cancer due to their advanced age. The American Cancer Society still believes that a battery of different tests for colorectal cancer screening should be available to the American people. This includes optical colonoscopy, virtual colonoscopy, stool blood testing, as well as sigmoidoscopy.

The Centers for Medicare and Medicaid issued a final National Coverage Decision on May 12, 2009 denying Medicare payments for CT colonography (virtual colonoscopy) to screen for colorectal cancer.

Despite an overwhelming number of comments urging that CMS overturn their provisional determination not to cover the test, the agency remained unconvinced that there was sufficient evidence to conclude that CT colonography was appropriate to screen for colorectal cancer.

Almost 95 percent of 357 comments supported CT colonography screening, including comments from the American Cancer Society and C3:Colorectal Cancer Coalition.

Briefly,

The Centers for Medicare and Medicaid Services (CMS) concludes the following:

The evidence is inadequate to conclude that CT colonography is an appropriate colorectal cancer screening test under § 1861(pp)(1) of the Social Security Act.  CT colonography for colorectal cancer screening remains noncovered.

In response to a proposed national coverage decision by the Centers for Medicare and Medicaid Services not to pay for screening CT colonography (CTC) for Medicare enrollees, C3 has submitted comments asking that CMS cover screening CT colonography (virtual colonoscopy) as part of a Coverage with Evidence Development (CED) process.

A CED would enable CMS to determine if CT colonography is safe and effective in the older Medicare population and which patients might benefit from screening using CTC rather than optical colonoscopy.

We believe that older patients should have a choice for colorectal cancer screening methods after a discussion of the risks and benefits of each method with their doctors.  And we want good information available for those patient decisions. 

Recognizing the difference in screening guidelines from the American Cancer Society developed in consensus with the Multi-Society Task Force on Colorectal Cancer and the American College of Radiology which include CTC as a test that can prevent colorectal cancer and those of the United States Preventive Services Task Force (USPSTF) which found “insufficient evidence to assess the balance of risks and benefits of CTC“, C3 urges coverage that could provide more information to clear up this confusion.

C3 comments included:

Therefore, C3 strongly urges CMS to gather the evidence by approving coverage of CTC, and implement the new coverage through a Coverage with Evidence Development (CED) process. A CED will generate additional safety and efficacy data in people over the age of 65, a population that is typically under-represented in clinical research. CED can also generate information that will help to identify patients who can benefit from CTC as opposed to optical colonoscopy.

A complete denial of coverage is akin to “throwing the baby out with the bathwater.” Thus, we urge CMS to use its unique ability to generate data from its consumer base, and determine whether CTC is appropriate for people over age 65.

Background information supporting our comments included:

• Studies that showed CTC equivalent to optical colonoscopy in finding large polyps and colorectal cancers with fewer colon perforations and other complications.
• The need to reach additional people who are not now being screened and who might agree to be tested if CTC were covered by Medicare.
• Confusing and conflicting guidelines that don’t provide clear guidance to balance  risks and benefits for Medicare patients who are deciding on a screening method.

In conclusion,

C3 urges reconsideration of the non-coverage decision by CMS, and strongly urges CMS to gather the evidence by approving coverage of CTC, and implementing the new coverage through a Coverage with Evidence Development (CED) process.

Click here to read the entire comment.

On February 11, 2009 the Centers for Medicare and Medicaid Services (CMS) issued a proposed national coverage decision memorandum not to pay for computed tomographic colonography (so-called virtual colonoscopy) to screen for colorectal cancer.

The evidence is inadequate to conclude that CT colonography is an appropriate colorectal cancer screening test under §1861(pp)(1) of the Social Security Act. CT colonography for colorectal cancer screening remains noncovered.

The national coverage decision will not be final until 30 days after February 11 to allow for public comments.  Individuals and organizations concerned about the proposed decision can submit a comment online. However, CMS does not now cover screening CT colonography.

IMPORTANT: If you want to submit a comment to CMS online, you MUST click on and open the CMS PHI Posting Policy and then check off that you have read it.  If you don’t click on the underlined link, you cannot enter a check mark, your personal information, or your comment.

The decision was based on a review of medical literature, information presented during a meeting of MEDCAC (Medicare Evidence Development and Coverage Advisory Committee) in November, and public comments submitted since May.

In March of 2008, the American Cancer Society in collaboration with the US Multi-Society Task Force on Colorectal Cancer and the American College of Radiology, included CT colonography in its updated colorectal cancer screening guidelines.

However, in October, the US Preventive Services Task Force  (USPSTF) found insufficent evidence to add CT colonography to their colorectal cancer screening guidelines.  They were also concerned about lifetime radiation exposure and the ability of CT colonography to find problems outside the colon that needed further, perhaps unnecessary, medical testing.

The results of a randomized national study of CT colonography were published in the New England Journal of Medicine in September 2008 showing no difference between optical colonoscopy and CTC in finding large polyps, uncovering 90 percent of those over 10 millimeters.  CTC was less sensitive for intermediate-sized lesions, finding 78 percent of them.

Based on the revised ACS guidelines and C3′s policy that reimbursement should include all ACS recommended screening tests, C3: Colorectal Cancer Coalition submitted comments  in June 2008 calling for Medicare payment for CT colonography during the comment period for the National Coverage Analysis on Computed Tomography Colonography.

Medicare should provide coverage for CTC that is consistent with all colorectal cancer screening tests recommended by the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology. Their recommendation includes tests such as fecal occult blood tests (FOBTs), barium enemas, flexible sigmoidoscopy and colonoscopy which are already covered under Medicare.

During the initial comment period in May and June of 2008, CMS received 100 comments. Of the 100, 79 supported payment for CT colonography, 20 opposed it, and 1 commentor offered no opinion.  While many comments came from professional societies and medical professionals, one-third (34) were submitted by the general public including patients, screening candidates, their families and other people with an interest in the prevention and early detection of colorectal cancer.  Of those, 32 supported paying for CTC, 1 opposed it, and 1 person offered no opinion.  A full discussion of the content of those comments is part of the material supporting the proposed coverage decision.

Medicare now covers colorectal cancer screening for beneficiaries over 50 with fecal occult blood testing, flexible sigmoidoscopy, barium enema, and colonoscopy.  There is no minimum age for screening colonoscopy.

Since Medicare began providing full coverage of screening colonoscopies in 2001, there has been a significant increase in the rates of screening colonoscopies for people covered by Medicare.  There are also been an increase in the percentage of Medicare patients whose cancer was detected at an early, highly curable stage I.

Although US health care spending grew more slowly in 2007, its rate still outpaced general economic growth.  Total health care costs in 2007 reached $2.2 trillion or $7,421 for every American.

The Centers for Medicare and Medicaid Services released a report from the CMS Office of the Actuary on Tuesday that showed overall health care spending grew at a 6.1 percent rate in 2007, down from 6.7 in 2006 and the slowest rate of growth since 1998.  Overall economic growth was 4.8 percent.

Health care spending’s share of the Gross Domestic Product continued to increase, reaching 16.2 percent, an increase of 0.2 percent over 2006.

CMS attributes the slower spending growth to retail prescription spending and lower costs of administering Medicare benefits.

• Prescription drug prices increased by 1.4 percent in 2007 compared to 3.5 percent in 2006.  The slower growth was driven by more use of generics and by generic drug discount programs in large retail chain stores.
• Spending for hospital care, which accounts for about a third of overall health costs, increased by 7.3 percent in 2007 over 6.9 percent in 2006.
• There was no change in physician and clinical services growth in 2007, increasing by 6.3 percent.  However, growth in payments to physicians decreased during the year, while costs for stand-alone clinics and urgent care centers increased.
• Costs for nursing home care increased by 4.8 percent compared to 4 percent in 2006.  Spending for home health care rose by 11.8 percent.
• Spending for public programs including Medicare and Medicare grew more slowly in 2007 at 6.4 percent, down from 8.2 percent.  However, private spending grew somewhat faster at 5.8 percent in 2007 compared to 5.4 in 2006.
• Private insurance health care premiums grew 6 percent, the same as the previous year, but significantly less than the 10.7 increase in 2002.  Increases in payments from health care insurance also slowed to 6.6 percent, down from 9.9 percent in 2002.
• Out-of-pocket spending by individuals grew 5.3 percent, up from 3.3 percent in 2006.
• Overall, the amount of health care paid for by individuals out-of-pocket is decreasing.  In 2007 it represented 12 percent of all health care spending.  It was 14.7 percent in 1998 and 34.8 percent in 1968.

Health care services and supplies were financed by

• businesses (25 percent)
• households (31 percent)
• other private sponsors (4 percent)
• governments (40 percent)

Commenting on the report CMS Acting Administrator Kerry Weems said,

This is another reminder that the cost of health care continues to be a real and pressing concern facing the American public and the federal government. This report – like the reports issued last year on the financial status of Medicare and Medicaid – is a stark reminder that we must redouble our ongoing efforts to reform the delivery of health care services in this country to bring about the goal of affordable, high quality health for all Americans.

C3 commented publicly this week to the Centers for Medicare and Medicaid Services (CMS) regarding the reimbursement of CT-Colonography (CTC), also known as Virtual Colonoscopies. CMS offered the opportunity to comment during their National Coverage Analysis (NCA).

The American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology issued revised guidelines for colorectal cancer screening in March 2008. Their rigorous, evidence-based evaluation of the various screening methods resulted in the addition of CTC to the screening guidelines. This decision opened up the question whether or not Medicare should begin covering CTC the same way it covers fecal occult blood tests (FOBTs), barium enemas, flexible sigmoidoscopy and colonoscopy.

Despite the passage of the Balanced Budget Act (BBA) of 1997, which authorized coverage for colorectal cancer screenings for Medicare recipients, colorectal cancer screenings are still very much under-used. The Centers for Disease Control and Prevention (CDC) estimates that as many as 60 percent of deaths could be prevented if everyone age 50 and older were screened regularly. One of the barriers to screening is patient concern about an invasive procedure such as colonoscopy and flexible sigmoidoscopy. CTC gives an attractive alternative for patients.

Click here to read C3’s comments

C3 fully supports the coverage of CTC by Medicare and believes that all Americans should have full access to credible colorectal cancer screening. In addition to submitting comments to CMS we have publicly endorsed legislation in Congress, The Virtual Screening for Cancer Act (HR 4879). This legislation would give authority to CMS to begin covering CTC under Medicare.