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UnitedHealthcare to Implement Prior Authorization for Certain Colonoscopies

Update on June 2nd, 2023: Following an outcry from physician groups and patient advocacy groups, UnitedHealthcare (UHC) has slightly modified their policy. Gastroenterologists will now be required to submit an advance notification to UHC before conducting diagnostic or surveillance colonoscopy procedures. Under the revised policy, care will not be denied, so patients will not face out-of-pocket costs. However, physician groups remain skeptical.

 

Individuals who are covered under UnitedHealthcare’s commercial insurance will now require prior authorization for a colonoscopy. This policy, which goes live on June 1, 2023, does not apply to screening colonoscopy, which is conducted in individuals (45-74 years) at average risk who are healthy and do not display any gastrointestinal symptoms.

To understand the prior authorization process, read more here.

Procedures that will require prior authorization include:

  • Diagnostic colonoscopies: conducted in those who have a greater risk of colorectal cancer. This would include individuals with abnormal gastrointestinal symptoms, polyps in the colon, or a positive screening test.
  • Surveillance colonoscopies: conducted in those who have a personal history of colorectal polyps or cancer.

Will This Create Access Barriers for Patients?

Physicians are concerned that this procedural change will impact both patients and healthcare staff. Prior authorization adds a layer of administrative burden for clinics and hospitals. More importantly, gastroenterologists and oncologists are concerned that patients may face unnecessary delays in diagnostic procedures, which can potentially affect disease outcome.

Folasade May, M.D., Ph.D., M.Phil., expressed her concerns with long wait times—maybe even weeks or months—for the approval to come through. For patients with aggressive disease, being left undiagnosed while waiting for insurance approval could mean advanced stage cancer, which is usually difficult to treat.

Colonoscopy procedures can be expensive if paid for out of pocket. The procedure alone can cost on average $2,125; this can increase to an average of $2,543 with the added costs of anesthesia, pathology, and bowel preparation.

 

Surabhi Dangi-Garimella, Ph.D. is a Scientific Consultant with the Colon Cancer Foundation.

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Adults Aged 45-49 Risk Losing Free Colon Cancer Screening Services

Millions of Americans risk losing free preventive care after a Texas judge ruled against the Affordable Care Act’s (ACA) preventive services requirement. This could potentially derail the gradual uptick in screening rates among 45-49-year-old Americans–the age group that was recently asked to start screening for colorectal cancer (CRC).

ACA requires insurers to offer full coverage of preventive services upon recommendation of the U.S. Preventive Services Task Force (USPSTF), the Advisory Committee on Immunization Practices, or the Health Resources and Services Administration. This means that enrollees do not have to pay anything out of pocket for those preventive services. However, Texas federal judge Reed O’Connor ruled that the USPSTF is an independent panel of volunteers who are not officers of the U.S. government, and therefore, they are not qualified to determine which preventive services should be free. 

The ruling applies explicitly to new and updated recommendations by the USPSTF since the ACA was established in March 2010. If it stands, additions and revisions to USPSTF recommendations made after March 2010 may be subject to out-of-pocket costs. These could include lung cancer screenings, medications to lower the risk of breast cancer for high-risk women, preexposure prophylaxis (PrEP) for HIV prevention, and statin use for heart disease prevention, among other recommendations. 

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ACA and Colorectal Cancer Screening

CRC is a leading cause of cancer-related deaths in the U.S., and its incidence among individuals younger than 50 is rising. For the longest time, average-risk adults were asked to start preventive screening for CRC at 50 years and continue till 74 years. In 2021, the USPSTF expanded its recommendation and lowered the screening age to include adults ages 45 to 49. It is this 45-49 age group that may potentially begin to face cost barriers to CRC screening if Judge O’Connor’s ruling stands.

The ruling does not immediately invalidate the complete coverage of preventive services under the ACA; however, millions will soon be required to pay for certain preventative care services, which could impact screening rates. Medically underserved communities that experience significant healthcare inequities, including access to preventive screening for CRC, could face additional barriers to CRC screening and disparities in CRC healthcare outcomes.

 

Sahar Alam is a Colorectal Cancer Prevention Intern with the Colon Cancer Foundation.

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Fecal Immunochemical Tests Affordable and Effective for Colorectal Cancer Screening

As we emerge from the initial waves of COVID-19, patients may have been reluctant to take more time out of their life for a colonoscopy prep, procedure, and recovery. Fortunately, non-invasive stool-based screening tools, such as fecal immunochemical tests (FIT) and multi-target stool DNA (mt-sDNA or Cologuard), are practical options that allow patients to provide a sample in the comfort of their home and could address access and care gap issues as they are less expensive. 

According to a new study presented during the Scientific Forum at the American College of Surgeons Clinical Congress 2022, these non-invasive stool-based screening methods are equally effective for screening for early-stage colorectal cancer (CRC). Pavan K. Rao, MD, a general surgery resident at Allegheny Health Network in Pittsburgh, Pennsylvania, presented study results that evaluated 117,519 enrollees within the Highmark claims database who underwent CRC screening in 2019. The researchers found:

  • About 60% of patients taking either the fecal immunochemical test or the DNA test at home instead of having a routine colonoscopy had early-stage cancer, but a FIT detected it at one-fifth the cost. 
  • The total annual costs for the tests were $6.47 million—$1.1 million for a FIT (about $24 per test) and $5.6 million for mt-sDNA (about $121 per test). Costs were calculated using Medicare reimbursement rates.
  • Transitioning all non-invasive CRC screening to FIT would result in $3.9 million in savings annually in the study population. 

Similarly, these results support previous studies out of Japan and the Netherlands that found FIT was more cost-effective than other types of non-invasive CRC screening tests. This provides our healthcare system with an efficient alternative at a reduced cost that maintains patient outcomes without compromising the quality of care. 

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NCCN Policy Summit: Supporting Workplace Needs of Cancer Patients, Survivors

On June 17, 2022, the National Comprehensive Cancer Network (NCCN) held a policy summit to discuss cancer care in the workplace and building a 21st century workplace for patients, survivors, and caretakers.

One of the distinct portions of this summit was a panel on Patients, Survivors, and Caregivers in the Workplace: Contemporary Barriers and Solutions to Achieving Inclusive Workplaces. Panel moderator John Sweetenham, MD, FRCP, FACP, FASCO, Chair, NCCN Board of Directors, and Professor of Medicine, Associate Director of Clinical Affairs, UT Southwestern Simmons Comprehensive Cancer Center, noted that the disproportionate distribution of accommodations due to socioeconomic differences leads to inadequate care and suboptimal outcomes for certain populations.

Rebecca V. Nellis, MPP, Executive Director, Cancer and Careers, shared results from a 2021 Cancer and Careers/Harris Poll Survey, which found that for three-fourths of responders, work helped them cope and aided in their recovery. These statistics show us that we can work towards a healthier workplace environment for cancer patients  and subsequently influence their health outcomes. Lynn Zonakis, BA, BSN, Principal, Zonakis Consulting, former Managing Director of Health Strategy and Resources for Delta Air Lines, shared the strategies employed by Delta for combating the difficulties associated with a cancer diagnosis. “At all levels, I would say that people were very open to disclosure, and that was the vast norm, because in each work unit, at every level, there were multiple cancer survivors or survivorship in family members, so they understood that it was to their benefit to disclose.”

She did elaborate on the associated risks,  citing the example of pilots at risk of losing their jobs when disclosing mental health risks. This can be applied to a cancer diagnosis as well. “At a lot of organizations it can put you at risk. Some people will feel that their job could be vulnerable, and they won’t disclose it, so there’s no one size fits all,” she noted.

Workplace Flexibility for Patients and for Caregivers

Angela Mysliwiec, MD, Senior Medical Director, WellMed, touched on an important aspect of the support process: the caregivers. She spoke about a program at WellMed dedicated to assisting caregivers, who she explained are experiencing the same challenges as the person they’re caring for. “When it comes to work they need flexibility, they need to take care of themselves, they need their mental health cared for, and the organizations themselves who are often ill equipped to manage a person on staff with cancer can often be even more ill equipped to manage the caregiver,” Mysliwiec said.

Randy A. Jones, PhD, RN, FAAN, Professor, Associate Dean for Partner Development and Engagement, and Assistant Director of Community Outreach and Engagement at the University of Virginia, concurred with Mysliwiec. “Caregivers share the anxiety, they share the fatigue, along with some of the patients with cancer that they’re dealing with.” He also made a point about institutions having the resources to empower patients, especially since “people are more aware of these issues, you know people understand that there is an issue between how patients are getting benefits as well as how they may be navigating the system.”

Sweetenham and Nellis closed the panel by highlighting the importance of proactive planning instead of reactive planning. They recommended that organizations should implement workplace flexibility that should be communicated upfront to new employees, and then practice it on a regular basis instead of making adjustments and assumptions as events occur.

Employer Policies Play a Big Role 

Joanna Fawzy Morales, Esq., Chief Executive Officer, Triage Cancer, spoke to the audience about The Policy Landscape to Support Patients, Survivors, and Caregivers at Work. Morales pointed out that employment can be a contributor to financial toxicity in the form of lost wages, employee benefits, and more. She further elaborated on a point that Nellis had made about battling assumptions, saying that “Employers have assumptions about their employees who’ve been diagnosed with cancer and their ability to do their jobs. Health care professionals make a whole lot of assumptions about their patients and whether or not they want to work or they can work.”

Explaining the current and suggested employment rights and accommodations, Morales said that they play a big role in helping patients make educated decisions on next actions. While there is a significant lack of awareness of protections available through the law, there are several gaps that need to be bridged. “There are many opportunities to close those gaps to improve the quality of life of patients and their families and mitigate the financial toxicity of a cancer diagnosis,” she added. She concluded her talk by emphasizing the need to educate employers, health care professionals, and the cancer community.

From informing the employer to the employee to equitable care for patients and their caregivers, this policy summit discussed various aspects of cancer in the workplace, and how we can improve the experience for those involved.

Juhi Patel is a Colorectal Cancer Prevention Intern with the Colon Cancer Foundation.

Image credit: Mohamed Hassan, Pixabay

 

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The Unintended Burden of a Cancer Diagnosis: Financial Toxicity

The past few years have seen a concerted effort from stakeholders to raise colorectal cancer awareness; however, those undergoing treatment can face significant financial impact. Financial hardship is one of several factors that has a recognized consequence on treatment outcomes. Many organizations like the National Cancer Institute and American Society for Clinical Oncology are ardent advocates for interventions to diminish the effects of “financial toxicity” that results from medical bills, indirect costs, and non-medical costs faced by patients and their families.

Several retrospective studies have previously found that 25-50% of long-term cancer survivors experience financial hardship. A study recently published in the Journal of the National Cancer Institute is the first prospective cohort study led by the SWOG Cancer Research Network to evaluate financial hardship in metastatic colorectal cancer (mCRC) patients over 12 months. The researchers evaluated the financial impact on newly diagnosed patients who may have an advanced illness. Self-reporting questionnaires were administered over 12 months and considered new debt accumulations in analyses. Of the 380 patients initially enrolled in the study, several became ineligible due to lack of baseline data or death, leaving 302 patients to be evaluated at the end of the one-year follow-up. 

Age, race, income, or marital status did not have a significant impact on major financial hardship. Additionally, unemployed individuals were less likely to face significant financial hardship, which the authors believe may be confounded by age and older individuals having more assets and savings. What the researchers observed was a trend of increased risk of major financial hardship in younger, non-white, lower-income patients (but no statistically significant association). They also found that financial toxicity increases over time, where two-thirds of the study subjects faced hardship during the 12-month study period. 

The bottom line is that patients with limited resources are more likely to be negatively impacted by the financial burden of a cancer diagnosis. Interventions to help ease the effects are only successful when there is a sense of trust between patients and clinicians and a working dialogue about cost and financial concerns surrounding treatment plans. Critical solutions include:

  • Developing policies that facilitate access to affordable healthcare
  • Designing insurance benefits to minimize costs 
  • Connecting patients and caregivers to resources for counseling and assistance

The first step to change is an acknowledgment of the issue and screening patients to identify those most vulnerable to financial hardship.

Image credit: Thomas Breher from Pixabay  

Juhi Patel is a Colon Cancer Prevention Intern with the Colon Cancer Foundation.

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