In a November 2022 press release, CMS finalized the rule that colonoscopies following positive at-home screening tests are considered a preventive service, and will now be covered without out-of-pocket costs for Medicare beneficiaries.  The removal of a cost barrier for Medicare beneficiaries could help hundreds of thousands more people avoid the dilemma of having to determine if they can afford follow-up testing after initial positive at-home test results.  

This is an extremely important policy that could increase screening uptake, enhance equity, and ultimately save lives; which are stated goals of the Biden-Harris Cancer Moonshot.

Media Stories & New Publication Highlight Coverage for
Cancer Screening Follow-Up Care

Recent national media stories and a new JAMA Network Open publication bring attention to the problem of cost-related barriers for follow-up evaluations for post-initial cancer screening, as well as the clinical and economic benefits of policies that remove these impediments.  These new resources contribute to ongoing efforts to eliminate cost-sharing for the entire cancer screening process, building on a federal guidance that went into effect on May 31st of this year that requires commercial insurers to eliminate cost-sharing for follow-up colonoscopy after a positive, non-invasive colorectal cancer screening test.

The distinction between whether a test is billed as ‘screening’ and ‘diagnostic’ is a technical one and a requirement to pay substantial amounts out of pocket for follow up care puts already vulnerable individuals who have been told that they may have cancer in a very difficult position. The federal government should clarify that commercial plans and Medicare should fully cover all the required steps to diagnose cancer or another problem, not just the first screening test.

Dr. A. Mark Fendrick

Elimination of out-of-pocket costs for the entire cancer screening process could increase screening rates, enhance health equity, and ultimately save lives.

Section 2713 of the Public Health Service Act as amended by the Patient Protection and Affordable Care Act (ACA) requires group and individual health insurance plans to provide coverage for specified preventive services to beneficiaries without patient cost-sharing.  This provision was designed and implemented to prevent financial barriers, like copayments and deductibles, from deterring patients from seeking necessary and evidence-based medical care – including cancer screenings for average-risk age-eligible individuals.

New guidance released as part of the Affordable Care Act Implementation Frequently Asked Questions Part 51 removes cost-sharing for colonoscopies following
non-invasive colorectal cancer screening tests, and will take effect on or after May 31, 2022.

While this rule was a well-intended step in the right direction, patients often still incur significant out-of-pocket costs associated with follow-up evaluations and procedures post-initial screening.  Failure to complete the screening process could allow cancer to progress, leading to worse patient outcomes and higher medical costs.

policy progress

As the White House reignites the Cancer Moonshot, it is imperative that policymakers consider available evidence to inform policies that remove financial barriers to increase the number of people – especially women and underserved populations – who follow up on abnormal test results of initial colon, breast, lung, and cervical cancer screenings.

Such policies can be viewed as an ‘easy lift off’ for the recently announced relaunch of the Biden Admin Cancer Moonshot.  The available evidence would suggest that the elimination of out-of-pocket costs for recommended follow-up after a positive, initial cancer screening test would increase screening uptake, enhance equity, and ultimately save lives – the explicitly stated goals of the moonshot.

For more about recommendations relevant to each specific cancer type, please see the companion briefs released by the President’s Cancer Panel below – 

Colon cancer screening

Many average risk adults opt for stool-based colorectal screening tests, such as those that look for blood or DNA markers of cancer, because they take less time and preparation than a screening colonoscopy, and can be done at home.  Clinical guidelines clearly state that those who test positive on these no-cost stool tests require a follow-up colonoscopy.

Recent JAMA Network Open study published in December examined how often and the amount patients actually paid out of their own pockets for needed colonoscopy follow-up after an initial non-invasive test.  Of 88,000 people with private insurance or Medicare coverage who had a stool-based test, 16% of them went on to have a colonoscopy.  During that colonoscopy, nearly 60% of the group had at least one polyp removed because it might be cancerous or precancerous.

More than half of the privately insured patients and 78% of the Medicare participants faced out-of-pocket costs or their follow-up colonoscopy.  Costs averaged around $100 for both groups, but those who had polyps removed paid more than those who didn’t have polyps removed.

Additionally, findings from a Preventive Medicine Reports study published in January shows that for those with a positive stool test, a follow up colonoscopy could lead to the prevention of four times as many cases of colorectal cancer, and twice as many deaths, when compared to those who receive colonoscopy as the initial colorectal screening test. 

These findings suggest that colonoscopies performed as a follow-up procedure on individuals with a positive stool test have the potential to prevent cancer progression and avoid death more than an initial screening colonoscopy, as individuals with an abnormal initial screening result are at higher risk of colorectal cancer.

Collectively, these studies show that individuals who needed a potentially life-saving follow-up colonoscopy faced non-trivial barriers to this high-value service. This insight provided input to a new guidance released as part of the Affordable Care Act Implementation Frequently Asked Questions Part 51 on January 10, 2022.  This new federal rule removes cost-sharing for colonoscopies following a non-invasive colorectal cancer screening tests.  Beginning on or after May 31, 2022, private health plans will be required to provide coverage for such colonoscopies without cost to beneficiaries.  In a November 2 CMS Press Release, HHS announced that cost-sharing for follow-up colonoscopies will also be waived for Medicare beneficiaries.

This is an extremely important policy that could increase screening uptake, enhance equity and ultimately save lives, which are stated goals of the Cancer Moonshot. The removal of a cost barrier starting this spring could help hundreds of thousands more people avoid the dilemma of having to decide if they can afford to follow up on their initial positive colorectal screening test. However, the new rule does not apply to other cancers for which screening tests are fully covered for some or all individuals: breast, lung and cervical cancer.”

Dr. A. Mark Fendrick

breast cancer screening

In this same vein, the U-M team and colleagues from the University of Washington have looked at the follow-up costs faced by women who have concerning findings on their screening mammograms.  Their results were published in 2021 in JAMA Network Open.

Screening mammograms for certain women have been free from out-of-pocket costs since the Affordable Care Act’s provision took effect.  But findings from a recent JAMA Network Open study show that between 2010 and 2017, women who got additional imaging and biopsies after their screening mammogram faced ever-rising out-of-pocket costs.

The study is based on data from 325,900 women between the ages of 40 and 64 who have job-related health insurance and had 418,378 additional breast imaging examinations or procedures after a screening mammogram.

Nearly all had a second mammogram, called a diagnostic mammogram, after the screening scan.  From there, many went on to have additional scans and even biopsies to remove a bit of tissue for examination to determine if they had cancer or not.

Those who went on to have a biopsy paid the most out of their own pockets rising from an average of $91 in 2010 to $152 in 2017 whether they had ultrasound or MRI imaging before the biopsy

lung cancer screening

In 2021, the U.S. Preventive Services Task Force (USPSTF) recommended expansions of the populations eligible for screening for lung cancer.  The changes were made with an eye toward reducing inequities in rates of early cancer detection among women and people who identify as Black, Indigenous, or Latinx. 

A study published in the Journal of American College of Radiology last Fall documented the cost of follow-up tests for patients whose CT scan showed signs of potential lung cancer.  Of the 7.4% of the patients who required follow-up invasive procedures, more than half faced out-of-pocket costs.  In some cases, the costs associated with specific tests required to complete the screening process amounted to hundreds or even thousands of dollars. 

Cervical cancer screening

In a 2022 paper published in Obstetrics & Gynecology, Dr. Fendrick collaborated with OBGYN Michelle Moniz, M.D., M.Sc., and others to look at what women paid out of their own pockets for a type of cervical exam called colposcopy.  Conducted after a Pap smear, HPV test or routine cervical exam gives abnormal results, a colposcopy can include a biopsy or other procedures.

Women who had a colposcopy without further procedures paid an average of $112, while those who had cells taken for further examination paid $155 on average.  Those who had further procedures faced hundreds of dollars more in costs — and this out-of-pocket cost rose sharply during the 13 years studied.  By 2019, a woman who had additional care beyond a biopsy could expect to face a total bill of nearly $1,000.

moving forward

The removal of a cost barrier for a diagnostic colonoscopy could help hundreds of thousands of people avoid the dilemma of having to decide if they can afford to follow up on their initial positive colorectal screening test.  This policy will increase screening uptake, enhance equity, and ultimately save lives. However, there is still much work to be done.  

A similar policy for Medicare beneficiaries, who are not included in the recent guidance for colorectal cancer, is warranted.  Moreover, it is our hope that our research showing that large numbers of people face substantial out of pocket costs for follow-up testing for the three additional cancers for which initial screening tests are fully covered – breast, lung and cervical – will lead to comparable policies to remove financial barriers.