Using data from the ACR’s National CT Colonography (CTC) Registry, a team of ACR researchers found that patients older than 65 are less likely to seek screening CTC examination because it is not covered by Medicare, and also determined that this policy disproportionately affects minority patients.1 As colorectal cancer remains the overall second leading cause of cancer-related deaths in the U.S., the CMS policy baffles the JACR® paper’s co-author Judy Yee, MD, FACR, who serves as chair of the ACR Colon Cancer Committee.
“The fact that CMS doesn’t cover screening CTC, while it covers every other single colorectal screening test that is included in the U.S. Preventive Services Task Force (USPSTF) guidelines and American Cancer Society guidelines, makes no sense,” Yee says. “Given that CTC must be covered by the Affordable Care Act (ACA) based on the USPSTF grading, the lack of CMS coverage is creating health disparities for many older Americans.” According to Yee, due to the ongoing COVID-19 pandemic, rates of screening tests have decreased significantly, which could lead to thousands of unnecessary deaths. “We need availability of all the screening tests,” says Yee. “The more colorectal cancer screening options that we have available — including CTC — the better.”
Creating Barriers to Access
Yee has been advocating for CMS to cover CTC examination for more than a decade, and her work with the College’s Colon Cancer Committee helped persuade the USPSTF to include CTC examination in its screening guidelines. During her early efforts, CMS asked for more evidence that CTC is effective in adults 65 years of age and older, as well as information on the cumulative effect of radiation and the implications of incidental and extra colonic findings. Since then, numerous studies have confirmed that CTC is as effective in patients 65 years of age and older as it is in younger patients, Yee explains.
The ACA mandates that private health plans fully cover the services recommended by the USPSTF. In 2016, the USPSTF added CTC examination to its list of recommended colorectal cancer screenings, triggering the ACA to require private insurers to cover the tests without patient cost-sharing. A recent Harvey L. Neiman Health Policy Institute® study, co-authored by Michal Horný, PhD, and published in the American Journal of Preventive Medicine, found a 50% increase in CTC examination rates by patients 50 to 64 years of age with private insurance.2
“When patients are old enough to be eligible for Medicare, CMS doesn’t pay for CTC for screening purposes, and patients who want CTC have to pay the full price out of pocket,” Horný, assistant professor at Emory University School of Medicine, explains. “That can be a problem, especially for individuals of low socioeconomic status.”
The drop in CTC examinations in patients over age 65 occurred in minority populations, says Courtney C. Moreno, MD, chair of the College’s CTC Registry and the JACR paper’s lead author. Yet, the study found that CTC examination rates for White patients increased after age 65. “It’s really a pretty striking difference,” Moreno says. “This overall utilization dipping above age 65 seems to be primarily driven by decreased utilization in minority populations.”
Medicare non-coverage not only affects a patient’s ability to pay for the test, but it also affects their access to the test. Safety net hospitals, which typically serve low income populations, may not have the equipment or may be unable to even purchase the equipment to perform CTC examinations. “It’s challenging or impossible to convince an institution administrator to buy an inflation pump to do CTC if the test won’t be reimbursed by CMS,” Moreno explains. In that case, if the institution can’t conduct a CTC examination, patients may be receiving barium enemas, which is not the recommended test for colorectal cancer screening from an imaging standpoint, she adds.
These barriers affect patients who are most at-risk for developing colorectal cancer, adding to the chronic challenges that patients and healthcare providers face. “We know that colorectal cancers are more common in Black Americans,” Yee notes. “If we don’t offer Black patients all the tools that are available and validated, they are excluded.”
“We need availability of all the screening tests. The more colorectal cancer screening options that we have available — including CTC — the better.”
Driving Quality Improvement and Progressive Policy Changes
For over a decade, the ACR’s CTC Registry has provided members with valuable data they can use to compare their performance with other practices across the country, which is especially helpful for providers who are just starting to conduct CTC. “The registry gives the radiology community a more comprehensive look at the practice of CTC so we can learn from each other,” Moreno explains. “The data also serve to help CTC programs identify areas for improvement and monitor performance over time.”
In addition to providing valuable data for program quality improvement, registry data enables research related to evidence-based health outcomes. Moreno and her co-authors were able to access more than 12,000 screening examinations to evaluate the use of CTC. However, participation in the registry is voluntary, and the available data is dependent upon institutional participation.
According to Horný, in the JACR study, White patients were overrepresented, and Black and minority patients were underrepresented. That could be due in part to the fact that well-resourced centers (e.g., centers with adequate resources to collect and submit data to the CTC Registry) are overrepresented in the registry.
Large and diverse datasets are a significant step for researchers interested in reducing health disparities. “To fix health inequity or disparities, we first need to know that they exist,” Horný says. “We know that only through documentation of these disparities using data. We need data to even start asking what the right policy response should be and how it can make the problem better.”