Colonoscopy Overused in Medicare Recipients, Adding Unnecessary Expenditures
Medicare may be paying for more screening colonos – copies than are warranted for the prevention of colorectal cancer (CRC), according to a new study (Goodwin JS, et al. Arch Intern Med. 2011 May 9 [Epub ahead of print]).
All relevant authorities recommend an interval of 10 years between normal screening colonoscopies. Although much attention has been given to the underuse of CRC screening, less attention has been paid to possible overuse, according to James S. Goodwin, MD, George and Cynthia Mitchell Distinguished Chair in Geriatric Medicine and Director, Sealy Center on Aging, University of Texas Medical Branch, Galveston.
Dr Goodwin led a study that assessed the timing of repeated colonoscopies after a negative screening colonoscopy finding in a pop – ulation-based sample of Medicare patients. A 5% national sample of Medicare enrollees from 2000 through 2008 was used to identify averagerisk patients undergoing screening colonoscopy between 2001 and 2003.
Colonoscopy was classified as a negative screening examination if no additional indications appeared in claims and if no biopsy or related procedure was performed. The time to repeated colonoscopy was calculated.
Among 24,071 Medicare patients with a negative screening examination, 46.2% underwent a repeated examination in less than 7 years. In 42.5% of these patients (23.5% of the overall sample), there was no clear indication for the early repeated examination, the study found.
“The actual practice of colonoscopy in the community seems quite different from the assumptions made in assessing the cost-effectiveness of CRC screening by colonoscopy,” maintained Dr Goodwin. He acknowledged, however, that investigators lacked information on the quality of the initial colonoscopy. Early repeated colonoscopies could result from incomplete or poor-quality initial examinations, he said, although the study eliminated subjects with incomplete examinations. “Also, one would expect repeated colonoscopies to follow up on suspicious findings to occur relatively soon after the initial colonoscopy, which is not the temporal pattern we found,” he added.
Repeated colonoscopies were also affected by the patient’s age. Among persons aged 75 to 79 years, 45.6% were screened within 7 years, as were 32.9% of individuals aged ≥80 years at the time of the initial negative colonoscopy result. In multivariable analyses, male sex, presence of more comorbidities, performance of colonoscopy by a high-volume colonoscopist, and performance of the test in an office setting were associated with higher rates of early repeated colonoscopy without clear indication.
There were also marked geographic variations, from less than 5% in some health referral regions to greater than 40% in others.
Looking for the Reasons
The investigators concluded that, “A large proportion of Medicare pa tients who undergo screening colonos copy do so more frequently than recommended.” Current Medi care regulations intending to limit reimbursement for screening colonos copy to every 10 years do not appear to be effective.
In an interview with Value-Based Cancer Care, Dr Goodwin noted, “Every authority (including the American Gastroenterological As – socia tion [AGA], American Cancer Society, US Preventive Services Task Force, and others) says that after a normal screening colonoscopy, another examination is not needed for 10 years, but surveys suggest that individual gastroenterologists often disagree. There is a strong opinion that they should be done more frequently. The gastroenterologists are doing what they feel is the right thing, but no other organization that lacks direct involvement in this situation, including the AGA, agrees.”
Could there be a profit motive at work? “The profit motive in American medicine is like gravity. It’s a force that will always be there,” he responded. “Clearly, when you have the people who are profiting from the procedure being the ones who decide when to do it, there will always be some force toward overuse. Yes, I think the profit motive is partly responsible for the findings.”
Medicare regulations preclude reimbursement for screening colonoscopy within 10 years of a negative examination result. However, Medicare denied only 2% of the claims for early repeated colonoscopies without indication in this study. The study showed that an understanding of such cases, where an indication was lacking, is complicated by the “seeming underuse of the screening code” in colonoscopies billed to Medicare.
“When we looked at the reasons for these examinations, many were exceptionally nebulous, and there was no evidence in prior billing that these indications existed. For example, if they indicated a ‘change in bowel habits,’ there was often no mention of this in previous billings. We thought this was suggestive of some ‘creative coding,’” he said.
Dr Goodwin elaborated that such practice has been ingrained for years. “You have to look historically. By 1990, colonoscopy had been shown to prevent cancer, detect it early, and reduce mortality, but Medicare did not start reimbursing for screening colon – oscopy until 2001. So all during the 1990s, physicians used creativity to do what they felt was the right thing—do screening colonoscopy—and to be reimbursed for it from Medicare.
“Many, many examinations were done throughout the 1990s, but they were not called ‘screening colon – oscopy,’ because these were not re – imbursed,” he continued. “I think when Medicare finally started reimbursing, the billing staff continued to use these codes.”
Fee-for-Service the Culprit?
Dr Goodwin reiterated that early repeated colonoscopies without clear indication veer from national recommendations, compose a substantial proportion of the present endoscopist’s workload, and represent “substantial Medicare expenditures,” he said. “And from my personal experience as a primary care provider, my gut feeling is that this is not something unique to Medicare but could happen under any fee-for-service program.”