Pushing for payment
Doctors group aims to get payers to cover lung cancer screenings
Some hospitals have been using low-dose CT scans in recent years to screen patients at high risk for lung cancer even though most payers, including the CMS, still don’t reimburse for the tests.
Within months of the publication of a 2011 study in the New England Journal of Medicine that found lowdose CT screening led to a 20% reduction in the mortality rates of lung cancer patients, several hospitals established lung cancer screening programs that offered free or relatively inexpensive scans to high-risk patients.
“It takes people a long time to process these studies,” said Dr. Richard Thompson, a cardiothoracic surgeon who started a screening program in November 2011 at Bryan Health, a two-hospital system in Nebraska. “Why should people have to wait to get this screening? Lives are being lost while we’re processing this information.”
More than a year later, there are still few payers that cover the screening. WellPoint is the only national insurer to cover the scans, in addition to some unaffiliated Blue Cross and Blue Shield plans, including ones in Nebraska and Massachusetts.
However, the American College of Chest Physicians updated its guidelines last week to recommend the screening, and the U.S. Pre- ventive Services Task Force is expected to take up the issue this fall. Those steps could lead to activity from more insurers and a national coverage decision from the CMS.
“Those guidelines are starting to get a lot of play and are going to be a tipping point … for third-party payers,” said Diane Robertson, director of the ECRI Institute’s health technology assessment information service. “Up to now, most have not established coverage policies for this type of screening.”
But reimbursement isn’t the only issue that healthcare providers face as they implement or consider lung cancer screening programs. There are also lingering concerns about the risks of radiation exposure, high falsepositive rates that could lead to unnecessary biopsies and patient worry, and the out-of-pocket costs of those programs.
“Unnecessary follow-up procedures are an enormous concern,” said Dr. Peter Bach, director of the Center for Health Policy and Outcomes at Memorial Sloan-Kettering Cancer Center, New York.
He and other physicians, though, noted that protocols can ensure the right patients are screened and the right multidisciplinary teams are in place to handle follow-up exams when nodules turn up in screenings.
The 2011 New England Journal of Medicine study that kicked off the screening recommendations analyzed the findings of the randomized National Lung Screening Trial, which enrolled about 53,000 high-risk patients and assessed the impact of annual
screenings over a three-year period.
High-risk patients are between 55 and 74 years old, smoked at least one pack of cigarettes a day for 30 years or two packs a day for 15 years, and who continue to smoke or quit within the past 15 years.
The National Comprehensive Cancer Network later issued similar recommendations for lung cancer screening using low-dose CT, which was followed by groups that included the ACCP, American Society of Clinical Oncology and the American Association of Thoracic Surgery.
In a clinical policy bulletin last reviewed in June 2012, Aetna said there is “presently inadequate evidence in the medical literature” that the use of CT scans as a screening test for lung cancer will lead to detection of smaller cancers or decrease mortality. The insurer is undertaking its annual review of the policy.
For now, the hospitals with programs in place usually charge a fee.
Pinnacle Health System, a three-campus hospital in Harrisburg, Pa., charges $99 for the scan and has screened about 155 patients since the program launched in September 2011. In Lincoln, Neb., Bryan Health’s program was free for one month but now charges about $200 a scan. It has detected lung cancers in five patients out of 700 screened.
“We saw it as a community benefit to this set population of individuals,” said John Woodrich, Bryan Health’s president and
“It takes people a long time to process these studies. Why should people have to wait to get this screening? Lives are being lost while we’re processing this information.” —Dr. Richard Thompson, cardiothoracic surgeon at Bryan Health
chief operating officer.
ECRI’s Robertson noted that the screening programs can also bring business into the hospitals. Yet 30% to 40% of patients who are screened are reportedly called back for follow-up exams that can be billed to their insurance. “They’re getting a lot of patients in the door,” she said.
However, offering the screenings for free or at a subsidized cost does have some negative impact on providers. The screenings are time-consuming and require radiologists to read the scans.
Yet there are troubling questions raised when hospitals charge what could be considered prohibitively high rates for some patients. “We don’t have established reimbursement from CMS,” said Dr. Andrea McKee, chair of radiation oncology at the Lahey Hospital and Medical Center in Burlington, Mass., and director of its free lung cancer screening program. “It becomes a real healthcare disparities issue when we begin to think about it in those terms.”
The 327-bed hospital now screens about 60 patients a week. The program follows the NCCN’s guidelines and McKee said the results have been comparable to what was reported in the National Lung Screening Trial.
“We are an accountable care organization,” McKee said. “Diagnosing early stage lung cancer is definitely more cost effective than latestage lung cancer.”