CMS to weigh cov­er­age of CT scans for smok­ers

Modern Healthcare - - NEWS - By Vir­gil Dick­son

Dr. Barry Kramer once had doubts that us­ing low-dose CT scans to de­tect early lung cancer is a good idea based on his re­search sug­gest­ing that a high rate of false-pos­i­tive re­sults could in­crease pa­tient anx­i­ety and harm­ful fol­low-up tests.

But in 2011, as an in­ves­ti­ga­tor on the Na­tional Lung Screen­ing Trial, he found a 20% re­duc­tion in deaths among cur­rent and for­mer heavy smok­ers over age 55 who were screened us­ing CT scans ver­sus those screened us­ing chest X-rays. Since then, Kramer, now di­rec­tor of the Na­tional Cancer In­sti­tute’s Di­vi­sion of Cancer Preven­tion, has been an ad­vo­cate of CT screen­ing for the es­ti­mated 9 mil­lion Amer­i­cans be­tween 55 and 80 who have a smok­ing his­tory of 30 years av­er­ag­ing a pack a day.

“In my es­ti­ma­tion, the ben­e­fits out­weigh the harms,” he said.

That will be the cen­tral is­sue on April 30 when the CMS con­venes a meet­ing of the Medi­care Ev­i­dence De­vel­op­ment and Cov­er­age Ad­vi­sory Com­mit­tee to de­cide if Medi­care will cover an­nual screen­ings for lung cancer with low-dose CT scans for cur­rent and past heavy smok­ers. The panel will make a rec­om­men­da­tion by the end of the meet­ing. The CMS ex­pects to re­lease a pro­posed de­ci­sion memo in Novem­ber and a fi­nal na­tional cov­er­age de­ter­mi­na­tion by Fe­bru­ary 2015.

Last De­cem­ber, the U.S. Pre­ven­tive Ser­vices Task Force rec­om­mended such an­nual screen­ings for cur­rent or past heavy smok­ers ages 55 to 80. Un­der the Pa­tient Pro­tec­tion and Af­ford­able Care Act, that rec­om­men­da­tion means pri­vate in­sur­ers are re­quired to cover the screen­ing on a first-dol­lar ba­sis for their non-Medi­care mem­bers. The test costs $300 to $400.

Many ex­perts sup­port Medi­care cov­er­ing CT scans for smok­ers. “Lung cancer is the leading cause of cancer death among both men and women and with­out screen­ing we can make no head­way,” said Dr. Ella Kaze­rooni, chair­woman of the Amer­i­can Col­lege of Ra­di­ol­ogy’s Lung Cancer Screen­ing Com­mit­tee.

Oth­ers raise con­cerns about po­ten­tial neg­a­tive ef­fects on pa­tients, in­clud­ing the cu­mu­la­tive ef­fect of an­nual ra­di­a­tion ex­po­sure from the scans. The Amer­i­can Academy of Fam­ily Physi­cians in Jan­uary con­cluded that the ev­i­dence is in­suf­fi­cient to rec­om­mend for or against the screen­ing. It urged a shared de­ci­sion­mak­ing dis­cus­sion be­tween doc­tors and pa­tients re­gard­ing the ben­e­fits and po­ten­tial harms of the screen­ing.

Medi­care’s cov­er­age de­ter­mi­na­tion for lung cancer CT scans for smok­ers comes af­ter con­tro­ver­sial rec­om­men­da­tions from the U.S. Pre­ven­tive Ser­vices Task Force sev­eral years ago that women un­der 50 with an aver­age risk of breast cancer should not re­ceive rou­tine mam­mo­grams—the rec­om­men­da­tion was not adopted by HHS for its cov­er­age pol­icy—and from the Amer­i­can Uro­log­i­cal As­so­ci­a­tion rais­ing ques­tions about the value of rou­tine prostate-spe­cific anti­gen tests for men. In both cases, the groups said the po­ten­tial harms may out­weigh the ben­e­fits.

Smok­ing-re­lated lung cancer kills about 130,000 Amer­i­cans each year. The five-year over­all sur­vival rate for lung cancer pa­tients in the U.S. is 16.8%. That low rate has been at­trib­uted to the late stage of di­ag­no­sis for the dis­ease. The pre­ven­tive ser­vices task force es­ti­mated that if its rec­om­men­da­tion was fully im­ple­mented, it could save as many as 20,000 lives an­nu­ally.

There has been dis­cus­sion about whether the CMS will or should con­sider cost-ef­fec­tive­ness in mak­ing its de­ci­sion. The 2008 Medi­care Im­prove­ments for Pa­tients and Providers Act au­tho­rized the Medi­care pro­gram to con­sider cost in mak­ing cov­er­age de­ci­sions about pre­ven­tive screen­ing ser­vices.

A Mil­li­man ac­tu­ar­ial anal­y­sis pub­lished in Health Af­fairs in 2012 con­cluded that cov­er­ing CT lung cancer scans for smok­ers ages 50 to 64 would save lives at a cost of un­der $1 per in­sured mem­ber a month. A sep­a­rate study pub­lished in the Jour­nal of Tho­racic On­col­ogy in 2011 found cost-ef­fec­tive­ness num­bers for CT lung cancer screen­ing that were less fa­vor­able than those for breast cancer or col­orec­tal cancer screen­ing. But it also found that com­bin­ing CT screen­ing with smok­ing ces­sa­tion coun­sel­ing could sig­nif­i­cantly im­prove the cost-ben­e­fit ra­tio.

The CMS pre­vi­ously has taken cost into con­sid­er­a­tion in mak­ing pos­i­tive cov­er­age de­ci­sions on screen­ings for de­pres­sion, HIV, and obe­sity screen­ing and coun­sel­ing, said James Cham­bers, an as­sis­tant pro­fes­sor of medicine at Tufts Med­i­cal Cen­ter, Bos­ton, who has stud­ied Medi­care cov­er­age de­ci­sions. “Since they did it for these, I would not be sur­prised if they did it for proac­tive CT scans of lungs in heavy smok­ers,” he said.

But Dr. Barry Straube, a for­mer CMS chief med­i­cal of­fi­cer who now is di­rec­tor of health­care con­sult­ing for the Marwood Group, said the CMS is un­likely to as­sess cost be­cause that is too con­tro­ver­sial po­lit­i­cally and be­cause no other screen­ing test is equally ef­fec­tive in de­tect­ing lung cancer.

A CMS spokesman said the agency has no plans to con­sider cost in mak­ing its cov­er­age de­ci­sion.

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