【观点】提高结直肠癌筛查依从性亟需突破政策障碍

Walter G. Park博士

机构： 斯坦福大学 介绍： 疾病： 结直肠癌

斯坦福大学Walter G. Park博士

在美国，不管是男性还是女性，结直肠癌都是癌症死亡的第2大原因。对于我们中的那些投身从事消化系统疾病的医生而言，我们都非常了解结肠癌筛查的可能性和漏诊的机会。有证据支持这种可能性，在过去10年里结直肠癌的诊断下降了30%，而更多的要归功于越来越多的人接受结肠镜筛查。当我们认识到在50~75岁之间的成人中约1/3没有进行推荐的检查时，我们意识到了漏诊的机会。

有许多因素参与改善结肠癌筛查的依从性。许多障碍可以通过联邦和州政府的政策层面解决。例如，患者保护与平价医疗法案免除了医疗保险受益人和私人医疗保险患者关于筛查的所有的免赔额和共同保险/共担额，比如美国预防医学工作组将结肠镜检查评为“A级”或“B级”。法律赋予各州医疗补助计划财政激励以覆盖这些预防服务而不需要个体参与的成本分担。尽管这一政策已经在推进，仍需要更进一步的政策行动。具体来说，参与联邦医疗保险的患者在结肠镜筛查时发现并切除了息肉，应该可以申请共同保险，因为从技术而言，这种操作已经成为一种诊断检查。考虑这是立法者的一个疏忽，因此我们需要新的立法来改变这一政策。

当我们仔细研究下是谁没有参与筛查，我们必须承认存在着显著的差异。特殊的人群包括西班牙裔、美国印第安人以及阿拉斯加原住民；那些居住在农村社区者；以及教育水平落后和低收入者。联邦计划，比如美国疾病控制和预防中心 (CDC)的结直肠癌控制计划(CRCCP)目前支持25个州的政策计划和4部落组织以解决显著的筛查差异。由于收入水平较低，其中许多个体可能会通过医疗补助计划而参与筛查。

平价医疗法案同时也为各个州提供了扩展医疗补助纳入资格的机会。这一点意义非常重大，因为医疗补助受益人不太可能参与癌症的筛查而更有可能出现进展期肿瘤。新近有一篇被PracticeUpdate选为研究热点的文章，Halpern和他的同事评估了各个州的医疗补助计划，并且发现接受结肠镜检查或者粪便潜血试验（FOBT）的人群的中位数分别为5.7%和4.4%。作者同时展示了增加筛查试验报销和接受结肠镜检查的比率之间的正相关性。更令人印象深刻的是，增加诊室就医报销和接受结肠镜检查的比率之间也存在正相关性。

得出这些结果正是时候,我们正在面对的以州为基础的医疗补助计划，其正在试图减少结肠癌筛查相关的医师报销。例如，俄亥俄州医疗补助计划部门最近减少了50%的在日间手术中心或者医院门诊部门完成的结肠镜检查的关于医师部分的还款。其他州也正在起草替代性的支付模型，这可能会减少关于癌症筛查策略的访问。尽管为了通过全面的努力来控制医疗成本，其中大部分内容可能是合理化的，但是，特别是针对或者包括癌症筛查检查方面的内容却是被误导的，尤其是对于那些存在明显差异的人群。Halpern和他的同事完成的这篇文章表明，当前状态的医疗补助计划报销政策是不够的，需要更准确地反映结肠镜检查在挽救生命方面的价值。

如果我们要实现由全国结直肠癌圆桌会议设定的目标——到2018年达到的80%的筛查比率，将需要在联邦和州的层面进行更为有效的且更有组织的宣传。在国会立法时，“消除结直肠癌筛查障碍法案”，这将会在医疗保险受益人中消除结肠镜筛查时切除息肉的共同保险，该议案已经存在了，但仍有待通过。宣传保护和扩展CDC的CRCCP是非常必要的。需要识别各个州执行的被误导的医疗补助计划。对于各位临床胃肠病专家来说，只是一个简单的步骤就会带来不一样的变化，即联系你的州和联邦立法代表以表达出你关心的问题。通过你的专业组织，包括ASGE、AGA和ACG等，可以获得更多的资源和机会。

独家授权，未经许可请勿转载！

Colorectal cancer remains the second leading cause of cancer death in both men and women in the United States. For those of us who have dedicated ourselves to a career in digestive diseases, we are all too aware of both the possibilities and missed opportunities of colon cancer screening. The possibilities are bolstered by evidence that shows colorectal cancer diagnoses have dropped 30% in the last decade, and much of this is attributed to more people getting screened by colonoscopy. We are reminded of the missed opportunities when recognizing that about 1 in 3 adults between 50 and 75 years old are not getting tested as recommended.

There are many factors involved in improving adherence to colon cancer screening. Many of these barriers can be addressed at federal and state policy levels. For example, the Patient Protection and Affordable Care Act waived all deductibles and coinsurance/copayments for Medicare beneficiaries and privately insured patients for screening tests, such as colonoscopy, with an “A” or “B” rating from the US Preventive Services Task Force. The law also gives state Medicaid programs financial incentives to cover these preventive services without cost sharing for adults. Despite this policy advance, further policy action is needed. Specifically, for Medicare patients who have polyps removed during a screening colonoscopy, coinsurance applies, as the procedure technically has become a diagnostic test. While considered an oversight by legislators, new legislation is required to change this policy.

When we look a little closer as to who is not getting screened, we must acknowledge that significant disparities exist. Specific populations include Hispanics, American Indians, and Alaska Natives; those who reside in rural communities; and those with lower education and income. Federal programs such as the Colorectal Cancer Control Program (CRCCP) at the Centers for Disease Control and Prevention (CDC) currently support 25 state initiatives and 4 tribal organizations to address significant screening disparities. Because of lower income levels, many of these individuals are likely to get screened through Medicaid programs.

The Affordable Care Act also offered opportunities for states to expand Medicaid eligibility. This is significant as Medicaid beneficiaries are less likely to be screened for cancer and more likely to present with advanced-stage cancers. A recent article highlighted in PracticeUpdate by Halpern and colleagues evaluated state Medicaid programs and found the median receipt of a colonoscopy or FOBT for colon cancer screening was 5.7% and 4.4%, respectively.¹ The authors also showed a positive correlation between increased screening test reimbursement and the odds of receiving a colonoscopy. More impressive was a positive correlation between increased reimbursement for office visits and the likelihood of receiving a colonoscopy.

These results are timely in that we are seeing state-based Medicaid initiatives to reduce physician reimbursement for colon cancer screening. For instance, the Ohio Department of Medicaid has recently reduced reimbursement for the physician component of colonoscopy performed in ambulatory surgery centers or hospital outpatient departments by as much 50%. Other states are piloting alternative payment models, which potentially may reduce access to proven cancer screening strategies. While much of this may be rationalized in a comprehensive effort to contain healthcare costs, specifically targeting or including proven cancer screening tests is misguided, particularly for this patient population where stark disparities exist. The article by Halpern and colleagues suggests that current state Medicaid reimbursement policies are inadequate and need to more accurately reflect the life-saving value of colonoscopy.

If we are to reach the goal of screening 80% by 2018 as set by the National Colorectal Cancer Roundtable, more effective and organized advocacy needs to occur at the federal and state levels. Legislation in Congress, the “Removing Barriers to Colorectal Cancer Screening Act,” which would remove the coinsurance for screening colonoscopies that remove polyps among Medicare beneficiaries, currently exists but remains to be passed. Advocacy to protect and expand the CDC’s CRCCP is sorely needed. Misguided state-based Medicaid initiatives need to be identified. A simple step for you—the practicing gastroenterologist—to do to make a difference is contacting your state and federal legislative representatives to voice your concerns. Resources to do this and opportunities to be more involved are available through your professional organizations, including the ASGE, AGA, and ACG.

General Gastroenterology Healthcare Policy/Healthcare Reform Expert/ACO Oncology Preventive Oncology and Screening

Copyright © 2015 Elsevier Inc. All rights reserved.

Walter G. Park博士 的文章

• • 【观点】提高结直肠癌筛查依从性亟需突破政策障碍