【声音】提高癌症筛查依从性需要积极的医疗补助和报销政策！

《癌症》杂志最新发表的研究调查了46个州医疗补助计划的数据以明确医疗补助资格和报销补助政策是否影响乳腺癌、宫颈癌和结肠癌的筛查率。结果发现，增加门诊报销补助与接受结肠镜检查的可能性存在阳性关联。然而，增加筛查报销同时存在阳性关联和阴性关联。增加门诊补助似乎是一个提高医疗补助受益人群癌症筛查的有效方法。斯坦福大学 Walter G. Park博士对此进行了点评。

专家评述

斯坦福大学 Walter G. Park博士

结直肠癌在美国男性和女性恶性肿瘤相关死因中列第2位。对于献身从事消化系统疾病我们来说，我们都十分清楚结肠癌筛查的可能性和漏诊的可能性。支持结肠癌筛查的证据显示在过去10年里结直肠癌的诊断下降了30%，而这归功于越来越多的人接受结肠镜筛查。当认识到后面的情形时，提醒我们可能存在漏诊的机会，在50至 75岁之间的成年人中，每3个人中就有1人没有接受推荐的筛查检查。

有许多因素与提高结肠癌筛查依从性有关。许多障碍可以通过联邦和州政府的政策解决。例如，患者保护与平价医疗法案免除了医疗保险受益人筛查检查方面的所有免赔额和共同保险。比如，美国预防服务工作组评定结肠镜检查为“A”级。尽管这一政策业已推进, 仍需要进一步的政策行动。值得注意的是，共同保险适用于在结肠镜筛查中行息肉切除术的患者, 因为该检查技术已经成为一个诊断测试手段。考虑到立法者的监督力度,需要新的立法来改变这一政策。

当我们进一步考察未接受癌症筛查的人群时, 我们必须承认筛查间存在着显著的差异。特殊人群包括西班牙裔、美国印第安人和阿拉斯加原住民，那些居住在农村的人群，以及那些文化水平和收入水平较低的人群。联邦项目目前支持25个州的政策计划和4部落组织以解决现存的显著差异，比如疾病控制和预防中心(CDC)的结直肠癌控制项目(CRCCP)。因为许多收入水平较低的病人，可通过州政府的医疗补助项目得到解决。

患者保护与平价医疗法案也为各个州提供了扩展医疗补助资格的机会。这一点意义重大，因为医疗补助受益人不太可能接受癌症筛查，而更有可能表现为进展期肿瘤。在本周PracticeUpdate的研究热点中，Halpern和其同事最近的一篇文章对各州的医疗补助计划进行了评估,发现接受结肠镜检查或粪便潜血试验检查的中位数分别为5.7%和4.4%。他们同时发现，增加筛查报销补助与接受结肠镜检查的几率存在阳性关联。更令人印象深刻的是，增加门诊报销补助与接受结肠镜检查的可能性存在阳性关联。

这些结果对纠正我们的错误是及时的，尤其是我们正在面对着各个州旨在减少结肠癌筛查医师报销的医疗补助计划。例如, 俄亥俄州医疗补助部门最近降低了50%在日间手术中心或医院门诊部门行结肠镜检查时的医师补助部分。其他州正在引进其他可供选择的支付模式,这可能减少关于确诊癌症筛查策略的渠道。尽管这可能是控制医疗成本的一个可以理解的合理化措施,但是特殊检查或包括确诊癌症的筛查却被误导了,特别是对于存在明显差异的人群。Halpern和其同事的文章表明,当前各个州的医疗补助报销政策是不够的,需要更准确地体现结肠镜筛查挽救生命的价值。

如果我们要完成全国结直肠癌会议预定的到2018年实现筛查率达80%的目标, 联邦和州政府需要更为有效和合理化的宣传。国会立法，将免除目前存在的结肠镜筛查时行息肉切除术的医疗保险受益人的共同保险，但仍有待通过。宣传保护和扩展疾病控制和预防中心(CDC)的结直肠癌控制项目(CRCCP)是非常必要的。各个州的医疗补助计划已经发现的错误亟待解决。一线胃肠病学家可以向州和联邦立法代表表达你的关注，一个简单的步骤便可带来重要的影响。可以通过你所属的专业组织（包括美国胃肠病协会AGA，美国胃肠病学会ACG, 和美国消化内镜学会ASGE），获得为此投入的更多资源和机遇。

TAKE-HOME MESSAGE

This study investigated Medicaid data from 46 states to determine if Medicaid eligibility and reimbursement policies affect rates of screening for breast, cervical, and colon cancers. Increases in office visit reimbursements correlated positively with the likelihood of receiving all screening tests. However, increases in reimbursements for screening tests resulted in both positive and negative associations.

Increases in reimbursement for office visits seem to be an effective way to increase cancer screening in Medicaid beneficiaries.

Expert Comment

Colorectal cancer remains the second leading cause of cancer death in both men and women in the US. 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 50-75 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 co-insurance for Medicare beneficiaries for screening tests such as colonoscopy with an “A” rating from the US Preventive Services Task Force. Despite this policy advance, further policy action is needed. Specifically, for 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, or Alaska Natives; those who reside in rural populations;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 patients are likely to get screened through state-based 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 this week’s 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. They 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 that 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 that 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. Identifying misguided state-based Medicaid initiatives need to be addressed. 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 AGA, ACG, and ASGE.  

Cancer

Impact of State-Specific Medicaid Reimbursement and Eligibility Policies on Receipt of Cancer Screening

Cancer 2014 Oct 01;120(19)3016-3024, MT Halpern, MA Romaire, SG Haber, FK Tangka, SA Sabatino, DH Howard

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.

This abstract is available on the publisher's site.

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Copyright © 2014 Elsevier Inc. All rights reserved.