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Removing Barriers to Colorectal Cancer Screening Act of 2019
Colorectal cancer (CRC) is a leading cause of cancer death in the US. Screening through use of colonoscopy is an effective means of preventing and detecting CRC early, through the removal of precancerous or cancerous polyps, leading to reduced costs and better outcomes. In general, preventative screenings are fully covered by Medicare, however a Medicare billing loophole exists, stating that if a colonoscopy leads to polyp removal, the service is considered diagnostic leading to a 20 percent coinsurance cost. Many Medicare beneficiaries, who are age 65 and older, are foregoing screening due to this financial burden. H.R. 1570, introduced in the House in March 2019 and as of October 2019 is awaiting committee discussion in the Subcommittee on Health, proposes to waive this coinsurance for colonoscopy. The enactment of this legislation, while increasing Medicare costs would aid in reducing cancer health disparity and over the next several decades, result in reduced CRC treatment costs. Nurses should urge policymakers to make this a priority to improve access to care for all..
Keywords: colorectal cancer, colonoscopy, coinsurance, Medicare, screening
H.R. 1570: Removing Barriers to Colorectal Cancer Screening Act of 2019
Colorectal cancer (CRC) is the second leading cause of death by cancer in the United States (US) in men and women combined and 145,600 new cases will be diagnosed this year, (American Cancer Society, 2019). CRC screening colonoscopies allows for early detection and removal of polyps that could become cancerous. Colorectal cancer is largely preventable and treatable when found at an early stage, but one in three adults over age 50 are not up to date with recommended screenings, the majority of which are Medicare beneficiaries, and many cite financial reasons as a barrier (American Cancer Society, 2019). Numerous studies have found that out of pocket costs create financial barriers causing individuals to limit the use preventative screenings such as colonoscopy. Medicare beneficiaries are at an increased risk of financial vulnerability, as 34% of Medicare beneficiaries fall below the federal poverty level (American Cancer Society, 2019).
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The Colorectal Cancer Screening Act of 2019 (H.R. 1570) proposes an amendment to title XVIII of the Social Security Act. This amendment would waive cost sharing coinsurance for colon cancer screening tests, as covered by Medicare, even if the screening test led to a diagnostic or therapeutic intervention. When Medicare beneficiaries go in for a screening colonoscopy, they assume there will be no cost sharing as it is a screening test. However, current Medicare regulations require a 20 percent coinsurance on any colonoscopy if a polyp is removed, because then the designation moves from a diagnostic procedure rather than a screening (Howard, Guy & Ekwueme, 2014). This out of pocket cost is a deterrent to many individuals. The enactment of H.R. 1570 would eliminate this cost sharing policy under Medicare. This bill was introduced to Congress on March 6th, 2019 and is currently being discussed by the House Subcommittee on Health.
Health equity can be defined as achieving the highest level of health for the entire population and that opportunities to obtain health are not denied due to social status or inability to pay (Alvarez & Villarruel, 2016). Being uninsured, underinsured or having lack of access to health care is a contributor to poor health. Currently, individuals are forgoing a potentially lifesaving screening test due to their inability to pay the coinsurance. Nursing has a rich history of working on behalf of the vulnerable and advocacy is fundamental to the nursing role (D’ Antonio, Fairman & Lewensen, 2016). Advocating for and encouraging policymakers to pass this legislation is a step towards eliminating health disparities which should be a goal of all nurses in the US. By enabling more individuals to be screened for cancer, CRC might be found at an earlier stage, leading to better outcomes, higher quality of life and les healthcare spending. It is the duty of all professional nurses to inform and educate policymakers about health prevention and promotion approaches that will have the greatest benefit and impact on population health and by supporting H.R. 1570, nurses would fulfill a foundational value of nursing, to bring equal opportunities for healthcare to the entire population.
Investigation of Legislative Process
The U.S. Congress, which is composed of the Senate and the House of Representatives, is the legislative branch of the federal government and generates laws for the country. Ideas for health care laws can come from many sources such as nurses, professional nursing associations or concerned constituents. A bill, which is a proposal for a new law, can only then be introduced into either the Senate or the House of Representatives by a senator or representative who sponsors it (usa.gov, 2019). Bills are often introduced at the same time in the Senate and the House, as companion bills that have different numbers and may be slightly different in details (Ridenour, 2016). Once a bill is introduced, it is sent to a committee where the bill is researched, opposing viewpoints are discussed and debated and the bill is often amended, or no action is taken, meaning the bill does not move forward. Only 15% of all bills that are sent to a committee are sent to the Senate or the House for a vote, as committees often select bills that meet their party priorities (Ridenour, 2016).
Once a bill is sent out of committee to the Senate or the House floor, members of Congress research, debate the bill and make changes to it before voting. During this time, special interest groups can attempt to change the outcome of the vote by lobbying both opponents and proponents. A final version of the bill is voted upon and if it passes, it must be sent to the other chamber of Congress and will go through a similar process of debate and amendment (Ridenour, 2016). After the bill is accepted by both the Senate and the House, differences between the bills must be changed and then both chambers vote on an identical bill. If this bill passes, it is sent on to the President, which is the executive branch of the government, and from there the president can approve the bill and sign it into law or veto the bill (Ridenour, 2016). If the president vetoes the bill, Congress can vote to override the veto and sign the bill into law (usa.gov, 2019).
The process of enacting legislature is arduous and complex, with many groups involved, thus making it easier to defeat a bill rather than to sign a bill into law. Every bill introduced in either chamber must be acted up within two years, or will no longer be active or able to be debated or voted upon. The Colorectal Cancer Screening Act of 2019 (H.R. 1570) was introduced to Congress on March 6th, 2019. It was referred to the Committee on Ways and Means, who then referred it to the Subcommittee on Health. This subcommittee will discuss and potentially amend the bill before deciding if it should be brought to the House floor for a vote.
Opinion on Legislation’s Merit
The American Cancer Society (2019) estimates that there will be 145,600 new cases of colorectal cancer diagnosed in 2019 and an estimated 51,020 deaths from CRC will occur in 2019. Despite these numbers, CRC incidence trends have been declining for the past several decades, largely due to increased preventative screening. With screening, it is possible to prevent CRC by allowing for the detection of precancerous lesions and removing them through a procedure called a polypectomy (American Cancer Society, 2019). If cancer is detected during a colonoscopy, it is likely that it will be diagnosed at an early stage when the treatment will be less extensive, burdensome and more successful. It is recommended that individuals who are at average risk for developing CRC begin screening with either a stool-based test or a visual examination of the colon and rectum, beginning at age 45 and continuing through age 75 (Smith et al., 2019). Regular adherence to a screening schedule results in a reduction in deaths from CRC.
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The five year relative survival rate for all stages of CRC is 65%, but when CRC is found at an early stage before it has spread, the survival rate increases to 90% (American Cancer Society, 2019). Unfortunately, only 39% of patients are diagnosed with early stage disease. These statistics illuminate the importance of regular screening with colonoscopy, but despite this, in 2015 only 61.1% of eligible individuals reported having CRC screening (Peterse et al., 2017). Screening remains underutilized which implies that a number of CRC deaths could be avoided through the use of regular screening exams.
Due to the importance of screening, increasing the number of adults screened for CRC as recommended by the US Preventive Services Task Force (USPSTF) is a leading national health indicator for Healthy People 2020 (Howard et al., 2014). With the implementation of the Affordable Care Act, Medicare is required to cover all preventative services for eligible beneficiaries. However, due to what is termed a Medicare billing loophole, when a polyp is found on a screening colonoscopy and necessitates removal, the service is found to be diagnostic or therapeutic and is not considered preventative, leading to patients being charged a 20% copay for the service (Howard et al., 2014). This out of pocket cost may discourage some individuals, particularly those of low socioeconomic status to use the service. Medicare beneficiaries, who are 65 years of age and older, are in the age range that has the highest likelihood of developing CRC, and also likely to be in the lowest socioeconomic class and are thus less likely to seek preventative services that may incur a financial cost (Peterse et al., 2017).
This issue is an example of a health disparity that currently exists in the US. This population that is underinsured and of low socioeconomic status will not seek healthcare that they are unable to afford. This will lead to worse health outcomes and higher mortality for this group. Disparities such as this affect this group, but also limited continued improvement in quality of care and will ultimately result in higher healthcare costs for all, as advanced CRC costs are greater than early stage CRC. Nurses should advocate for the enactment of H.R. 1570 as it is a small step in reducing disparities in cancer care.
CRC is the second leading cause of cancer death in the US, but has been declining in the past decades, and this is largely attributable to increased CRC screening efforts. However there are still a large number of individuals who do not participate in screening, suggesting that more CRC deaths could be prevented. One barrier to CRC screening is financial, particularly among those eligible for Medicare and of low socioeconomic class, due to the potential of having to pay out of pocket costs. The enactment of H.R. 1570 would eliminate these cost sharing requirements and make a preventative colonoscopy, regardless of need for polypectomy, a fully covered service.
Since the 2011-12 session of Congress, some form of H.R. 1570 has been introduced. Due to the lack of studies on the potential impact of waiving the coinsurance for diagnostic colonoscopies upon screening rates and savings in CRC treatment costs, the bills have remained idle and not been signed into law (Peterse et al., 2017). Additionally, concern over growing Medicare costs have slowed enactment of this legislation. Medicare spending was 15 percent of all federal spending in 2018 and has been projected to climb by 18 percent by 2029 (Cubanski, Neuman & Freed, 2019). It is estimated that Medicare spending will increase at an average rate of 5.1 percent over the next ten years through an increase in Medicare enrollment, rising costs of services and increased demand for care. With these looming increases, many wonder if adding the Medicare spending by enacting this legislation is a wise choice. Howard et al. (2015) estimated that in Medicare eliminated the coinsurance for colonoscopies with polypectomy, Medicare spending on the service would increase by 10% and would result in an 18% increase in screening. This may seem like more costs up front, but in reality, expanding access to preventative screenings will lower the cost of CRC treatment for Medicare over time.
It is estimated that 14 billion dollars is spent annually on CRC treatments and the costs are expected to increase to 20 billion dollars by the year 2020, and of these figures, Medicare pays for over half of the cost (Meester et al., 2015). Treatment costs for an individual with advanced CRC can exceed $240,000 in a year (Meester et al., 2015). Preventing CRC from occurring through the use of screening tests, may increase Medicare costs in the short term, but by increasing screening, considerable reductions in CRC mortality and cost will occur. It is imperative that legislators enact this bill.
A recent study (Meester et al., 2015) estimated that 63% of all CRC deaths in 2020 will be due to individuals not being screened with a colonoscopy. This is a significant number of deaths that could be prevented and signifies an indirect cost on treatment at end of life and a loss in productivity. Mortality benefits from screening do not only occur with cancer detection, they also occur with the detection and treatment of precancerous lesions. As nurses, and as leaders, it is the professions duty to advocate for legislative change that will eliminate health disparities and promote the health of the population. Nurses have the power to evoke legislative changes and improve the quality of care that is offered to underinsured patient populations and the enactment of H.R. 1570 will save thousands of lives in the next decades.
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