When the Centers for Medicare and Medicaid Services decided to deny coverage (and therefore, payment) for computed tomography colonography (CTC) in February, it set off a firestorm of debate among imaging advocates, providers, payers, and consumers.

Traditional colonoscopy has been the gold standard to screen for colon cancer. It can be uncomfortable or inconvenient.

CTC, sometimes called virtual colonoscopy, is less invasive compared to traditional colonoscopy, does not require sedation, and is more convenient.

Assessing the evidence

Is virtual colonoscopy as effective as the traditional screening? CMS says “the evidence is inadequate” and CTC will not be covered. A final decision is scheduled for May, but had not been made at press time.

Linda Yee, MD, professor of radiology at the University of California–San Francisco, disagrees with CMS’s decision. “We have numerous screening tools that are covered, yet less than 40 percent of the American public comes in for any kind of colon cancer screening.”

And a screening test that is more convenient and less invasive is more likely to appeal to people.

National coverage needed

Yee says that every state has local coverage decisions. “Local payers will pay for virtual colonoscopy if it’s considered diagnostic,” she says. “What’s needed, however, is national screening coverage.”

Medical directors need to be aware that not enough screening is being performed on the target population, which “is a shame because this malignancy can be prevented. CTC has been proven to be as effective as colonoscopy and we should fight for reimbursement for screening,” says Yee.

Summary of findings of comparative value

The Washington State Health Care Authority conducted a health technology assessment on computed tomography colonography.

CTC vs. no screening CTC vs. colonoscopy
The following numbers compare no screening to a strategy of screening with CTC every five years and referring for colonoscopy all lesions ≥ 6mm.
Cost of CTC $523
CTC cost to prevent one case of cancer vs. no screening $19,000
CTC cost to prevent one death vs. no screening $37,000
CTC cost per life-year gained vs. no screening $1,500
In direct comparison to colonoscopy, CTC every 10 years is more expensive and marginally less effective in preventing cases of cancer (47 vs. 52 in a lifetime cohort of 1,000 individuals) and cancer deaths (24 vs. 26). Only one CTC screening strategy is more effective than colonoscopy every 10 years, and that strategy is to perform CTC every five years with colonoscopy referral for polyps ≥ 6mm. For this strategy the cost-effectiveness is:
Cost of CTC $523
Cost of colonoscopy $522
The cost per life-year gained for CTC vs. colonoscopy $630,700
Source: Washington Health State Health Care Authority. Health Technology Assessment. Computed Tomography Colonography. Feb. 1, 2008.

Managed Care’s Top Ten Articles of 2016

There’s a lot more going on in health care than mergers (Aetna-Humana, Anthem-Cigna) creating huge players. Hundreds of insurers operate in 50 different states. Self-insured employers, ACA public exchanges, Medicare Advantage, and Medicaid managed care plans crowd an increasingly complex market.

Major health care players are determined to make health information exchanges (HIEs) work. The push toward value-based payment alone almost guarantees that HIEs will be tweaked, poked, prodded, and overhauled until they deliver on their promise. The goal: straight talk from and among tech systems.

They bring a different mindset. They’re willing to work in teams and focus on the sort of evidence-based medicine that can guide health care’s transformation into a system based on value. One question: How well will this new generation of data-driven MDs deal with patients?

The surge of new MS treatments have been for the relapsing-remitting form of the disease. There’s hope for sufferers of a different form of MS. By homing in on CD20-positive B cells, ocrelizumab is able to knock them out and other aberrant B cells circulating in the bloodstream.

A flood of tests have insurers ramping up prior authorization and utilization review. Information overload is a problem. As doctors struggle to keep up, health plans need to get ahead of the development of the technology in order to successfully manage genetic testing appropriately.

Having the data is one thing. Knowing how to use it is another. Applying its computational power to the data, a company called RowdMap puts providers into high-, medium-, and low-value buckets compared with peers in their markets, using specific benchmarks to show why outliers differ from the norm.
Competition among manufacturers, industry consolidation, and capitalization on me-too drugs are cranking up generic and branded drug prices. This increase has compelled PBMs, health plan sponsors, and retail pharmacies to find novel ways to turn a profit, often at the expense of the consumer.
The development of recombinant DNA and other technologies has added a new dimension to care. These medications have revolutionized the treatment of rheumatoid arthritis and many of the other 80 or so autoimmune diseases. But they can be budget busters and have a tricky side effect profile.

Shelley Slade
Vogel, Slade & Goldstein

Hub programs have emerged as a profitable new line of business in the sales and distribution side of the pharmaceutical industry that has got more than its fair share of wheeling and dealing. But they spell trouble if they spark collusion, threaten patients, or waste federal dollars.

More companies are self-insuring—and it’s not just large employers that are striking out on their own. The percentage of employers who fully self-insure increased by 44% in 1999 to 63% in 2015. Self-insurance may give employers more control over benefit packages, and stop-loss protects them against uncapped liability.