Copyright (C) 2009 Robert S. Rosson. all rights reserved.
Medicare Blow to Virtual Colonoscopies: New York Times, Friday, February 13, 2009
Screening for colorectal cancer is undoubtedly a worthwhile and laudable process. At present the gold standard is optical colonoscopy, which has the advantage of permitting removal of pre-cancerous polyps. This procedure, however, requires a dedicated endoscopy unit, a skilled, highly-trained gastroenterologist or surgeon, one or two nurse assistants, expensive equipment, and the presence of an anesthesthetist (or two!) to administer the currently recommended sedation.
A relatively new and possibly more cost effective, screening tool has been developed utilizing CT technology. While this procedure, “virtual colonoscopy,” requires essentially the same unpleasant preparation as colonoscopy, it requires only one technician, a radiologist and a CT scanner in a standard radiology suite. With increasing utilization, this procedure should incur lower costs to the patient and to Medicare.
Now in its infinite wisdom the Centers for Medicare and Medicaid Services has tentatively decided not to pay for virtual colonoscopy. Each method has its strengths and weaknesses. Virtual colonoscopy sees only larger polyps and requires the patient to be referred for conventional colonoscopy for removal of the polyps. Conventional colonoscopy can find smaller polyps, but most of these do not need to be removed. Virtual colonoscopy does not carry the slight but definite risk of perforation of the colon associated with the conventional procedure. I believe this is a short-sighted and ill-conceived decision by Medicare
I would suggest a way to improve the situation and decrease the cost in which two procedures are required when polyps are found by the CT method. I would have colonoscopy units reserve a certain number of time slots the next day for patients found to have polyps by virtual colonoscopy. The patient could be kept on a clear liquid diet and not need further colon preparation. The professional and facility charges for such a “targeted” colonoscopy and the CT scan could then be reduced significantly for the combined procedures.
As Dr. Howard Spiro and I suggested in our letter to the Annals of Internal Medicine in 2003, virtual colonoscopy or other developing tests should become alternatives to optical colonoscopy as primary screening tests for colorectal cancer.
Published originally in YJHM February 17, 2009
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