Asinine, Backasswards Colonoscopy Insurance Rules Make Patients Decline Medically Necessary Testing


I’ve had several telephone calls in the last two weeks from a 40-year-old woman with abdominal pain and changed bowel habits. She obviously needs a colonoscopy, which is what I told her when I saw her.

If she needed an MRI to rule out a brain tumor I think she would accept that there would be co-pays or deductibles, because the seriousness of our concern for her symptoms would make her want the testing.

But because in the inscrutable wisdom of the Obama Affordable Care Act, it was decided that screening colonoscopies done on people with no symptoms whatsoever are a freebie, whereas colonoscopies done when patients have symptoms of colon cancer are subject to severe financial penalties.

So, because there’s so much talk about free screening colonoscopies, patients who have symptoms and need a diagnostic colonoscopy are often frustrated, confused and downright angry that they have to pay out-of-pocket to get what other people get for free when they don’t even represent a high risk for life-threatening disease.

But, a free screening colonoscopy turns into an expensive diagnostic one if it shows you have a polyp and the doctor does a biopsy – that’s how the law was written. If that polyp turns out to be benign, or hyperplastic, there is no increased cancer risk associated with it, but you still have to pay your part of a diagnostic colonoscopy bill because they found something.

For those who don’t know:

A “precancerous“ adenomatous polyp has only a 2% risk of actually turning into a cancer. So screening colonoscopies, while they make some sense on the population level, are less obviously a statistically good deal for the majority of people who have them if you consider the out of pocket cost when something is found.

Cologuard, the noninvasive screening test, sounds like a good deal but a positive test result represents no disease at all 50% of the time and non-cancerous conditions about 45% of the time. And if you have a positive Cologuard, the subsequent colonoscopy is technically definitely a diagnostic colonoscopy subject to all the financial penalties people are so upset about.

So, my 40-year-old woman with colon cancer until proven otherwise keeps calling me, saying she won’t have the colonoscopy unless I can make sure it’s billed as a screening colonoscopy.

Well, traditional guidelines have been to start screening at age 50, and now there is a movement to start screening at age 45 because colon cancer is seen in many younger people now. You can also qualify for a screening colonoscopy 10 years before a first-degree relative developed colon cancer.

Those are the rules. I didn’t make them up. Somebody working for Obama did.

In the area where I practice, there are no gastroenterologists. General surgeons are the ones who do colonoscopies. And unlike big city gastroenterologists (Bangor, Maine) our local surgeons meet with the patients first to take their history and establish the need for and classification of the colonoscopy.

We have urged my patient to at least go and talk with the surgeon. That will not cost $5,000 but will hopefully make her understand her situation better.

This is what I call Metamedicine. I know what my patient needs, but how do I get her there? What are all the bureaucratic and financial obstacles standing between me and my patient on one hand, and what we both agree she needs to have done on the other?

Hans Duvefelt is a Swedish-born rural Family Physician in Maine. This post originally appeared on his blog, A Country Doctor Writes, here.