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Testimony on Medicare Colon Cancer Prevention Efforts
by Michael McMullan
Deputy Director, HCFA Center for Beneficiary Services
Health Care Financing Administration
U.S. Department of Health and Human Services

Before the Senate Special Committee on Aging
March 6, 1999

Chairman Grassley, Senator Breaux, distinguished committee members, thank you for inviting us to discuss Medicare's efforts to increase awareness and screening for colon cancer. We are especially proud to be here as partners in National Colorectal Cancer Awareness Month.

Colon cancer kills more than 55,000 Americans each year. But many of these deaths can be prevented by screening tests that Medicare now covers. These tests can detect polyps that can be removed before they become cancerous, and find early stage cancers for which treatments are highly effective. This is one of several important new preventive health benefits enacted as a part of the Balanced Budget Act of 1997 (BBA).

We have several outreach efforts underway to help Medicare beneficiaries and their physicians understand and take advantage of Medicare's colon cancer screening benefit. Our colleagues at the Centers for Disease Control and Prevention and the Agency for Healthcare Research and Quality are also working to promote screening.

However, far too few people are being screened. Only about 1 million of our 38 million beneficiaries had claims submitted for these life-saving tests in 1998, the first year they were covered by Medicare. We are eager to explore new ways to educate beneficiaries and providers about these important tests, and to address special challenges among groups such as women and minorities.

That makes this hearing very valuable and timely. We greatly appreciate the support of this Committee in helping us to raise awareness of the benefit of early detection and Medicare's coverage for screening tests. With your help and the assistance of our many partners in this effort, we believe we can meet the challenges before us, increase the number of beneficiaries who are screened, and save lives as a result.

BACKGROUND

Colon cancer is the second leading cause of cancer-related deaths in the United States for both men and women. When caught early, the five-year survival rate is 91 percent. However, if not caught before spreading locally, the five year survival rate drops to 60 percent. And if not caught before further spreading, the five-year survival rate plummets to only 6 percent.

The U. S. Preventive Services Task Force recommends colorectal cancer screening for all persons aged 50 or over. However, the National Colorectal Cancer Roundtable found that half of all Americans over age 50 are not getting these tests. Women and members of minority groups have particularly low screening rates. And most not screened say physicians never recommended screening to them.

Prior to the Balanced Budget Act (BBA) of 1997, the Medicare statute prohibited coverage for colorectal cancer screening and most other preventive care services. Medicare could cover tests for colon cancer only when conducted to investigate related symptoms or to monitor an individual with a history of colon cancer or inflammatory bowel disease.

Congress and the Clinton Administration changed this policy in the BBA. It authorized coverage for colon cancer screening, along with several other important preventive services, most of which took effect January 1, 1998. Regulations implementing the colon cancer screening benefit, published in the Federal Register on October 31, 1997, are based on recommendations by the American Gastroenterological Association, the Agency for Healthcare Research and Quality, and other appropriate agencies, associations, and medical groups.

• Fecal occult blood tests are covered annually for all beneficiaries age 50 and over. This is the least expensive and least invasive colorectal cancer screening test. It detects blood in the stool that is an indication of the need for further investigation.
• Flexible sigmoidoscopy is covered every four years for beneficiaries not at high risk. It is more expensive and invasive and can require local anesthesia. But it gives a view of one-third to one-half of the colon, there are fewer false positive results than with fecal occult blood tests, and lesions can be removed for biopsy.
• Colonoscopy is covered every two years for beneficiaries at high risk. This is the most expensive and invasive colorectal screening option and can require anesthesia. But it gives the best view of entire colon and lesions can be removed for testing.
• Barium enemas are covered as an alternative if a physician determines that its screening value is equal to or greater than sigmoidoscopy or colonoscopy.

Other Preventive Services

The BBA authorized or expanded coverage of preventive services for several other diseases, as well, and in some cases reduced beneficiary cost sharing in order to further encourage use.

• Breast Cancer: Annual mammography screening is covered for all female beneficiaries age 40 and over, and a one-time baseline mammogram for beneficiaries ages 35-39. Patients pay 20 percent of the Medicare approved amount, but there is no deductible.
• Cervical Cancer: Screening pelvic exams, screening pap tests and clinical breast exams are covered every three years for most women, and every year for women at high risk. Patients do not have to pay either a copayment or deductible for pap tests. For pelvic and breast exams, they must pay the standard 20 percent coinsurance but not the deductible.
• Prostate Cancer: Annual digital rectal exams and prostate specific antigen (PSA) tests are covered for all males age 50 and over, with no coinsurance or deductible for the PSA test.
• Diabetes: Glucose monitors, lancets, and test strips which help patients control blood sugar are covered, as are programs to teach diabetics how to care for their condition.
• Osteoporosis: Bone density measurement is covered for all beneficiaries at risk.
• Vaccinations: Annual vaccinations for influenza, as well as vaccinations for pneumococcal pneumonia, are covered with no coinsurance or deductible. Hepatitis B shots are also covered for patients at medium to high risk.

The Presidents fiscal 2001 budget would further encourage beneficiaries to take advantage of life-saving preventive benefits. It would:

• eliminate existing cost-sharing for all Medicare-covered preventive benefits, including colorectal screening (NOTE: As indicated earlier in my testimony, there are a variety of different beneficiary cost-sharing requirements for the individual preventive services authorized for coverage under Medicare. The President's Budget would waive all existing cost-sharing for these services to simplify the process for beneficiaries and to encourage their utilization.);
• initiate a three-year demonstration to evaluate the most successful and cost-effective smoking cessation services; and
• launch a two-year, nationwide education campaign to promote the use of preventive health services by older Americans and people with disabilities. We believe these provisions are important and prudent steps that will help increase use of preventive services, reduce illness and costs related to preventable conditions, and save lives. We look forward to working with this Committee to secure their passage.

Beneficiary and Provider Education

Helping beneficiaries and providers understand and take advantage of the colorectal cancer screening benefit is a high priority for us. We are working to raise consciousness and encourage use of these tests among both beneficiaries and their physicians. We have several educational efforts already underway.

• "Screen-for-life" posters and tear-off sheets. We have produced and distributed more than 23,000 of these posters with tear-off sheets that beneficiaries can take with them to their physician as a reminder to discuss their screening options. The tear-off sheets are particularly helpful, since screening can involve unfamiliar words, sensitive issues, and unpleasant options that may be difficult for patients to bring up on their own.
• Public Service Announcements. We distributed to 873 television and radio stations public service announcements (PSAs) that address the misconception that colorectal cancer is a man's disease and promote discussion with physicians.
• CDC Partnership. We are partners with the Centers for Disease Control and Prevention (CDC) in its national colorectal cancer screening campaign, Screen for Life. This campaign, which began in March 1999, encourages Medicare beneficiaries and others to take advantage of screening and promotes the new Medicare coverage of colorectal cancer screening procedures. We are also working with the CDC in conducting formative research and developing targeted messages for this national effort.
• AHRQ Consumer Guide. Our colleagues at the Agency for Healthcare Research and Quality have produced a consumer guide with information on colorectal cancer screening.
• National Colorectal Cancer Roundtable. We participate with several other public and private organizations on this Roundtable, which was established by CDC and the American Cancer Society. Through this effort we are strengthening the network of public and private organizations promoting colorectal cancer screening among all people for whom screening is appropriate.
• Medicare.gov. We provide information on colorectal cancer on our beneficiary web site, including information on Medicare coverage of colorectal screening tests; questions and answers on the colon and colorectal cancer; causes of the disease; symptoms; who is at risk; screening techniques, risk and treatment; and where to find additional information.
• Medicare & You Handbook. Information on colorectal cancer screening and other preventive benefits is featured in this guide sent to all Medicare beneficiaries each year.

We are sharing these materials through senior centers, hospitals, health plans and insurers, state and local health departments, medical colleges and foundations, Aging Councils, Medicare Peer Review Organizations, advocacy groups including those focused in minorities, and others. And materials can be ordered through our website and our 1-800-MEDICARE hotline.

We face important challenges in our efforts to encourage colorectal screening. One of these challenges is the need to address the misperception that colorectal cancer is a man's disease. We therefore have campaign materials that target women. For example, we and our CDC partners aired a live, interactive satellite broadcast on women's health to more than 5000 physicians last August that focused on colon cancer screening. A booklet explaining Medicare coverage for colorectal screening tests was distributed to all attendees.

Another challenge is reaching African Americans, who are at higher risk of colon cancer than other population groups. We therefore, have materials targeted directly at them, as well as other ethnic groups who have low screening rates. For example, four versions of our Screen for Life poster were printed, targeting African-American, Caucasian, Hispanic and Asian populations. We are sharing materials with organizations such as The National Black Leadership Initiative on Cancer and disseminating them through our Medicare claims processing contractors, who have specific contract requirements to outreach to minority populations on health care issues.

We are also now working with partners to expand efforts to specifically educate physicians and provide them with materials and support to help them educate their patients. These include:

• a fact sheet for physicians on the importance of screening;
• a decision aid tool that physicians can use to help patients understand and choose among the various screening options;
• a brochure to share with patients on how removing polyps can prevent cancer;
• a teaching aid poster illustrating the colon and explaining screening options;
• a "Get Screened" poster that physicians can put up in their office waiting rooms; and
• public service announcements discussing screening and prevention through polyp removal.

We share these materials through our cms.hhs.gov website and through items included in newsletters sent to physicians by Medicare claims processing contractors.

To further these efforts, Medicare's physician-lead Peer Review Organizations are beginning a special study to better understand the use of colorectal cancer screening and determine effective ways to promote testing through such things as physician office reminder systems. We will also calculate national and state screening rates among Medicare beneficiaries to help us target our outreach efforts.

These steps are in addition to steps already taken to distribute articles on colon cancer prevention in newsletters that our claims processing contractors send to physicians, and to make Continuing Medical Education credits available for physicians who take the time to learn about colon cancer screening and prevention by studying the video of our satellite broadcast or taking computer-based courses on that are available through our Internet site.

Colorectal Cancer Awareness Month

As mentioned above, we are proud participants with the Cancer Research Foundation of America, the National Colorectal Cancer Roundtable, and the American Digestive Health Foundation, the CDC, National Cancer Institute, and others, in National Colorectal Cancer Awareness month. This collaborative effort can help to generate widespread awareness of how to prevent the disease through a healthy lifestyle and regular screening.

During the month, participants will:

• distribute a video news release that we have prepared on colorectal cancer screening;
• air a colorectal cancer television segment on CNBC and the Bravo Network;
• develop radio and print PSAs and articles for distribution in medical journals; and
• conduct an advertising campaign.

Conclusion

While we have made some progress, much work remains to be done to increase use of Medicare's colorectal cancer prevention benefit. With support from this Committee and our many other partners, we believe we can meet this challenge. Enactment of the President's fiscal year 2001 budget proposals would provide further incentive to Medicare beneficiaries to use their preventive benefits and further resources for Medicare to publicize their availability and importance. We look forward to working with you further in all these efforts. Thank you again for inviting me to be here today, and I would be happy to answer any of your questions.