Surprise! It’s a Colonoscopy Bill

The Affordable Care Act mandates that preventive care recommended by the U.S. Preventive Services Task Force be covered by insurance without cost sharing. In reality, many Americans report getting bills for colonoscopies, which are recommended as an option for colon cancer screening starting at age 50. The problem? The law does not mandate that out-of-network services be provided without cost sharing, unless there is no in-network provider available. A letter published Oct. 13 in the Annals of Internal Medicine finds that around 12% of the time, commercially insured patients who receive screening colonoscopies from in-network hospitals and endoscopists likely receive bills for out-of-network services. The researchers looked at data on 1.1 million claims from a national health insurer made between 2012 and 2017. Out-of-network anesthesiologists contributed to the out-of-network claims in 64% of cases, and out-of-network pathologists were implicated 40% of the time. “Colonoscopy is the most effective colorectal cancer prevention strategy in our medical toolbox,” James M. Scheiman of UVA Health in Charlottesville, Virginia, said in a press release. “We cannot let out-of-pocket costs deter patients from undergoing this potentially lifesaving screening test.”

Using Machine Learning to Spark Conversations

Discussions of prognosis and goals of care may help improve quality of life and help people with cancer plan out the end of life. But many people with cancer do not have these discussions with their doctors. For a study published Oct. 15 in JAMA Oncology, researchers used a machine learning algorithm to estimate mortality risk based on electronic medical record data and to nudge clinicians to have serious illness conversations with cancer patients. The researchers enrolled 78 doctors, physician assistants and nurse practitioners at nine medical oncology clinics in an academic health system. These clinicians all received training in how to have serious illness conversations. During a control period of the study, they got weekly emails reporting on their progress at having serious illness conversations and how they compared to others. During the intervention period of the study, they continued to receive a weekly email, this time reporting on their progress and also including a link to a dashboard listing up to six patients predicted by the algorithm to have the highest risk of dying within 180 days. Finally, they received text messages reminding them to have serious illness conversations. In the control period of the study, clinicians had serious illness conversations during just 4% of encounters with patients with high mortality risk. While getting the nudges including the insights from the algorithm, the clinicians had these conversations in 15% of these encounters.

Cancer Patients Lose Health Insurance

Researchers estimate that 190,000 or more Americans with a history of cancer have lost their health insurance since the 2016 general election, according to correspondence published Oct. 15 in the Lancet Oncology. Using data from the Behavioral Risk Factor Surveillance System survey, the researchers found that insurance rates increased for adult cancer patients and survivors after the passage of the Affordable Care Act. In more recent years, insurance rates for this group have declined. The researchers point out that in 2017, the federal mandate to have health insurance was reversed, the enrollment period for health insurance marketplace plans was reduced, funding was reduced for outreach to promote enrollment, and subsidies to insurers from the federal government were eliminated. “Although causality cannot be concluded in an observational analysis, it is striking how these observed patterns coincide with policy changes,” the researchers write.​
​