Colon cancer screening loophole in Medicare - and surprise billing - still waiting for Congress to act | Opinion

Two years later, and legislation for lifesaving colon cancer screening is still at a standstill.

Last week, I returned to Capitol Hill with a new slew of issues to discuss with legislators. But the one that was all too familiar was the proposed bill to close the colonoscopy loophole. Patients and physicians have spoken loud and clear regarding this issue, but it seems to have fallen on deaf ears.

In a prior piece for The Inquirer, I shared a story about a patient who had Medicare insurance and received a surprise bill after a screening colonoscopy — a procedure that should have been covered completely, per the Affordable Care Act. However, due to a loophole that is triggered when a polyp is removed, he was charged several hundred dollars. He lost trust in the medical system, with very real consequences. He has not yet scheduled his follow-up colonoscopy, which is even more crucial since we found a polyp the first time.

» READ MORE: A doctor's view: The colonoscopy loophole that takes patients' money - and trust

About one in three Americans who need colon cancer screening — about 38 million people — are still not getting it. Initiatives to improve screening rates for colon cancer are falling short, and costs remain a big factor.

So what has the government done?

Shockingly, Medicare has taken a step backward. Instead of closing the loophole within the agency — which could be done without Congress’ approval — it has proposed that physicians be required to inform patients of potential surprise costs. The idea of price transparency is one that I wholeheartedly support, but Medicare’s proposal has doctors doing its dirty work. Instead of Medicare informing patients of costs, it puts the burden on physicians. To be clear, doctors are not responsible for the surprise bills — this is in Medicare’s arena.

This is how the proposal would go, theoretically:

You are a 65-year-old man with worsening heartburn. You get an appointment to see your gastroenterologist for a 30-minute slot. The bulk of the visit is spent on heartburn management. Your doctor uses the last few minutes to discuss the importance of colon cancer screening. Taking off from work and drinking laxatives doesn’t sound fun, but you agree. Your doctor now broaches the topic of cost. Since you have Medicare, you are potentially vulnerable to fall into this loophole. Your doctor explains that it may be free if we don’t find polyps (great news), but finding and successfully removing polyps is how we prevent colon cancer.

So, you may get a bill, but you won’t know in advance for how much because it depends on how many polyps, what tools are used to remove them, and which lab techniques are used to analyze them. And your doctor won’t know until you are already sedated and undergoing the procedure. You are left with a slew of unhelpful information, and a great amount of uncertainty, all discouraging you from pursuing lifesaving preventive screening.

Imagine a different scenario in which you are guaranteed a colonoscopy will be free regardless of the findings — just as it is for your friends with private insurance or VA health care.

Which scenario would you prefer?

Medicare has said its hands are tied because it does not have funding to cover these costs. Bills are sitting in Congress with strong bipartisan support and over 300 cosponsors, but have not yet moved forward.

The rumor on the Hill is that the current congressional leadership is not interested in promoting health-care legislation, given controversy over the Affordable Care Act, and the 2020 elections. But while health care is being politicized, patients continue to suffer.

Senator Bob Casey is cosponsoring* the legislation. However, Senator Pat Toomey has yet to lend his support, despite patient advocacy visits, and meetings with the American Gastroenterological Association and the American Cancer Society. Will you join us in urging Sen. Toomey to close the loophole?

Shazia Mehmood Siddique, M.D., MSHP is an instructor of medicine in the Division of Gastroenterology at Penn Medicine, a senior fellow at Penn’s Leonard Davis Institute of Health Economics, and director of the Congressional Advocates program for the American Gastroenterological Association.

*Editor’s note: This post has been updated to correct a previous statement that neither Pennsylvania senator has cosponsored the bill.