State Medicaid Coverage for Lung Cancer Screening Is Spotty

Screening can reduce mortality from lung cancer by catching the disease early, but coverage is still uneven, despite the green light given by the US Preventive Services Task Force (USPSTF) in 2013.

Although Medicare and most private insurers will reimburse for low-dose computed tomography (LDCT) in eligible high-risk patients, screening is not universally covered by Medicaid. According to a new report by the American Lung Association (ALA), 31 Medicaid fee-for-service programs cover lung cancer screening, 12 programs do not provide coverage, and seven states lack available information on their coverage policy. The analysis also found that Medicaid programs vary in the eligibility criteria they use for screening as well as whether they require prior authorization.

“We are working to educate state-level decision makers on where there are gaps in coverage,” said Hannah Green, MPH, National Director of Health Policy, ALA. The ALA has partnered with the University of Texas MD Anderson Cancer Center, Houston, for educational initiatives to improve coverage in state Medicaid programs, she added. 

Myrna Godoy, MD, PhD, associate professor, Department of Diagnostic Radiology, MD Anderson, noted it is surprising that there is disagreement over this. “We have two large trials that have shown the benefits of screening and that it is appropriate for high-risk patients,” she told Medscape Medical News. “It is recommended by the Task Force and CMS, and private insurance will reimburse for it, but Medicaid doesn’t for everyone.”

That isn’t fair and it should be standardized   Myrna Godoy, MD, PhD

“That isn’t fair and it should be standardized,” she added. “It’s not fair that the same person with the same risk [isn’t covered] just because of their location. Everyone should be able to benefit from screening.”

In December 2013, the USPSTF finalized its recommendations on lung cancer screening for high-risk populations. The recommendation was in-line with those issued by several other bodies, including the American Cancer Society, American College of Chest Physicians, and National Comprehensive Cancer Network. Medicare finalized a National Coverage Determination in February 2015, which reimbursed for LDCT scans in a high-risk population between the ages of 55 and 77.

Medicaid Confusion

Standard Medicaid insurance does not require coverage of USPSTF recommended screenings, and each state can decide how coverage will work, explained Green. Coverage can also vary between fee-for-service and managed care plans within a state’s Medicaid program.

The ALA report only looked at fee-for-service plans and not managed care plans in each state. “So just because the fee-for-service plans don’t cover lung cancer screening, it doesn’t mean that managed care plans aren’t covering it,” she said. “That is another area of research that we need to look at.”

Another variable is Medicaid expansion, which took place under the Affordable Care Act (ACA). Medicaid expansion plans are required to cover preventive services that received an “A” or “B” by USPSTF, which means that lung cancer screening should be covered without cost-sharing for patients with Medicaid expansion.

“States have to provide Medicaid coverage for lung cancer screening, but only for those who entered under the expansion program,” said Green. “So even within a single state, there can be different eligibility criteria.”

In their assessment of Medicaid coverage in the fee-for-service program, the ALA found that eligibility criteria for screening varied considerably. Among states offering coverage, 13 states follow the USPSTF criteria, three states followed the Medicare criteria, and 15 states used other criteria.

In addition, 13 states also required providers to obtain prior authorization before screening will be covered.

In their report, the ALA points out this information is especially concerning as Medicaid recipients are disproportionately at risk for lung cancer. Whereas 11.1% of individuals with private insurance are current smokers, that percentage is more than double (26.3%) in the Medicaid population. The 5-year survival rate for lung cancer patients with Medicaid is also significantly lower compared with those with other types of insurance (13.0% vs 20.4%).

They urge “all state Medicaid programs to cover lung cancer screening based on evidence-based guidelines across all fee-for-service and managed care plans and to remove any financial or administrative barriers that limit access to this lifesaving service.”

False Positives

A major problem with LDCT screening is the high rate of false positives, which can lead to unnecessary patient anxiety and unnecessary invasive follow-up procedures.

An advertisement for a lung cancer screening initiative by the ALA called “Saved by the Scan,” set off a recent flurry of tongue in cheek comments on Twitter, following a tweet by Medscape Editor in Chief Eric Topol, MD.

“How do you name an initiative ‘Saved by the Scan’ when there is a 60% false-positive rate?” he tweeted.

One person commented that “‘Terrorized by the Scan’ didn’t do well in the focus group.”

However, although it’s possible the high rate of false positives may play a part in Medicaid coverage decisions, one expert says the rates are nowhere near as high as currently perceived. “There is a lot of misinformation out there about the false-positive rate,” said Andrea McKee, MD, Radiation Oncology Associates, Burlington, Massachusetts, and volunteer spokesperson for the ALA. “I often ask people who say that: What do you think the rate is in a lung cancer screening program? And I hear rates from as low as 3% to as high as 98%.”

This misinformation is a problem, and McKee explained very high rates have been reported throughout the medical literature and even in peer-reviewed journals. “But what we think is happening is that people are confusing the terminology,” she told Medscape Medical News. “False positive is a very specific statistical term.”

The number of positive exams for lung cancer is very low, as only about 1-2% of patients will be diagnosed with lung cancer. Thus, McKee explained, “the definition of false positive is the total number of positive exams over the number of exams when it comes to a screening test like this when there aren’t a lot of people who actually have the disease.”

The use of modern screening techniques, such as the Lung-RADS that was introduced by the American College of Radiology in 2014, has lowered the baseline false-positive rate to 12%, and for the annual screen after that the number drops to 5% because the radiologist now has a comparison. “Mammography has almost the exact same statistic,” she said. “It’s about 10% at baseline and then drops to 3% after that,” said McKee.

She added that when people talk about a “98% false-positive rate,” they are confusing it with the false-discovery rate. “What that means is that if you have a positive exam, the likelihood that you don’t have lung cancer is 98%,” she said. “So seriously, why would we ever do a test where you are told that 98% of the time you have something that you don’t.”

McKee added that “we really want to correct this information because doctors may be telling people that there is a high false-positive test and that may be discouraging patients.”

ALA report. Lung Cancer Screening Coverage in State Medicaid Programs. 2019. Report

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