Stool-based colorectal cancer tests, boosted by their noninvasive nature and the federal requirement that they be covered at no cost to insured patients as a free preventive screen, have surged in popularity. Until recently, however, a positive test result could prompt a surprise bill for a follow-up colonoscopy—one of many examples of how the promise of widely accessible cancer screening still faces substantial hurdles.
In 2010, the Affordable Care Act heralded a major shift in how preventive care is handled in the United States. Among its many provisions, the act requires private insurers to fully cover, at no cost to consumers, preventive services endorsed by one of three groups: the Advisory Committee on Immunization Practices, the Health Resources and Services Administration, or the US Preventive Services Task Force (USPSTF).
To date, the law has made screening for colorectal, cervical, breast, and lung cancers—all of which have received an A or B rating from the USPSTF—freely available for eligible individuals. In practice, health policy experts such as Mark Fendrick, MD, director of the University of Michigan’s Center for Value-Based Insurance Design in Ann Arbor, have noted that “free” is not always free for what is more often a screening continuum than a single test. In one case, he learned about a patient who had to pay more than $1000 for a follow-up colonoscopy after a positive stool-based DNA test. “I blew a gasket,” says Dr Fendrick, who helped to write the Affordable Care Act’s preventive services provision.
If a gastroenterologist removed a polyp during a colonoscopy, some medical institutions also changed the billing code from a preventive screen to a therapeutic intervention; this switch was dubbed the “post polypectomy surprise.” Such recoding defeats the whole point of preventive care, says Paul Shafer, PhD, an assistant professor of health law, policy, and management at the Boston University School of Public Health in Massachusetts. “If they cut polyps out, great—that’s a good thing,” he says. “I don’t think that we should be penalizing the patient for doing the thing that we’ve tried to incentivize them to do through this policy.”
To better understand the magnitude of the problem, Dr Fendrick and his collaborators assessed how often and how much patients paid after receiving a positive test result for each of the four cancers in the USPSTF screening recommendations and how those costs were changing over time. For all four, they documented some surprisingly common charges.
In a 2021 JAMA Network Open study of 88,000 patients, Dr Fendrick and his colleagues found that among the more than 1 in 6 who had a stool-based test and underwent a follow-up colonoscopy within 6 months, nearly half with commercial insurance incurred out-of-pocket costs.1 For Medicare patients, more than three quarters had to pay out of pocket. A similar study found that after an initial mammo
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