This ASG video tip is sponsored by Braintree, maker of the newly approved Suflav and SuTab. So let's start with the Affordable Care Act. So the Affordable Care Act, the Patient Protection and Affordable Care Act was signed into law in March 2010, and it requires screening for average risk adults be covered. And this includes for colon cancer screening as well, with no consumer cost sharing. However, despite this law now being present for over 13 years, there are still threats to the Affordable Care Act and specifically colonoscopy and colon cancer screening. So cost sharing refers to the patient's portion of cost for healthcare services covered by their health insurance plan, and the ACA has actually limited this for most plans up to $9,100, but this does not include grandmothered or grandfathered plans, and these are plans that existed prior to ACA becoming into law. And then some other plans are not regulated under ACA, and so these limits don't apply. And then prior authorization is the process by which insurance companies use to determine if a prescribed product or service will be covered. So let's talk about cost sharing. So in this study by Fendrick and colleagues, they looked at market scan data and Medicare data using claims, and found over 80,000 individuals from whom they had data on. And what they looked at was this 90-day period prior to when a colonoscopy was ordered, and then the 90 days afterwards, so looking at the cost of the bowel prep, anesthesia related to the services, as well as any pathology that might have been processed that patients might have been charged for. And what they found was that out-of-pocket costs were really quite common for colonoscopy. These were all individuals who had actually had a stool-based test, and so they were having this colonoscopy as part of that follow-up and completion of care. On about 80% of those who were under Medicare had out-of-pocket costs, and about 48% of those on commercial plans had out-of-pocket costs. This averaged to be over $100, and it was up to $500 for those who had had polypectomies completed. So they also found that cost sharing is allowed by many plans, including Medicare, Medicaid, and 12 different states, and commercial plans up until May of 2022. And the implications are really quite profound, including that individuals are less likely to complete screening. For those who have abnormal stool-based or non-invasive screening tests, that they're less likely to follow up, and that the cost that individuals pay as part of their screening process can lead to reduction in spending for other essential items, such as food and rent. So what about prior authorizations? So prior authorizations really came into the spotlight this year. And as many of you know, this was due to March 29th, specifically, the UnitedHealthcare Group initially announcing that they were going to cut back prior authorizations by about 20%. But then in that same week, then announced that they would actually require prior authorizations for surveillance colonoscopies, upper endoscopies, and capsule endoscopies starting in June of this year. You can imagine that there was massive uproar by patients, professional societies, and many others. And in May of this year, media coverage peaked with more than 4,000 stories on this topic. And many of our societies were advocating against this policy as well. On May 26th, UnitedHealthcare met with the GI societies and offered to delay the prior authorization policy in exchange for an advanced notification system. And really what that meant was that gastroenterologists had to provide UnitedHealthcare plan with information prior to being able to do colonoscopies. So yes, it wasn't a prior authorization, but it was still delaying care. And actually when the leaders had asked UnitedHealthcare why there was this push for this policy, they said it was due to overutilization of procedures, but we never really saw data to support that assertion. So the GI societies, as you can imagine, did not support this. UnitedHealthcare on June 2nd went ahead and announced this anyway and said that they'll be using this data to create a gold card prior authorization policy that for now is planned to go into effect in early 2024. And so you can imagine that it is still quite important that we continue to fight against this because of the possible implications for our patients. So this is a survey that was published in Gastro. It was a survey of over 200 gastroenterologists, and they were asked what were their top priority concerns. And you can see here that close to 80% of respondents said that prior authorization burden was a significant issue, and they believe the top priority concern for us as gastroenterologists and as GI societies when we engage in advocacy. And so this, you know, again, continues to remain a top priority and a top concern with a lot of practitioners saying that they spend the equivalent of up to two days of their week in practice dealing with prior authorizations. So there are several implications for prior authorization policies. We know that many of our gastrointestinal conditions already have disparate outcomes by race and ethnicity and socioeconomic status, and you can imagine that prior authorizations could further exacerbate those disparities. So when we think about colorectal cancer, how this could lead to higher mortality in black and Native American populations, as you've already heard. This could also lead to individuals just not being able to access screening and treatment, and that could further compound disparities as well. This could lead to delays in care. So for example, delays in surveillance colonoscopy for patients who have inflammatory bowel diseases and for those who have already survived colon cancer, as well as could significantly contribute to abandonment of care in high-risk patients who need the endoscopic procedures most. And then finally, also increasing burnout and cost. You know, prior authorizations, I'm sure anyone in this room can talk about the amount of time it takes for themselves or their practice to complete these. It diverts time from caring for patients because of the burdensome paperwork, and if we were to pass this time charge along to health plans, then in turn that would drive up health care costs even more.

Affordable Care Act

colon cancer screening

cost sharing

prior authorizations

healthcare disparities