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Patients needing colonoscopy after a non-invasive, stool-based test (SBT) often paid out of pocket for it, a study showed.

One in six older adults who had a colonoscopy in the 6 months after some form of SBT ended up with cost-sharing, including 48% of commercially insured and 78% of Medicare patients in the insurance database claims analysis.

Those out-of-pocket costs ranged from $99 to $231, reported Nicole Princic, MS, of IBM Watson Health in Cambridge, Massachusetts, and colleagues in a research letter in .

Just how much patients paid depended on the original screening test performed -- a fecal immunochemical test, fecal occult blood test, or multi-target stool DNA test -- and costs increased if patients had a polypectomy.

"Consumer cost-sharing is associated with decreased use of evidence-based medical care and reduction of spending for other essential items (e.g., food, rent)," the researchers wrote. "It is important for payer policies to cover all components of screening to avoid discouraging patients from completing the evaluation."

"Patients are still footing out-of-pocket costs, and it's impacting screening," commented Allen Kamrava, MD, of Cedars-Sinai Medical Center in Los Angeles. "Cost concerns are real for patients and impact our ability to follow up and effectuate care."

The Patient Protection and Affordable Care Act () aimed to eliminate cost-sharing for necessary screening procedures for patients who meet eligibility criteria, depending on their age, health risk, timing, and the test required. However, potentially illegal cost-sharing has been reported, including "surprise bills" for colonoscopies by in-network commercial providers.

"It is common for insurance companies to say they cover a screening colonoscopy; but the minute you do something like a polypectomy or anything else that changes the CPT code to something other than 45378, they say it is now not covered," lamented Kamrava, who was not involved in the study.

"There was a pause on this behavior for some time, it seemed as a response to rules with the ACA," he told 乌鸦传媒. "But more recently we have been finding that they have reverted to old practices again."

The assumption is that insurers "found a legal technicality in the language of the law that allows them to restrict coverage to certain CPT codes and not others, yet again," he added. "It's not entirely clear how the system works."

For their current study, Princic and colleagues evaluated de-identified administrative claims data on 87,667 patients, among whom 92% were commercially insured patients and 8% were Medicare beneficiaries. Patients who got a non-invasive SBT from 2014 to 2019, were ages 50 to 75 at their index SBT, and were continuously enrolled in the databases for 10 years before and 6 months after their index SBT were included. Patients who were above average-risk for colorectal cancer or not due for screening were excluded.

Costs analyzed 30 days prior to and after colonoscopies were performed included costs of bowel preparation prescriptions, use of anesthesia, and pathology, in addition to the procedure itself.

Within 6 months, 16% (n=12,823) of patients required a subsequent colonoscopy, of whom 58% (n=7,416) underwent a polypectomy.

The researchers acknowledged that their analysis excluded costs of associated complications, which could have underestimated out-of-pocket costs. Findings are not generalizable to those with other forms of insurance or the uninsured, they added. Clinical data on positive SBT results were unavailable.

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