Virtual Colonoscopy: A Window Into the Challenges of Health Care Reform
Ruth Faden and Sean Tunis M.D
Two recent events underscore dilemmas at the heart of the future of Medicare, and health care reform more generally. The first one was the Hospital Trust Fund’s finding that Medicare will run out of money in 2117. The other was Medicare’s
decision not to pay for virtual colonoscopy, a noninvasive CT imaging test to screen for colon cancer. The story behind this decision and the reaction it has provoked illustrates just how difficult it is to control health care costs.
Medicare’s decision was based on a comparison of the risks and benefits of virtual colonoscopy and standard optical colonoscopy, an invasive procedure. After an exhaustive review of all published studies, and extensive consultation with experts and organizations, Medicare concluded that there was not enough evidence to determine whether virtual colonoscopy was as good as regular colonoscopy, particularly for the older patients that Medicare covers.
While some proponents argued that virtual colonoscopy would encourage more people to be screened for colorectal cancer, Medicare noted that there was no clear evidence that more screening had occurred in places where the procedure was available.
Medicare also addressed the question of whether the higher cost of virtual colonoscopy factored into its decision;
it said that the costs were considered but emphasized that its decision was based on uncertainty about the clinical benefits.
When Medicare first proposed to deny payment for virtual colonoscopy, prominent industry groups, professional societies, and cancer patient advocacy organizations that strongly favored reimbursement protested vigorously. Members of Congress signed letters urging Medicare to change its position. After Medicare made its decision, opponents continued to argue that the scientific evidence was good enough to conclude that virtual colonoscopy is a reasonable alternative, and that Medicare beneficiaries should be able to decide with their doctors which approach was best for them.
We agree that respect for patient choice is at the heart of the practice of medicine and should be fully reflected in public policy. But this commitment should be understood in the broader content of what also matters morally for current and future Medicare beneficiaries – preserving guaranteed access to high quality medical care.
Ruth Faden, PhD., M.P.H., directs the Johns Hopkins Berman Institute of Bioethics.
rfaden@jhsph.edu
, 443-287-0413. Sean Tunis, M.D., directs the Center for Medical Technology Policy, a nonprofit organization in Baltimore and is the former Chief Medical Officer for Medicare.
Sean.tunis@netzero.net
, 410-963-8873.
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