Once you know you need to get screened, the next question is which test is best and who should pay for it. That’s where the United States Preventative Services Task Force (USPSTF) comes in, the group who is responsible for determining which tests your insurance is required to pay for.
In their own words, the USPSTF, “is made up of 16 volunteer members who are nationally recognized experts in prevention, evidence-based medicine, and primary care. Their fields of practice and expertise include behavioral health, family medicine, geriatrics, internal medicine, pediatrics, obstetrics and gynecology, and nursing.”
So why does this matter to you? In short, what the USPSTF says about your test connects directly to your wallet.
How Do Tests Get Paid For?
The Affordable Care Act (ACA or Obamacare) says that insurance must cover preventative services at no cost that receive an A or B rating from the USPSTF. The ACA defines preventative services as tests for those of average risk and who aren’t having any symptoms.
As a side note, tests for people who’ve had colon cancer, their kids (who are at a higher risk) and anyone who is experiencing symptoms doesn’t count as preventative, and can expect to pay.
The USPSTF looks at scientific studies to determine their ratings. A test must prove that it does more good than harm.
Harm vs. Good: A Careful Balance
If a test finds one case of cancer out of 100 and seriously harms five out of 100, it’s not going to get a good rating. On the other hand, if it finds 10 cases of cancer out of 100 and only harms one out of 100, it will likely get a high rating. The USPSTF also takes into account things like accuracy, the number of false positive and false negatives the procedure creates, and other medical issues.
It is a tough balancing act to look at lives saved vs. lives harmed.
For example, would you approve a hypothetical test that saved four lives out of 100 but caused two strokes, a heart attack and three bowel perforations?*
This careful balance is one of the reasons the USPSTF doesn’t recommend colonoscopies for average risk asymptomatic people under 50 and over 75. Statistics still say that changing the screening ages would do more harm than good to the overall population.
Let us say here, if you are experiencing symptoms, you need to get screened.
Changing the System
Sometimes new information comes to light and the USPSTF has to change its recommendations. This is currently happening in both prostate cancer with the PSA test and breast cancer with mammograms. Both tests generate a lot of unnecessary medical procedures.
The colon cancer community is lucky in that we have several safe and reliable screening tests. If performed correctly following the guidelines, tests like the FIT and Cologuard are good tests for average risk people. Following the guidelines could reduce the cases of colon cancer in America by 90%.
Of course, colonoscopies remain the gold standard and are the only test for high risk people.
So if you are an average risk person with no symptoms, you have a variety of screening test to choose from. All of them should be covered 100% even for people on a high deductible plan. Private insurance is not allowed to charge you by rule for anesthesia or polyp removal either. If you are high risk or symptomatic, we’ll have to talk another time about how that is covered.
*This is a made up test and imaginary numbers. Don’t confuse with a real test.