Medicare May Punish Doctors for Prostate Cancer Screening

Both You and Your Doctor Pay the Price

Medicare prostate cancer screening
Medicare may discourage prostate cancer screening with PSA. GIPhotoStock/Cultura/Getty Images

The American Cancer Society reports that one in seven men will be diagnosed with prostate cancer in their lifetime. In 2012, 177,489 American men were diagnosed with prostate cancer and 27,244 died from the disease. With these numbers in mind, can prostate cancer screening save lives?

Screening for Prostate Cancer

There are not many ways to screen for prostate cancer. A doctor can perform a digital rectal exam (DRE) or perform a blood test that checks the level of prostate specific antigen (PSA), a protein secreted by the prostate gland.

PSA tends to be secreted in higher amounts when cancer is present. However, it can also be increased when the prostate is infected or if blood work is taken too soon after a rectal exam. Repeating the test can be helpful to verify the PSA level is accurate.

Controversy Over Prostate Cancer Screening

In 2012, the U.S. Preventive Screening Task Force (USPSTF) put out a recommendation that recommends against using the PSA test. The argument is that too many false positive PSA tests occur and this leads to unnecessary testing. These tests, including biopsies, can have side effects all their own. The USPSTF expresses concern that more harm than good comes from testing.

Controversy has arisen about this recommendation. Other organizations such as the American Urological Association (AUA) have differing opinions. The AUA recommend PSA screening after age 55 years old after someone discusses the risks and benefits of screening with their healthcare provider.

Screening after age 70 years old is only recommended if a man is expected to live another ten years or more.

The question remains: Without PSA screening, how will men find out if they have prostate cancer? Men will likely be symptomatic and diagnosed at later stages of the disease if routine screening is not pursued.

Does Medicare Cover Prostate Cancer Screening?

Most cases of prostate cancer occur in men older than 65 years old. This brings us to Medicare coverage. Medicare covers both digital rectal exams and PSA screening. Each test will be covered once every 12 months. You will pay a 20 percent coinsurance for the rectal exam but PSA screening is free of charge as long as your doctor accepts assignment.

Medicare's Proposal Against PSA Screening

Ironically, though Medicare covers prostate screening for its beneficiaries, it aims to penalize doctors who actually perform the screening. The Centers for Medicare and Medicaid Services (CMS) has recently put forth a controversial recommendation to discourage use of PSA testing unless a man has known prostate cancer, has known dysplasia (pre-cancer) of the prostate, had a PSA level greater than 4.0 ng/mL within the past year or is on a medication known as a 5-alpha reductase inhibitor.

Healthcare providers who perform this test in men without these criteria will be considered to be giving lesser quality care.

As a result, Medicare will pay them less.

What Does This Mean for You?

Even though Medicare pays for testing for you, healthcare providers may be less likely to offer PSA screening if it is going to hit their bottom line. The risks and benefits of prostate cancer screening should be for you to decide. Everyone's health situation is unique. Ask your healthcare provider to find out if screening is right for you.

Sources:

American Cancer Society. What are the key statistics about prostate cancer? http://www.cancer.org/cancer/prostatecancer/detailedguide/prostate-cancer-key-statistics. Revised March 12, 2015. Accessed December 21, 2015.

American Urological Association. Early Detection of Prostate Cancer: AUA Guideline. http://www.auanet.org/education/guidelines/prostate-cancer-detection.cfm. Accessed June 21, 2016.

Centers for Disease Control and Prevention. Prostate Cancer Statistics. http://www.cdc.gov/cancer/prostate/statistics/. Updated August 20, 2015. Accessed December 21, 2015.

Mathematica Policy Research. Non-Recommended Based PSA Screening. https://talkaboutprostatecancer.files.wordpress.com/2015/11/psa-screening_framing-document_measure-specification_hqmf-header3.pdf. Accessed December 21, 2015.

U.S. Preventive Screening Task Force. Prostate Cancer: Screening. http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/prostate-cancer-screening. Published July 2015. Accessed December 21, 2015.

Continue Reading