What does a USPSTF Grade Mean?
Here's the rundown
On October 5, 2015, the U.S. Preventive Services Task Force (USPSTF) released a draft statement regarding colorectal cancer screening.
Unfortunately, CT colonography (CTC) was absent from the list of recommended screening strategies. The task force indicated in the draft that CTC may be appropriate in certain clinical settings. However, failure to explicitly include CTC in the list of recommended screenings creates uncertainty regarding reimbursements. Regardless of the USPSTF’s decision, the release of the draft provides the opportunity to discuss the impact of a USPSTF recommendation on reimbursement.
What is the USPSTF?
The USPSTF makes “evidence-based recommendations about clinical preventive services such as screenings, counseling services, and preventive medications.” Recommendations are assigned a grade based on available evidence in the medical literature; the available grades are A, B, C, D, and I. In the case of the proposed colorectal cancer screening recommendations, the USPSTF gave an A grade to “screening for colorectal cancer starting at age 50 years and continuing until age 75 years.” The recommendation also includes a list of “screening strategies,” which does not include CT colonography. Instead, CTC appears under “alternative tests,” along with stool DNA testing.
What does the grade mean?
The USPSTF’s grading system directly affects reimbursement from commercial payers. A grade of A or B indicates that the USPSTF finds sufficient evidence to recommend the screening. A grade of C indicates there is sufficient evidence to recommend screening in certain patients. A grade of I indicates insufficient evidence to recommend for or against screening, and a grade of D indicates a recommendation against screening. A screening recommendation of A or B requires that commercial payers both cover and pay for the screening.
What’s the difference between covering and paying for a service?
Coverage and payment are not the same thing. A service is considered a covered benefit if the service will be paid for. However, how and when payment will occur is not specified. Payment describes the process of receiving reimbursement (i.e. the “how” and the “when”). This is an important difference.
Lung cancer screening showcases the difference between coverage and payment. While Medicare has decided to cover the service, the Medicare Administrative Contractors (MACs) are not paying for screening yet because the mechanism for reimbursement (i.e., appropriate coding and claims instructions) has not been implemented. In this example, lung cancer screening is a covered service (meaning the patient is not receiving a bill for the co-pay) but it is not currently paid for. Lung cancer screening will be paid for once the MACs receive the appropriate coding and claims instruction from CMS.
Does the USPSTF recommendation determine Medicare coverage?
No. USPSTF recommendations do not determine whether or not Medicare covers screening, as only the secretary of Health and Human Services has the authority to determine Medicare coverage. Instead of relying on the USPSTF, Medicare uses the National Coverage Determination process to decide if a service or procedure will be covered. The USPSTF recommendations and Medicare coverage often align, but the two decisions are not required to match. Therefore, Medicare will decide independently if colorectal cancer screening should be covered and which screening strategies are recommended.
However, the USPSTF grade can affect Medicare payments. An A or B rating by the USPSTF requires Medicare to pay for the entire service, including the co-pay, but only if the service is covered by Medicare. If Medicare issues a positive coverage determination for a service via the National Coverage Determination process and the USPSTF has assigned an A or B rating to the service, then Medicare will cover the cost of the service, including the co-pay. If Medicare does not cover the service, then a USPSTF grade does not affect Medicare payments.
What happens next?
The USPSTF’s failure to include CT colonography in the draft colorectal cancer screening list of recommended studies is a mistake. The medical literature supports CTC as a screening strategy. Furthermore, certain private payers recognize the benefit of CTC and already offer this service as a covered benefit. Since Medicare uses the National Coverage Determination process to determine which services are covered, CMS can potentially correct this mistake by including CTC in the list of recommendened colorectal screening strategies for medicare beneficiaries.
By Colin Segovis, MD, PhD, Moorefield Fellow in Economics and Health Policy