A Win for Our Patients and Our Communities
The journey to obtain Medicare coverage for lung cancer screening with low-dose CT
Any new practice innovation is a journey that begins with solid scientific research. The new ACR Strategic Plan emphasizes our commitment to innovation in one of the five goal areas: “Innovation and Research: From Science to Practice and Policy.” However, in the era of health reform, innovation alone will not be enough. We have to do much more than show a new innovation is safe and effective; we also have to demonstrate that it improves outcomes and can be delivered at a reasonable cost.
Once that occurs, we need to develop sound parameters for standardized clinical practice so that we can show the results will be reproducible throughout a wide range of practice settings. Then we must convince our policy-makers and payers that these new innovations should be covered services in order to promote equitable access to care. Medicare’s announcement that it plans to provide coverage for lung cancer screening with low-dose CT for heavy smokers is the latest example of why a continued focus on innovation and research, along with the quality metrics necessary to demonstrate improved outcomes and advocacy for equitable access to care, is necessary for the future of our specialty.
About 450 Americans die every day from lung cancer, but we know that if we can detect lung cancer in its earliest stages, it can be cured. But it wasn’t until ACRIN’s National Lung Screening Trial (NLST) was published in 2011 that we had results from a prospective randomized trial clearly demonstrating a reduction in mortality in smokers through early detection and treatment of lung cancer. The multi-center nature of the trial with standardized protocols and interpretation criteria across multiple sites and geographic locations allowed us to demonstrate that if the selection criteria, protocols, and interpretation standards used in the study were followed, the results obtained in the NLST could be achieved across the spectrum of clinical practice, providing access to this valuable innovation to those at risk for lung cancer.
Based on the outcomes of the NLST, the U.S. Preventive Services Task Force (USPSTF) recognized the benefit of low-dose CT for lung cancer screening and, in December 2013, the task force recommended the service be provided in clinical practice. Since then, it has been a busy year for the College as we worked to convince Medicare to provide coverage. Since the peak age for diagnosis of lung cancer is 70, Medicare coverage for screening is critical to providing equitable access to care. The Medicare coverage decision process lasted nearly a year and included meetings with CMS officials, testimony at the Medicare Coverage Advisory Committee meeting, and numerous comment letters. We developed alliances with our colleagues in other medical specialties and with patient advocacy groups to collectively promote the value of lung cancer screening for our patients.
To convince policy-makers that we could advance the science of lung cancer screening into clinical practice, we also recognized that we would need standardized parameters for performing and interpreting lung cancer screening studies in routine practice. Based on the ACR’s experience with breast cancer screening, we developed a specific practice parameter for low-dose CT for lung cancer screening. Our practice parameter includes specific requirements for CT protocols, interpretation guidelines using standardized reporting terminology such as Lung-RADS, and communications criteria for follow-up. The College has also set up a program allowing facilities to become Designated Lung Cancer Screening Centers by adhering to the standardized practice and reporting parameters. We had everything we thought Medicare would want in order to provide coverage.
Then, somewhat inexplicably, the Medicare Coverage Advisory Committee recommended CMS not provide coverage for low-dose CT for lung cancer screening. At that point, we recognized the coverage decision would not be just about the science, but would be a political battle as well. We coordinated another round of pressure on CMS from both within and beyond the medical community. We promoted a resolution that was adopted by the American Medical Association supporting lung cancer screening. We leveraged our political contacts on Capitol Hill and had scores of Senators and members of Congress write CMS supporting coverage for lung cancer screening. Finally we coordinated a massive alliance of stakeholders in the medical and lay communities to urge CMS to provide coverage for lung cancer screening. Thankfully for our patients, the effort paid off, and, with Medicare on board, all payers will now provide coverage for lung cancer screening, bringing this life-saving innovation to millions of high-risk patients.
Between all of the physician volunteers and our tremendous ACR staff, there are way too many folks for me to thank individually. But this was truly a team effort. We all owe tremendous thanks to Ella A. Kazerooni, MD, FACR, who heads up our Committee on Lung Cancer Screening, as well as Geraldine B. McGinty, MD, MBA, FACR, chair of our Commission on Economics, who lead the effort with the CMS regulators, and Debra L. Monticciolo, MD, FACR, chair of the Commission on Quality and Safety, who coordinated the practice parameters and Designated Lung Cancer Screening Center program. This is another example of how your colleagues, with the help of our great staff at the ACR, are working to better our practices and help our patients.
Obtaining coverage for lung cancer screening should have been an easy task. However, the challenges we faced demonstrate the realities of moving from science to practice to policy in this new climate of health care reform. The College continues to stand ready to partner with researchers and our physician volunteers to bring the next life-saving innovation to our practices and patients.
From the Chair of the Board of Chancellors
By Bibb Allen Jr., MD, FACR, Chair