First colonoscopy: $0Second colonoscopy: $2kAnother example of how the fine print can put patients on the hook for bills that should be covered, especially in this case of a preventative screening. Patients deserve better.https://t.co/v55XVdGAeB

— Terry Wilcox (@Terrilox) June 2, 2022

— Terry Wilcox, Vienna, Virginia

In Michelle Andrews’ story about unexpected costs after a polyp removal during a colonoscopy, she states the anesthesiologist “merely administers a sedative.” This is an understatement. Anesthesiologists perform a review of the patient’s chart, see the patient pre-procedure, monitor their vitals during the procedure, and assess them post-procedurally. Furthermore, anesthesiologists are prepared to manage unexpected emergencies, including unexpected aspiration, allergic reactions, cardiac arrest, etc. This is more than “merely administering a sedative.”

We keep folks from dying or having complications and train a long time to do so. The flippant manner in which our actions are framed in the article is unfortunate.

— Dr. Elizabeth Leweling, Chicago

Preventive care, like screening colonoscopies, are free of charge to patients under the Affordable Care Act. @DrLindaMD @AlexMMTri @EvanKirstel @FriedbergEric @nkagetsu @rstraxMDhttps://t.co/qLP9l5SSPl

— Ian Weissman, DO (@DrIanWeissman) June 1, 2022

— Dr. Ian Weissman, Milwaukee

As president of the American Society for Gastrointestinal Endoscopy, I listened with interest to a recent segment on “All Things Considered” regarding patient cost sharing for a screening colonoscopy. The segment featured patient Elizabeth Melville, who received a bill for her screening colonoscopy that involved a removal of a polyp.

I was dismayed by the segment, which included several factually incorrect and misleading statements by Dr. Elisabeth Rosenthal, and which were incredibly damaging to efforts to eliminate impediments and misinformation about screening colonoscopy. ASGE has been at the forefront of policy efforts to eliminate patient out-of-pocket costs for screening colonoscopy, including those screenings that involve the removal of a polyp or other tissue. As the segment correctly noted, the Affordable Care Act provides for coverage without patient cost sharing of preventive services that have an “A” or “B” rating from the U.S. Preventive Services Task Force, which includes colorectal cancer screening. Recognizing that colonoscopy is the only cancer screening modality that also allows for actual removal of precancerous lesions in real time (and thus preventing the cancer), it is particularly important that patients and consumers understand the facts.

Following passage of the ACA, legislative and regulatory corrective actions have been necessary to ensure that patients who undergo a screening colonoscopy that includes a polyp removal are not stuck with a surprise bill. As noted, screening colonoscopy is a unique preventive service in that it not only detects cancer, but it can prevent it through removal of suspicious or potentially precancerous polyps or lesions. In 2020, Congress passed legislation that would phase out by 2030 cost sharing for Medicare beneficiaries when a screening colonoscopy turns diagnostic during the screening encounter. That means, if a Medicare beneficiary has a screening colonoscopy today and a polyp is removed, that patient is likely to have an out-of-pocket payment obligation.

The difference in cost-sharing rules for commercially insured patients and Medicare beneficiaries has created confusion for patients, and the changes in regulation have created complex billing scenarios. Dr. Rosenthal referred to billing for colonoscopy as a “gray area.” This is not a gray area to ASGE, as coding rules are clear. But there are scenarios that could impact whether a patient has an out-of-pocket obligation for a colonoscopy. For example, often insurers will not cover a screening colonoscopy without cost sharing if the screening occurs less than 10 years after the patient’s previous colonoscopy. These shorter screening intervals typically occur when a patient is considered high-risk, or if there was a finding during the previous colonoscopy, such as a polyp, as used in your illustration. Many insurers regard these colonoscopies as “surveillance” or “high-risk” colonoscopies and will not cover them as a preventive screening without cost sharing. This is not the decision of the physician or hospital; this is a decision made by the insurance company.

I was particularly struck by Dr. Rosenthal’s comment that “it is not OK to change the game in the middle of the test,” which leads to a patient getting a bill. I want to be very clear that when a patient is scheduled for a screening colonoscopy, the physician performing the colonoscopy has no idea whether a polyp or tissue will be found and will need to be removed. This is not a “gotcha” game that physicians are playing with patients, as insinuated by Dr. Rosenthal’s remarks; there are coding and billing rules that must be followed when facilities and physicians are submitting claims to insurance companies. ASGE continually works to ensure that we educate and promulgate coding rules and updated guidance for our 15,000 members worldwide.

The cost-sharing policy for colorectal cancer screening, and screening colonoscopy specifically, is complex and confusing. We are disappointed that NPR did not use the segment as an opportunity to work through the complexity to provide consumers with a better guide of questions to ask their insurance company before scheduling a colonoscopy, including whether a screening colonoscopy performed at an interval of less than 10 years will be covered under their health plan without cost sharing.

— Dr. Bret T. Petersen, ASGE president, Rochester, Minnesota

Great Bill of the Month reporting today by @mandrews110 for @KHNews. Nobody likes getting a colonoscopy. Patients shouldn’t be penalized for doing the right thing and getting recommended cancer screenings: https://t.co/cNlEj85IZ4

— Ryan Holeywell (@RyanHoleywell) May 31, 2022

— Ryan Holeywell, Washington, D.C.

Taking the Doctor’s Advice

Dr. Taison Bell was wonderful to listen to (“Watch: UVA Doctor Talks About the State of the Pandemic and Health Equity,” May 26). I really appreciated his presentation and the valuable things he had to say. Thanks for including it in your KHN mailing!

— Jan McDermott, San Francisco

I spoke with ⁦@hnorms⁩ from ⁦@KHNews⁩ about the state of the pandemic and health equity. There is still a lot to be done to movement smart policies that help high risk communities of color. https://t.co/LAf2WCIN0X

— Dr. Taison Bell (@TaisonBell) May 26, 2022

— Dr. Taison Bell, Charlottesville, Virginia

Mad Over ‘New MADD’ Coverage

This article is grossly inaccurate and insulting (“The New MADD Movement: Parents Rise Up Against Drug Deaths,” May 23). Most fentanyl users are not all-star athletes or honor students. Their parents are not more educated than the parents of addicts. And the parents of addicts have been mobilized for years, with many feeling that the fentanyl movement has distracted attention away from needed health care. The article says that the drugs are being introduced by Mexican cartels that seek vengeance against low-level dealers, many of whom are just friends getting things for one another. The article distinguishes between drug users and fentanyl “victims,” creating and reinforcing the stigma these groups claim to be trying to eliminate. It does a great disservice to those of us who lost children to addiction and overdose, and is insulting to our children and to us as parents. Thank you.

— Susan Elamri, Detroit

Interesting read detailing the lack of accountability for drug dealers selling fentanyl laced counterfeit pills resulting in death/overdoses. Consequences and rehabilitation should not be mutually exclusive solutions, we can do both. https://t.co/KlvBH3O1kq

— Chief Paco Balderrama (@BalderramaPaco) May 23, 2022

— Paco Balderrama, chief of police, Fresno, California

When ‘Overweight’ Is ‘Normal’

Quoting from the article “‘Almost Like Malpractice’: To Shed Bias, Doctors Get Schooled to Look Beyond Obesity” (May 24): “Research has long shown that doctors are less likely to respect patients who are overweight or obese, even as nearly three-quarters of adults in the U.S. now fall into one of those categories.”

Perhaps the answer is to change the scale of weight. Why do 25% of adults get to be called “normal” and 75% of adults are “overweight”? Let’s base the decision on reality-based observation!

— Leslie Rigg, Lake Worth Beach, Florida

1) Anti-fat bias is real and certainly an issue. For physicians and others who treat people with #obesity, the question becomes where to draw the line. ‘Almost Like Malpractice’: To Shed Bias, Doctors Get Schooled to Look Beyond Obesity https://t.co/ap127widIs via @khnews

— Stewart Lonky, MD (@LonkyMD) May 24, 2022

— Dr. Stewart Lonky, Los Angeles

Innocent Until Proven Otherwise

I wanted to raise a concern about the story “‘Desperate Situation’: States Are Housing High-Needs Foster Kids in Offices and Hotels” (June 1) — and it’s certainly not unique to your story. It says:

“These children already face tremendous challenges, having been given up by their parents voluntarily or removed from their homes due to abuse, neglect, or abandonment.”

Sometimes, of course, that’s true. But no reporter would write that every person in jail is a criminal. Many are awaiting trial and can’t make bail. Similarly, children can be in foster care for weeks, even months before any court ever determines if they have been “abused” or “neglected.” Until then, they are in foster care because their parents have been *accused* of abuse or neglect.

(Also, by the way, neglect laws are so broad and vague that often what the parent really is guilty of is poverty — but that’s another issue.)

— Richard Wexler, executive director of the National Coalition for Child Protection Reform, Alexandria, Virginia

[Editor’s note: Thanks so much for your insight. The article has been updated to reflect that the parents are absent “due to accusations of abuse, neglect, or abandonment.”]

.@sclaudwhithead looks at “hoteling,” Georgia’s practice that makes high-need foster kids sometimes sleep in hotels or offices. The pandemic made the problem worse, but state lawmakers spent more to try to pay extra for foster parents to take kids. #gapol https://t.co/xRXbKCSVEM

— Jeff Amy (@jeffamy) June 1, 2022

— Jeff Amy, Atlanta

Key to Harm Reduction: Buy-In From People With Addiction

With overdose deaths skyrocketing to never-before-seen levels, the United States needs harm reduction strategies to protect the health and wellness of Americans. In 2020, 41 million Americans needed substance use treatment within the previous year; however, of those who needed such treatment but did not receive it at a specialty facility, a staggering 97.5% did not feel they needed it. Although America has a troubling treatment gap exacerbated by systemic legal and regulatory barriers to evidence-based addiction care, most people who need substance use treatment don’t want this treatment as it is currently being offered.

To support our friends and family members living with addiction, our system must also embrace harm reduction approaches that engage people who use drugs (PWUD) before they are ready for abstinence-based treatment (“As Biden Fights Overdoses, Harm Reduction Groups Face Local Opposition,” June 14).

Harm reduction saves lives. Drug checking services and naloxone distribution prevent overdose deaths, while syringe and related service programs help stop the spread of infectious diseases such as HIV/AIDS and hepatitis. These are all worthy ends in themselves, but harm reduction has the further benefit of building a meaningful alliance between health care professionals and PWUD. With this therapeutic relationship, PWUD have facilitated access to high-quality, evidence-based treatment and services when they become ready for this help. It’s an obvious point, but too many people overlook the fact that a person can’t receive treatment or enter recovery if they’re dead.

As a physician, I swore an oath to do no harm — not to do nothing. Failing to embrace and expand harm reduction efforts, by definition, leaves too many of our friends, family members, and loved ones at an unacceptable risk of dying. The dichotomy between offering more addiction treatment and providing PWUD with the tools they need to live healthier lives is a false choice. The United States must simultaneously invest in treatment expansion and increase the availability of low-threshold harm reduction services; otherwise, I fear the country’s addiction and drug overdose crisis will continue to get worse.

— Dr. Brian Hurley, president-elect of the American Society of Addiction Medicine’s Board of Directors, Los Angeles

. @POTUS wants to expand #harmreduction programs as part of strategy to reduce #drug #overdose deaths, but idea faces complicated reality on the ground as programs operate on fringes of legality, w/ scant budgets, & fierce opposition. @renurayasam @khnews https://t.co/qbSBtMkn38 pic.twitter.com/pYV8mB1nEc

— Deni Carise (@DeniCarise) June 21, 2022

— Deni Carise, Philadelphia

How to Beat the Opioid Epidemic

Do you want to control the scourge of fentanyl in America (“The Blackfeet Nation’s Plight Underscores the Fentanyl Crisis on Reservations,” May 25)? There are two options:

1. Distribute the drug solely by the government, ensuring its purity, proper dosage, and safe setting for the user, providing real-time overdose care and optional consulting for anyone who wants to quit, all for free.

2. Make some nonaddictive antidepressants (generally SSRIs, or selective serotonin reuptake inhibitors) less restrictive. You know, how health care in your country is expensive, visiting a psychiatrist or psychologist, refilling, blah-blah. I know, the nation who can’t agree on banning AR-15s from being sold to 18-year-olds won’t agree on this.

What if you let people have some SSRIs over the counter? These are not recreational, are generally safe (way safer than opioids), and do help with anxiety. Hey, what drives people to opioids? Aren’t anxiety levels at their highest all across the globe?

Also, the drugmaker mafia will support it.

Just as we have embraced over-the-counter drugs for widespread diseases like colds, we might adopt the same concept in mental health care as well. Anxiety is becoming more widespread compared with colds (my gut says).

— Alireza Mohamadi, Tehran, Iran

Fentanyl spreads west, including to the Blackfeet Nation.https://t.co/ZrykuZQ06c

— Keith Humphreys (@KeithNHumphreys) May 25, 2022

— Keith Humphreys, Stanford, California

Dust-Up Over Pollution Coverage

This article appears written from a lopsided viewpoint (“Some People in This Montana Mining Town Worry About the Dust Next Door,” June 8).

Very few cities pass the World Health Organization’s unrealistic threshold of 5 micrograms per cubic meter, and why would you get a mechanical engineer to provide input on environmental issues? Why, because the real environmental specialist said this was not an issue? As for dust on a picnic table, that is a horrible example. We get dust on our picnic table anytime the wind blows, and we don’t live by a mine. Maybe WHO should recommend that the wind stop blowing because it causes dust.

From the WHO’s website: “In 2019, 99% of the world population was living in places where the WHO air quality guidelines levels were not met.” This is not a reasonable standard and was selected by bureaucrats that are out of touch with life and the real world. All of the real information and statistics say there is not a problem, but your article makes a problem where one does not exist and people who are not willing to fact-check you will think there is a problem. All these people with health issues are unfortunate and that’s very sad, but people everywhere have sad health issues. Stick to the scientific facts and real monitoring numbers, and don’t drag “The Sky Is Falling” people into news articles. Facts matter!

— John Utaz, Salt Lake City

Cultivating an interest in ‘dusts’ at the moment and this article includes extractive industries/ mining. https://t.co/JsXCA7rxkD

— Cat Rushmore (@CatRushmore) June 9, 2022

— Cat Rushmore, Glasgow, Scotland