Medicare pays for lung cancer screening, counseling, and shared decision-making visits, and for an annual screening for lung cancer with low dose computed tomography (LDCT) as a preventive service benefit under the Medicare program. In February, the Centers for Medicare and Medicaid Services (CMS) updated and significantly modified its National Coverage Determination (NCD) of this preventive health care service.
Current smokers or those who have quit smoking in the past 15 years and who are asymptomatic of cancer can be referred for the LDCT lung cancer screening (LCS) following a “shared decision-making visit” with their provider. Shared decision-making (SDM) includes counseling on the importance of adherence to annual lung cancer LDCT screening, the impact of comorbidities, and ability or willingness to undergo diagnosis and treatment. Additionally, the counseling focuses on the importance of maintaining cigarette smoking abstinence for former smokers, the importance of smoking cessation for current smokers, and the furnishing of information about tobacco cessation interventions.
A criticism of this screening program has been the perceived burdens of the shared decision-making process. In the latest issue of the Journal of the American College of Radiology, research was published that reported, even though required by CMS, documentation of shared decision-making for lung cancer screening remains suboptimal, with only 41.9% of individuals undergoing lung cancer screening having shared decision-making documented in their electronic health record. And in commentary in that same issue of JACR (which is attached to this blog), some advocate that the approach to shared decision-making must be rethought. They believe that "[c]urrent CMS policies mandating LCS SDM documentation are a potential barrier to screening utilization. Adapting the current SDM model to a more practical and meaningful opportunity for patient-clinician communication may increase utilization of high-quality LCS and improve screening equity."
These are important issues to discuss and could potentially influence CMS policy. If barriers can be removed to patients receiving lung cancer screening studies to detect evidence of lung cancer as early as possible when treatment can be more successful, mortality from this deadly cancer can be significantly decreased. Removal of such unnecessary barriers to the early detection of lung cancer, therefore, should be encouraged.
A side note. Another barrier to lung cancer screening in the NCD has been the requirement of a written order for the lung cancer screening LDCT study to qualify for the preventive services benefit. The NCD has not been perfectly clear as to the ordering testing requirements. CMS did remove the requirement for written orders for the initial and subsequent annual lung cancer screenings with low dose CT. Electronic orders are accepted for the initial order. I had earlier written that the NCD allows annual screenings without an order other than the initial order. I have now taken a new look at the question of whether new orders for the annual screening LDCT studies are required and have come to understand that a new order, albeit not a "written" order, is expected for each annual screening LDCT study.
[Shared decision making] is a critical component to patient-clinician communication, but in its current form, the evidence shows that it is not happening and it is not being documented in time-constrained primary care clinic visits.