Posts Tagged lung cancer

Fee for Counseling Service — another CPT code

cptwowWow, you could have had a CPT code and $60.  While fee-for-service is widely excoriated for excessive cost what is CMS doing?  They want primary care providers or someone to have another fee-for-service.  The fee is for “counseling” about lung cancer CT screening and “counseling” about weight loss.  Both things that are currently part of an office visit with no additional CPT code — just good patient care.

Both topics could easily be covered on YouTube in several languages but NO — lets do this the old fashioned way and spend a zillion dollars for each provider to reinvent the discussion each time.   CMS:  don’t be so lazy — make the patient education video and tell primary care providers the URL!  And, update the video every 6 months.

The bottom line:

  • Lung Cancer CT Screening:
    • Don’t do it if the patient can’t have surgery
    • Don’t do it until the patient has 30 pk yrs accumulated (number of packs per day times number of years)
    • Don’t do it if the patient is less than 55 or over 80 years old.
    • Don’t do it if the patient quit smoking more than 15 years ago.
  • Weight-loss counseling:
    • Say in a loud voice “you weigh too much” then say “eat less”.  (that was not so hard!)
    • Doctors have been doing this for decades without sustained  results.
    • There are 20,000 books about diets to loose weight without sustained results.
    • This is not going to work — at least be honest.

Follow the money:  

Counseling fees for CT scans is an incentive to do the CT scans.   The primary care provider makes money, the x-ray office makes money and the radiologist makes money.  A better idea is to have the radiology office pay the primary care provider for the counseling out of CT revenue so this is a no-sum-gain.  Better yet — make it a provided service under an ACO plan!

Counseling fees for intensive weight-loss is an incentive for lots of repeat visits or a referral.  The Primary care provider makes money (and changes from a primary care provider to a specialty provider).  The incentive reduces the pool of available visits for primary care with little if any benefit to the vast majority of obese people.  A better idea is not to add another CPT code.  If the patient needs more time — make another appointment!

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Lung Cancer Screening — wheel of fortune

lung nodule

You smoked 2 packs a day for 20 years.  Your doctor orders  the low-dose CT screening (above).  Your doctor says you have a lung nodule, now what?  That’s a lot to think about but before anxiety builds too much you need to know that of all the people with a nodule on their first scan 19 times out of 20 it is NOT lung cancer.

By asking some questions it is possible to work through the complicated logic of what to do next.

What if I am that unfortunate 1 out of 20?

If you know for sure the nodule is cancer you would get that nodule removed.  Sure it’s a big surgery, hurts for weeks (sometimes longer), in the hospital for several days, and tons of risks the surgeon will recite.  No walk in the park but the odds of a cure are better at an early stage.  Lung cancer is a killer so it is easy to conclude:  get rid of that nodule

What if that nodule is a bad type called “small cell” cancer? 

Most specialists agree that chemotherapy is the treatment of choice.   Surgery for small-cell cancer is not helpful and may actually shorten your life.  A biopsy before surgery may help to avoid surgery for this type of cancer.

What if I am one of the lucky 19?

If all 19 get surgery there would be a lot of discomfort only to be told after surgery the nodule was just a scar or a harmless irritation.  Biopsy or follow-up x-rays are sometimes helpful to avoid surgery.

What if I get a needle biopsy of the nodule?

A shot of numbing medicine, a long needle between the ribs,  a tiny bit of tissue removed, and finally the pathologist sends a report.  Such biopsies are 95% accurate.  The wheel of fortune lands in one of 5 major categories:

  • No cancer found
  • Small-cell lung cancer
  • Non-small-cell lung cancers
    • Adenocarcinoma
    • Squamous cell carcinoma
    • Large cell carcinoma
  • Other cancers (much less common)
    • Mesothelioma
    • Sarcoma
    • etc.
  • Something which is not cancer

A needle biopsy answers critical questions.  If it shows non-small-cell lung cancer surgery is the next step.  If it is small-cell cancer the next step is chemotherapy.  If it is something else, like tuberculosis, then entirely different treatment is needed. If it is “no cancer found” then you are back to square one — meaning a nodule is present and the cause is unknown (possibly a cancer that was missed by the needle).

I am willing to take some risk to avoid procedures.

We started this discussion with a 1 out of 20 chance of cancer.  Is there some way to improve on the accuracy of that prediction?  1 out of 20 does not sound so good.  But, if the odds of cancer in your situation are 1 out of 100 that would be more favorable.

Improved risk assessment

Canadian Annette M. Williams, MB and others reported in the New England Journal of Medicine in September 2013  an improved mathematical prediction method.  Most pulmonary doctors and radiologists can readily provide the statistic.  Basically, if the calculated risk score is below 5% then the chance of cancer is about 1 out of 100 .

If the risk is low  you might just choose to get a CT scan every few months.  If the size of the nodule does not change for 2 years then it is harmless.  One sure thing, cancers grow.  No growth means no cancer.  But, if the nodule does grow you could change the plan and get the biopsy or surgery — there is a risk to letting a cancer grow for a few months (it could spread) but there are risks to biopsies and surgery as well.

If the cancer risk is high you might want to go ahead with a biopsy.

nodule shape

The above are the outlines of nodules 1) round  2) lobulated  3) irregular and 4) spiculated.  Cancerous nodules can take any shape but tend toward the spiculated (spiny) form.

The improved statistical method is based on a few details about the nodule.  Sex (women are more likely to have malignant nodules), size (the larger the nodule the more likely it is malignant),  location (upper lobe nodules are more likely malignant) and spiculation (see diagrams).

If you want to calculate the risk statistic yourself, have a calculator and know the details listed above then click this: Calculate Risk.  But, be warned, this calculation only applies to people who have a risk for cancer to begin with, not the incidental nodule found in a lifetime non-smoker or someone who only smoked a few years.

The forgoing material is intended as education, not a substitute for the evaluation and advice of your health care provider.  If it seems helpful print it and take it to your provider for discussion.  Medical care changes with time so always get up to date information.

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Lung Cancer Screening — questionable

spot on ct

Recently published guidelines for lung cancer screening (USPSTF) lack sufficient consideration of side effects and give no consideration to cost.  Insurance companies, so far, don’t pay for it and the American Lung Association has many questions about the basis for the recommendations.

Is CT screening really helpful to people at risk for lung cancer?  Is screening driven by profit motives for hospitals and radiologists?  The latter question may seem harsh but the well documented price gouging by radiology on other CT tests forces the question.

The data are clear: chest CT scans can detect early lung cancer soon enough to allow successful surgical removal.   But, the devil is in the details.

Can the US healthcare system afford this screening — what health services should be eliminated to pay for this very expensive endeavor (like childhood immunizations)?  Can patients who eventually are found not to have lung cancer (the vast majority of those screened) afford the test and the side effects of the invasive tests screening causes?

The recommendation seems premature.  The formation of national guidelines without adequate considerations of cost is hard to believe given our national problem with excessive health care cost.

Many other countries consider the cost of a test or treatment needed to give a person a “quality year of life”.  How much is that year worth? a billion dollars, a million dollars, a thousand dollars, all your money, all the money you wanted your kids to inherit?  Tough questions, especially if you are not a billionaire.  Well, experts on national health care say that dollar figure should not exceed $50,000.

Whether you believe the $50,000 number or not, at least we need to know exactly what such screening will cost.  We purchase healthcare — we don’t get it by magic.

So, what are patients and health care provider to do?  At this point: follow the recommendations and hope less costly and less invasive means are discovered.  Here is what the American Lung Association advises:

The best way to prevent lung cancer is to never smoke or stop smoking now.

  • Q: Who is a good candidate for lung cancer screening?
  • A: The National Lung Screening Trial (NLST) criteria are:
    • a current or former smoker (former smokers having quit within the past 15 years)
    • and in the age group from 55 to 74 years
    • and with a smoking history of at least 30 pack-years (1 pack/day for 30 years, 2 packs per day for 15 years, etc.)
    • and no history of lung cancer
  • There is no evidence at this time that other high-risk groups should be screened. Patients with lung disease, particularly COPD should be evaluated by a pulmonologist regarding the advisability of CT screening in the context of the severity of their disease.
  • At this time, only Low Dose CT scans are recommended for screening. Chest X-rays are not recommended for screening.

Beyond the question of cost is the question of who pays.  Should smokers as a group pay for the screening or perhaps cigarette makers?  Given the lackadaisical attitude of congress about the risks of smoking, ostensibly representing US citizens, perhaps we should all gladly pay for the screening through insurance.

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