[Congressional Record Volume 141, Number 172 (Thursday, November 2, 1995)]
[Senate]
[Pages S16627-S16629]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Mr. BREAUX (for himself, Mr. Conrad, Mr. Dorgan, Mr. Kerrey, 
        Mr. Daschle, and Mr. Hollings):
  S. 1385. A bill to amend title XVIII of the Social Security Act to 
provide for coverage of periodic colorectal screening services under 
part B of the Medicare Program; to the Committee on Finance.


              the colorectal cancer screening act of 1995

 Mr. BREAUX. Mr. President, I introduce a measure that I 
believe should garner widespread support in both parties. The 
Colorectal Cancer Screening Act of 1995 would provide screening under 
Medicare for the third most prevalent type of cancer, cancer of the 
colon and rectum, which will strike 138,200 Americans this year. The 
bill would provide screening in a cost-effective manner which would 
ensure that doctors and their patients, not the Federal Government, 
decide which of the several recommended screening procedures are used. 
I am joined by Senators Conrad, Dorgan, Kerrey, Daschle, and Hollings.
  Let me share with you some of the frightening facts about colorectal 
cancer. According to the American Cancer Society, 55,300 Americans will 
die this year from this disease. Of the 138,200 new cases that will be 
reported, about half will be among men--70,700--and half among women--
67,500. Only lung and prostate cancer attack more Americans. In my own 
State of Louisiana, 2,000 citizens will get this type of cancer this 
year.
  As with most cancers, early detection is key to surviving colorectal 
cancer. About 90 percent of colorectal cancer victims whose cancer is 
detected in an early localized stage survive beyond 5 years. That 
number drops to between 50 and 60 percent when the cancer has spread 
regionally and to less than 10 percent when it has spread more widely.
  Mr. President, colorectal cancer is a major cost to the Medicare 
Program. According to the Centers for Disease Control, 168,000 seniors 
were hospitalized with colon or rectum cancer in 1991--the most recent 
year for which data is available. The average hospital stay for these 
patients was 16 days.
  While private health plans are beginning to provide coverage for 
colorectal cancer screening, Medicare--which serves older Americans who 
are most at risk--does not. According to a report from the 
Congressional Officer of Technology Assessment released earlier this 
year, screening for colorectal cancer is more cost-effective than many 
of the other procedures the Medicare Program already covers. Screening 
provides benefits at a cost of about $13,000 per life-year saved, 
versus $40,000 to $50,000 per life-year saved for some preventive and 
other services that Medicare already covers. At a time when we are 
looking for ways to control the overall cost of the Medicare Program, 
we must continue our efforts to use those limited funds in ways that 
are cost-effective.
  Mr. President, I know that other Members of this body have introduced 
a bill to provide for colorectal cancer screening. This measure differs 
from theirs in only a few ways. First, this bill is not procedure-
specific. It would provide Medicare coverage for all of the colon 
cancer screening recommended by the American College of Physicians and 
which the Office of Technology Assessment found to be cost-effective. 
Second, the would allow the Secretary to add new procedures once they 
are developed. This is critically important to encouraging innovation 
and research in this area. As a number of medical companies have 
explained in recent correspondence, legislation that ``limits Medicare 
reimbursement to only a few of the current screening technologies does 
not allow for the development and diffusion of new medical procedures 
which might ultimately prove more effective and cost-efficient in the 
detection of colorectal cancer.'' Mr. President, I believe Medicare 
should cover all types of recommended screening and let the patient and 
his doctor, not the Federal Government, decide which one is 
appropriate.

  This bill would follow the guidelines approved by the American 
College of Physicians on April 23, 1990, which read as follows:

       Recommendations:
       1. Screening with fecal occult blood tests is recommended 
     annually for individuals age 50 and older.
       2. Screening with sigmoidoscopy is recommended every 3-5 
     years or with air-contrast barium enema every 5 years for 
     individuals age 50 or older.
       3. For individuals age 40 and older who have familial 
     polyposis coli, inflammatory bowel disease, or a history of 
     colon cancer in a first degree relative, i.e., parent or 
     sibling, screening with air-contrast barium enema or 
     colonoscopy in addition to annual fecal occult blood tests, 
     is recommended every 3-5 years.

  For individuals over the age of 50 who are on Medicare and at average 
risk of colorectal cancer, this bill would allow payment for: every 12 
months, a fecal blood test; and every 5 years, a sigmoidoscopy, barium 
enema, or other procedure approved by the Secretary. For individuals at 
high risk of colorectal cancer, the bill would allow Medicare 
reimbursement for: every 12 months, a fecal blood test; and every 2 
years, a colonoscopy, barium enema, or other procedure approved by the 
Secretary.
  Here's how the American Cancer Society described these different 
procedures in its 1995 Cancer Facts and Figures report:

       The stool blood test is a simple method to test feces for 
     hidden blood. The specimen is obtained by the patient at home 
     and returned to the physician's office, a hospital, or a 
     clinic for analysis. The Society recommends annual testing 
     after age 50.
       In proctosigmoidoscopy, the physician uses a hollow lighted 
     tube or a fiberoptic sigmoidoscope to inspect the rectum and 
     lower colon. To detect cancers higher in the colon, longer, 
     flexible instruments are used. The American Cancer Society 
     recommends sigmoidoscopy, preferably flexible, every 3 to 5 
     years after age 50.
       If any of these tests reveal possible problems, more 
     extensive studies, such as colonoscopy (examination of the 
     entire colon) and barium enema (an x-ray procedure in which 
     the intestines are viewed), may be needed.

  Mr. President, if we are to provide screening for colorectal cancer, 
which I believe is desperately needed, we should allow all types of 
procedures recommended by the American College of Physicians and 
described by the American Cancer Society. This bill would do just that. 
I know that other Members of this body have indicated their support for 
colorectal cancer screening under Medicare. My hope is that we can all 
join together on a proposal that will give seniors and their doctors 
the maximum choice and protection from this dreaded disease.
  I ask unanimous consent that the full text of the Colorectal Cancer 
Screening Act of 1995 and the recommendations from the American College 
of Physicians on screening for colorectal cancer be printed in the 
Record.
  There being no objection, the material was ordered to be printed in 
the Record, as follows:

                                S. 1385

       Be it enacted by the Senate and House of Representatives of 
     the United States of America in Congress assembled,

     SECTION 1. SHORT TITLE.

       This Act may be cited as the ``Colorectal Cancer Screening 
     Act of 1995''.

     SEC. 2. MEDICARE COVERAGE OF COLORECTAL SCREENING SERVICES.

       (a) In General.--Section 1834 of the Social Security Act 
     (42 U.S.C. 1395m) is amended by inserting after subsection 
     (d) of following new subsection:
       ``(e) Frequency and Payment Limits for Colorectal Screening 
     Procedures.--
       ``(1) Screening fecal-occult blood tests.--
       ``(A) Payment limit.--In establishing fee schedules under 
     section 1833(h) with respect to screening fecal-occult blood 
     tests provided for the purpose of early detection of colon 
     cancer, except as provided by the Secretary under paragraph 
     (3)(A), the payment amount established for tests performed--
       ``(i) in 1996 shall not exceed $5; and
       ``(ii) in a subsequent year, shall not exceed the limit on 
     the payment amount established under this subsection for such 
     tests for the preceding year, adjusted by the applicable 
     adjustment under section 1833(h) for tests performed in such 
     year.

[[Page S 16628]]

       ``(B) Frequency limits.--Subject to revision by the 
     Secretary under paragraph (3)(B), no payment may be made 
     under this part for a screening fecal-occult blood test 
     provided to an individual for the purpose of early detection 
     of colon cancer if the test is performed--
       ``(i) on an individual under 50 years of age; or
       ``(ii) within the 11 months after a previous screening 
     fecal-occult blood test.
       ``(2) Periodic colorectal screening procedures for 
     individuals not at high risk for colorectal cancer--
       ``(A) Payment amount.--The Secretary shall establish a 
     payment amount under section 1848 with respect to periodic 
     colorectal screening procedures provided for the purpose 
     of early detection of colon cancer that is consistent with 
     payment amounts under such section for similar or related 
     services, except that such payment amount shall be 
     established without regard to subsection (a)(2)(A) of such 
     section. The Secretary shall establish a single payment 
     amount for periodic colorectal screening procedures, which 
     shall be based on the cost of a flexible sigmoidoscopy or 
     barium enema procedure, as the Secretary determines 
     appropriate.
       ``(B) Frequency limits.--Subject to revision by the 
     Secretary under paragraph (4)(B), no payment may be made 
     under this part for a periodic colorectal screening procedure 
     provided to an individual for the purpose of early detection 
     of colon cancer if the procedure is performed--
       ``(i) on an individual under 50 years of age; or
       ``(ii) within the 59 months after a previous periodic 
     colorectal screening procedure.
       ``(D) Periodic colorectal screening procedure defined.--The 
     term `periodic colorectal screening procedure' means a 
     flexible sigmoidoscopy, barium enema screening procedure, or 
     other screening procedure for colorectal cancer, as 
     determined by the Secretary.
       ``(3) Screening for individuals at high risk for colorectal 
     cancer.--
       ``(A) Payment amount.--The Secretary shall establish a 
     payment amount under section 1848 with respect to each 
     eligible procedure for screening for individuals at high risk 
     for colorectal cancer (as determined in accordance with 
     criteria established by the Secretary) provided for the 
     purpose of early detection of colon cancer that is consistent 
     with payment amounts under such section for similar or 
     related services, except that such payment amount shall be 
     established without regard to subsection (a)(2)(A) of such 
     section. The Secretary may establish a payment amount for a 
     barium enema procedure pursuant to this paragraph that is 
     different from the payment amount established pursuant to 
     paragraph (2) for a periodic colorectal screening procedure 
     for an individual not a high risk for colorectal cancer so 
     long as the payment amount established pursuant to paragraph 
     (2) is not based on the cost of a barium enema procedure.
       ``(B) Eligible procedures.--Procedures eligible for payment 
     under this part for screening for individuals at high risk 
     for colorectal cancer for the purpose of early detection of 
     colorectal cancer shall include a screening colonoscopy, a 
     barium enema screening procedure, or other screening 
     procedures for colorectal cancer as the Secretary determines 
     appropriate.
       ``(C) Frequency limit.--Subject to revision by the 
     Secretary under paragraph (4)(B), no payment may be made 
     under this part for a screening procedure for individuals at 
     high risk for colorectal cancer provided to an individual for 
     the purpose of early detection of colon cancer if the 
     procedure is performed within the 23 months after a previous 
     screening procedure.
       ``(D) Factors considered in establishing criteria for 
     determining individuals at high risk.--In establishing 
     criteria for determining whether an individual is at high 
     risk for colorectal cancer for purposes of this paragraph, 
     the Secretary shall take into consideration family history, 
     prior experience of cancer or precursor neoplastic polyps, a 
     history of chronic digestive disease condition (including 
     inflammatory bowel disease, Crohn's Disease or ulcerative 
     colitis), the presence of any appropriate recognized gene 
     markers for colorectal cancer and other predisposing factors.
       ``(4) Reductions in payment limit and revision of 
     frequency.--
       ``(A) Reductions in payment limit.--The Secretary shall 
     review from time to time the appropriateness of the amount of 
     the payment limit established for screening fecal-occult 
     blood tests under paragraph (1)(A). The Secretary may, with 
     respect to tests performed in a year after 1998, reduce the 
     amount of such limit as it applies nationally or in any area 
     to the amount that the Secretary estimates is required to 
     assure that such tests of an appropriate quality are readily 
     and conveniently available during the year.
       ``(B) Revision of frequency and determination of eligible 
     procedures.--
       ``(i) Review.--The Secretary shall review periodically the 
     appropriate frequency for performing screening fecal-occult 
     blood tests, periodic colorectal screening procedures, and 
     screening procedures for individuals at high risk for 
     colorectal cancer based on age and such other factors as the 
     Secretary believes to be pertinent, and shall review 
     periodically the availability, effectiveness, and cost of 
     screening procedures for colorectal cancer other than those 
     specified in this section.
       ``(ii) Revision of frequency and determination of eligible 
     procedures.--The Secretary, taking into consideration the 
     review made under clause (i), may revise from time to time 
     the frequency with which such tests and procedures may be 
     paid for under this subsection and may determine that 
     additional screening procedures shall be considered to be 
     `periodic colorectal screening procedures' or an eligible 
     procedure for the screening of individuals at high risk for 
     colorectal cancer, but no such revision shall apply to tests 
     or procedures performed before January 1, 1999.
       ``(5) Limiting charges of nonparticipating physicians.--
       ``(A) In general.--In the case of a periodic colorectal 
     screening procedure provided to an individual for the purpose 
     of early detection of colon cancer or a screening provided to 
     an individual at high risk for colorectal cancer for the 
     purpose of early detection of colon cancer for which payment 
     may be made under this part, if a nonparticipating physician 
     provides the procedure to an individual enrolled under this 
     part, the physician may not charge the individual more than 
     the limiting charge (as defined in section 1848(g)(2)).
       ``(B) Enforcement.--If a physician or supplier knowing and 
     willfully imposes a charge in violation of subparagraph (A), 
     the Secretary may apply sanctions against such physician or 
     supplier in accordance with section 1842(j)(2).''.
       (b) Conforming Amendments.--(1) Paragraphs (1)(D) and 
     (2)(D) of section 1833(a) of the Social Security Act (42 
     U.S.C. 1395l(a)) are each amended by striking ``subsection 
     (h)(1),'' and inserting ``subsection (h)(1) or section 
     1834(e)(1),''.
       (2) Section 1833(h)(1)(A) of such Act (42 U.S.C. 
     1395l(h)(1)(A)) is amended by striking ``The Secretary'' and 
     inserting ``Subject to paragraphs (1) and (3)(A) of section 
     1834(e), the Secretary''.
       (3) Clauses (i) and (ii) of section 1848(a)(2)(A) of such 
     Act (42 U.S.C. 1395w-4(a)(2)(A)) are each amended by striking 
     ``a service'' and inserting ``a service (other than a 
     periodic colorectal screening procedure provided to an 
     individual for the purpose of early detection of colon cancer 
     or an eligible screening procedure provided to an individual 
     at high risk for colorectal cancer for the purpose of early 
     detection of colon cancer)''.
       (4) Section 1862(a) of such Act (42 U.S.C. 1395y(a)) is 
     amended--
       (A) in paragraph (1)--
       (i) in subparagraph (E), by striking ``and'' at the end;
       (ii) in subparagraph (F), by striking the semicolon at the 
     end and inserting ``, and''; and
       (iii) by adding at the end the following new subparagraph:
       ``(G) in the case of screening fecal-occult blood tests, 
     periodic colorectal screening procedures, and screening 
     procedures provided for the purpose of early detection of 
     colon cancer, which are performed more frequently than is 
     covered under section 1834(e);''; and
       (B) in paragraph (7), by striking ``paragraph (1)(B) or 
     under paragraph (1)(F)'' and inserting ``subparagraphs (B), 
     (F), or (G) of paragraph (1)''.

     SEC. 3. EFFECTIVE DATE.

       The amendments made by section 2 shall apply to services 
     furnished on or after January 1, 1996.
                                                                    ____


               [From the American College of Physicians]

                    Screening for Colorectal Cancer


                                Disease

       Invasive colorectal cancers arise from adenomas or 
     originate (de novo) from the mucosa of the colon. Progression 
     from adenoma to invasive cancer takes about five years.
       Colorectal cancer accounts for 150,000 new cases each year 
     and 61,000 deaths. It is the second most common form of 
     cancer in the US. On the average, it deprives patients of 
     nearly 10 percent of their expected life span.
       Risk factors for colorectal cancer include inflammatory 
     bowel disease, familial ployposis syndromes, family history, 
     and a previous history of noeplasms. A diagnosis of familial 
     polyposis syndrome or inflammatory bowel disease requires 
     monitoring.


                           Screening Test(s)

       Several tests and procedures have been proposed for 
     colorectal cancer screening; the most common are digital 
     examination, fecal occult blood tests (FOBT), and 
     sigmoidoscopy. Air-contrast barium enemas and colonoscopy 
     have been proposed for screening individuals at high risk of 
     developing colorectal cancer.
       The digital rectal examination entails a manual exploration 
     of the rectum.
       Fecal occult blood tests entail smearing a stool specimen 
     on a slide and submitting the specimen for analysis. 
     Recommended practice is to take two samples on each of three 
     consecutive days, while on a diet designed to reduce the 
     frequency of false positives.
       Sigmoidosocpy is the inspection of the interior of the 
     colon through an endoscope inserted via the rectum. 
     Sigmoidolscopes vary in length and may be rigid or flexible. 
     When available, use of a flexible scope is preferred; 
     otherwise, a rigid scope is acceptable.
       Air-contrast barium enema and colonoscopy allow the 
     inspection of the entire colon. The former involves the 
     administration of barium into the rectum, followed by x-ray 
     study of the entire intestine; the latter introduction of a 
     fiberoptic instrument.


                            Recommendations

       1. Screening with fecal occult blood tests is recommend 
     annually for individual age 50 and older.
     
[[Page S 16629]]

       2. Screening with sigmoiodoscopy is recommended every 3-5 
     years or with air-contrast barium enema every 5 years for 
     individuals age 50 and older.
       3. For individuals age 40 and older who have familial 
     polyposis coli, inflammatory bowel disease, or a history of 
     colon cancer in a first degree relative, i.e., parent or 
     sibling, screening with air-contrast barium enema or 
     colonoscopy in addition to annual fecal occult blood tests, 
     is recommended every 3-5 years.


                               Rationale

       Although there is little direct evidence of the 
     effectiveness of colorectal cancer screening, there is 
     indirect evidence, based on the natural history of the 
     disease and the effectiveness of screening tests, that 
     screening should reduce colorectal cancer incidence and 
     mortality.
       Risks associated with colorectal cancer screening include 
     perforations from sigmoidoscopy, colonoscopy and barium enema 
     and the extensive diagnostic tests associated with false-
     positive results of fecal occult blood testing.
       Individuals at high risk for colorectal cancer due to 
     familial polyposis coli or inflammatory bowel disease, a 
     history of colorectal cancer in a first degree relative 
     should be encouraged to have a complete examination of the 
     colon. Factors influencing the choice between air contrast 
     barium enema and colonoscopy include cost and access to 
     qualified physicians able to perform safe and accurate 
     studies.
                                 ______