MCBS Highlights: Screening for Osteoporosis and Colon Cancer Under Medicare

Screening for Osteoporosis

Osteoporosis, a disease in which the bones lose mineral content and weaken, is a primary cause of disabling fractures in the elderly, mostly in females. Low bone density can be detected by X-ray and other radiographic techniques, as well as by ultrasound. Early detection can permit measures to delay the progression of osteoporosis, such as intake of dietary calcium and vitamin D, weight-bearing exercise, estrogen therapy, and stopping smoking (U.S. Preventive Services Task Force, 1996).

The Balanced Budget Act of 1997 expanded Medicare coverage of a number of preventive services, including bone density measurement for those “at risk for osteoporosis and other bone abnormalities,” beginning July 1, 1998. The criteria of risk are broad, however, including estrogen deficiency. The procedure is covered once every 2 years, or more frequently if deemed medically necessary (Health Care Financing Administration Press Office, 1998).

Data from the 2000 Medicare Current Beneficiary Survey (MCBS) Access to Care File show that osteoporosis affects mainly, but not exclusively, females. Among the 30.3 million beneficiaries age 65 or over living in the community, 23 percent of females report having ever been diagnosed with osteoporosis, compared with 3 percent of males. Because osteoporosis is primarily a disease of females and its epidemiology differs between the genders, this article will focus on these 17.5 million females.

The data indicate a fertile field for an information initiative to publicize the bone density screening benefit, both to physicians who ought to be talking to more of their patients about osteoporosis, and to patients who should know more about the disease, the screening tests, and the Medicare benefit.

Screening for Colorectal Cancer

Colorectal cancer is second only to lung cancer in causing cancer-related deaths in the U.S., accounting for 55,000 deaths a year. It is largely a disease of people age 50 or over, and the risk increases with age. The early progression of the disease is largely asymptomatic: about 60 percent of patients with colorectal cancer have regional or distant metastases at the time of diagnosis. Survival is markedly improved by detecting the disease at an early stage (U.S. Preventive Services Task Force, 1996). According to the MCBS, about 3 percent of the Medicare aged report having been diagnosed with colon cancer.

Detection of colorectal cancer is via several types of screening tests, all of which are aimed at finding evidence of cancerous or precancerous growths. The most useful of these for population screening are: fecal occult blood testing and sigmoidoscopy.¹ The following are screening tests for colorectal cancer: digital rectal exam, fecal occult blood test (FOBT), sigmoidoscopy, colonoscopy, and barium enema.

Medicare covers a FOBT once a year under Part B, with no coinsurance or deductible. FOBT is given to the patient as a card with spaces for stool samples, which are collected at home. The samples are then sent to the doctor's office or a laboratory to be tested for the presence of hidden (occult) blood.

Medicare covers a sigmoidoscopy once every 4 years, subject to a 20-percent copayment after the Part B deductible is met. In this test the doctor visualizes the lower third of the colon (large intestine) through a flexible lighted tube, checking for cancerous lesions or polyps, which may be precancerous. This is usually done in the doctor's office. A colonoscopy is similar, using a longer tube to see more of the colon. Since it is more invasive, the procedure is often done in a hospital under anesthesia. Medicare covers a colonoscopy every 2 years for persons at high risk, otherwise every 10 years.

Figure 1. Percent of Aged Medicare Females Living in the Community Who Have Ever Been Told by a Doctor They Had Osteoporosis: 2000.

• In this population, 23 percent report ever having been told by a doctor that they had osteoporosis.
• Another 26 percent had not been diagnosed, though they had talked with a doctor about the disease.
• The remaining 51 percent had never talked to a doctor about osteoporosis.
• Given the high frequency of this condition, the proportion who had not discussed it with their doctor seems quite high.

Figure 2. Percent of Aged Medicare Females Living in the Community Who Have Heard of Bone Mass or Bone Density Measurement Test: 2000.

• About 1 in 3 (34 percent) of females in this population have had a bone density measurement test at any time in the past.
• Another 41 percent have heard of the test but not had it, and the remaining 26 percent have not heard of it.

Figure 3. Number of Years Since Most Recent Bone Density Test, by Percent of Aged Medicare Females Living in the Community: 2000.

• Many of those who had the test had it relatively recently; 75 percent had it within the 2 years before the interview—roughly since the Medicare benefit began.

Figure 4. Percent of Aged Medicare Females Living in the Community Who Know Medicare Pays for Bone Density Tests: 2000.

• Just as knowledge about the test is low, knowledge that Medicare pays for bone density tests is very low. Of those who have not had the test, only 30 percent know that Medicare will pay some of the cost of these screening tests.

Figure 5. Percent of Aged Medicare Females Living in the Community Who Have Ever Had a Fecal Occult Blood Test (FOBT): 2000.

• The Medicare population age 65 or over living in the community, 48 percent report ever having an FOBT (an additional 3 percent were given the test card but did not complete the samples), 22 percent have heard of the test but have not had it, and 27 percent have not had the test or heard of it.
• Thus, a sizable proportion of those who have not had the test are unaware of it.

Figure 6. Number of Years Since Most Recent Fecal Occult Blood Test, by Aged Medicare Population Living in the Community: 2000.

• Many of those who have had the test have done so in the past year (38 percent) but this means that the remaining 62 percent have not had the test within the recommended 1-year timeframe.
• Thus, the proportion of the overall population who been tested in the recommended time is only 18 percent.

Figure 7. Percent of Aged Medicare Population Living in the Community Ever Having a Colonoscopy/Sigmoidoscopy: 2000.

• One-half of the population has ever had a sigmoidoscopy or colonoscopy.
• Thirty-two percent did not have the test but heard of it, while the remaining 18 percent had neither had it nor heard of it.

Figure 8. Number of Years Since the Most Recent Sigmoidoscopy/Colonoscopy, by Percent of Aged Medicare Population Living in the Community: 2000.

• The timeframe of the most recent test is more spread out than is the case with the FOBT, as might be expected.

Figure 9. Percent of Aged Medicare Population Living in the Community Having Had a Sigmoidoscopy/Colonoscopy and a Fecal Occult Blood Test: 2000.

• The rates for the combination of the two tests: 18 percent of the population have had FOBT only, another 18 percent sigmoidoscopy/colonoscopy only 31 percent have had both, and 33 percent have had neither.
• We can assert that two thirds of the community-dwelling Medicare population age 65 or over have had some kind of screening for colon cancer, but concern arises for the one-third who have not.