Most Patients have Out of Pocket Costs for Bowel Prep

Colon and rectal cancer is treatable when caught early and even preventable by removing polyps during colonoscopy screening. But colorectal cancer remains the second most common cause of cancer deaths in the U.S., the numbers have been decreasing over the past few decades for older adults — largely due to more people getting colonoscopies.

Even with the life-saving nature of a colonoscopy, barriers remain for many to have access to this preventive procedure, including concerns about the cost of colonoscopies — which are required to be covered by private insurance, Medicare, and Medicaid by the Affordable Care Act (ACA) — and the cost of the necessary bowel prep medications. A complete bowel is important prior to a colonoscopy to help fully clean the colon and allow gastroenterologists to easily see the walls of the colon and identify and remove any polyps.

A study by Dr. Eric D. Shah at the University of Michigan found that out-of-pocket costs for bowel prep medication are not covered by insurance or Medicare, despite the ACA requirement, leading many patients to avoid colonoscopies or pay high cost for prescription and over-the-counter bowel prep medications.

According to the study, despite the ACA mandate, many colonoscopy patients are responsible for at least a portion of the cost of bowel prep that’s required before a colonoscopy. Many patients were found to be paying more for modern low-volume or tablet prep medication that have been shown to be more effective at bowel cleansing and more tolerable for the patients.

Cost and the limited choice of prep medication is a barrier for many patients and may even prevent some from getting this crucial screening, as newer, highly effective, and more tolerable low-volume bowel preps are not as readily available and come with higher associated out-of-pocket costs.

The ability to choose a high-quality bowel prep that works for each individual, regardless of their financial situation, can help reduce barriers and ensure that more people can undergo this life-saving procedure. Eliminating the cost barrier for FDA-approved bowel prep medications may improve screening rates for CRC, and save lives.

Additional findings from Dr. Eric Shah, et. al.:

• Most prescribed colonoscopy preps for CRC screening are subject to cost sharing, contrary to the ACA mandate.
• For commercial insurance plans, 65% of high-volume colon preps had $0 out-of-pocket compared to 39% of low-volume colon preps. The median out-of-pocket costs for high-volume prep was $10, compared to $60 for low-volume.
• For Medicare Part D, 25% of high-volume preps had a $0 out-of-pocket versus 10% for low volume preps. The median out-of-pocket costs were $8 for traditional prep and $55.99 for low volume.
• Out-of-pocket costs were highly variable among insurance plans, with the top 25 plans having a range as low as 5% to as high as 92% of patients paying $0 out-of-pocket.
• Low-volume preps were less frequently provided at $0 OPC despite evidence of positive efficacy and tolerability profiles. Commercial plans outperform Medicare Part D plans on this metric.
• Previous analysis of this dataset has shown that 51% of colonoscopy patients are subject to an over-the-counter bowel prep not covered by insurance.
• A weighted average assessment suggests that about 83% of patients are subject to cost sharing for bowel preparations related to screening colonoscopy (i.e., only about 17% pay zero overall).

Learn more about choices for bowel prep.