53, 83, and 27 percent of commercial claims, Medicare Part D claims, and Medicaid claims had out-of-pocket costs >$0
By Elana Gotkine HealthDay Reporter
WEDNESDAY, July 2, 2025 (HealthDay News) — A considerable proportion of bowel preparation claims for screening colonoscopy involve patient cost-sharing, according to a research letter published online June 20 in Gastroenterology.
Eric D. Shah, M.D., from the University of Michigan in Ann Arbor, and colleagues conducted a cross-sectional analysis to examine out-of-pocket costs for bowel preparations among patients enrolled in commercial and Medicare Part D plans undergoing screening colonoscopy, focusing on differences across high- and low-volume bowel preparation categories.
A total of 2,593,079 prescription drug claims were analyzed: 52.9, 35.0, and 8.3 percent from commercial, Medicare Part D, and Medicaid plans, respectively. The researchers found that 53, 83, and 27 percent of commercial claims, Medicare Part D claims, and Medicaid claims had out-of-pocket costs greater than $0, respectively. Compared with high-volume products, low-volume products consistently had a higher percentage of claims with out-of-pocket costs. Among commercial plans, 35 and 61 percent of high- and low-volume product claims had any out-of-pocket costs compared with 75 and 90 percent among Medicare plans and 27 and 30 percent among Medicaid plans, respectively. The median nonzero out-of-pocket cost was $10 and $60 for high- and low-volume product claims among commercial plans; $8 and $55.99, respectively, among Medicare plans; and $1 and $60, respectively, among Medicaid plans.
“Study findings emphasize the need for consistent enforcement of ACA (Affordable Care Act) compliance in health plans and for payer practices to align with evidence-based bowel preparation guidelines in order to support effective screening,” the authors write. “It is crucial for CMS (the Centers for Medicare & Medicaid Services) to reaffirm its 2016 guidance, stating that colonoscopy preparations must be covered at no cost to patients. Strengthening adherence to this mandate would improve access, increase [colorectal cancer] screening rates, and promote equitable preventive care.”
Several authors disclosed ties to industry, including Sebela Pharmaceuticals, which funded the study.
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