Adding Ancillaries: Flexible sigmoidoscopy

Mike Pendleton, a family physician in Hood River, OR, does three to five flexible sigmoidoscopies a month, but not for profit. In fact, as he and other doctors acknowledge, there's little money in this low-paid procedure. By all accounts, the declining number of FPs and general internists who perform flex sigs do them mainly because they see it as a patient service.

Here's how Pendleton explains it: Clinical guidelines recommend that people age 50 and over get tested periodically for colorectal cancer. Annual fecal occult blood tests (FOBTs) are among the methods recommended, but have low sensitivity and a high false-positive rate. Colonoscopy, widely considered a more effective screening method, takes up to a day and a half of a patient's time and has a higher complication rate than flexible sigmoidoscopy does.

"With colonoscopy, you have to clean out your colon, modify your diet, and go in for a procedure that's not without risk," notes Pendleton. "Flexible sigmoidoscopy, in my hands, takes between 90 seconds and five minutes, and the only preparation is two enemas ahead of time. It's straightforward and easy to do. It screens about 60 percent of your colon. And until the data changes substantially, I'm not persuaded that I need to do anything different."

Medicare allows Pendleton $114 per flex sig (nationally, Medicare allows $120 before geographical adjustments), and private health plans pay him up to $180. He's not losing money at these rates, but he isn't making much, either. Some physicians actually make less on a flex sig than it costs them to do the procedure, says FP John B. Pope, professor of clinical family medicine at Louisiana State University School of Medicine in Shreveport.

Considering the low reimbursement for flex sigs-doctors are paid four times as much for a colonoscopy-it's not surprising that the number of primary care doctors who do them is falling. Today, 20-25 percent of internists provide flexible or rigid sigmoidoscopies, down from over 75 percent in 1986, says internist Robert S. Wigton, professor at the University of Nebraska Medical Center College of Medicine at Omaha. About 25 percent of family physicians perform flex sigs, according to recent AAFP surveys.

Another reason for these dwindling numbers is that more and more patients prefer colonoscopies. Some patients like them better because, with sedation, they're less painful than flex sigs are. And, partly because of Katie Couric's on-air colonoscopy on the "Today" show in 2000, public opinion has shifted in favor of this test.

With interest in flex sigs decreasing, both the AAFP and the ACP have stopped teaching the procedure at their annual conferences. While it's still part of the curriculum in most family practice residencies, the number of residency programs that teach it is declining. Most internal medicine programs offer flexible sigmoidoscopy training only as an elective course, says internist Patrick C. Alguire, director of education and career development at the ACP.

But is flex sig more cost-effective?

Still, many primary care physicians continue doing flex sigs because they believe it's a convenience for patients or because there aren't enough specialists in town to do colonoscopies on everybody who needs them. Some doctors also view sigmoidoscopy as a cost-effective screening method that saves money for both patients and society as a whole. That's one reason why FP David W. Wallace of Shelbyville, KY, still does the procedure. Even though screening colonoscopy is available at his local hospital for about $5,000, he feels it's a waste of limited resources.

Wallace might be correct about the short-term cost impact of screening millions of average-risk people with colonoscopies. Yet the US Preventive Services Task Force (USPSTF) has concluded that all four methods of colorectal cancer screening-FOBT, sigmoidoscopy, colonoscopy, and double-contrast barium enemas-are cost-effective compared with no screening.