A counseling requirement included in Medicare’s proposed decision to cover screening for lung cancer with low-dose computed tomography could pull primary care physicians out of the decision loop.

The proposed national coverage decision from the Centers for Medicare & Medicaid Services, announced Nov. 10, includes a requirement that patients “receive a written order for [low-dose computed tomography screening] during a lung cancer screening counseling and shared decision making visit, furnished by a physician … or qualified nonphysician practitioner.” CMS has proposed covering low-dose computed tomography (LDCT) screening only for certain high-risk patients, with strict limitations on eligibility.

But the time requirement and questions on how this counseling would be covered could make it challenging for patients to make this decision alongside their primary care physician.

“One of the most interesting things in the Medicare requirement for payment focuses on the counseling visit,” said Steven Zeliadt, Ph.D., core investigator at Veterans Affairs Health Services Research & Development Services and professor at the University of Washington, Seattle. “That’s very different than other cancer screening tests and for Medicare to really be encouraging that and requiring that is something providers and systems are going to figure out how to offer that and make sure that [this] actually happens.”

Dr. Zeliadt said that he expects to see specialized screening centers similar to those related to pulmonary or mammography screening to gain traction. These will be the places that integrate both parts of the screening by conducting the LDCT test as well as providing the prescreen counseling. This differs from the model used for colon cancer and prostate cancer screening, where the consultation and decision to conduct screening tests are typically done with the primary care physician.

“The Medicare guidelines encourages that [counseling] as well, to make sure that that’s a visit that gets built in,” Dr. Zeliadt said.

Such centers exist now, he noted. “They hire counselors and [conduct] an hour-long prescreening visit that happens with a counselor to talk about lung cancer screening, [the length of which] could never happen in a primary care setting.”

This model does not take advantage of the physician/patient relationship, he added. “There is an opportunity for a familiar provider to engage patients around counseling, so the more that we move CT screening outside of primary care, it takes away from the long-term relationship that providers have” with their patients, he said, including knowing more deeply the risks a patient has, as well as the patient’s history with smoking and attempts to quit.

It also takes away opportunities to maintain conversations about smoking cessation, which could be important as screening sometimes deemphasizes the need to quit in patient’s eyes because patients “feel protected by screening.”

The CMS is soliciting comments on the proposed national coverage decision until Dec. 10.