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In their analysis of 2 studies^1-2 of colon cancer screening, Marshall et al³ overlook another major impediment to proper screening, namely, physician reimbursement.

With the advent of capitated managed care, several health maintenance organizations, including Aetna U.S. Healthcare, which participated in one of the aforementioned studies, refuse to pay for sigmoidoscopies performed by primary care physicians. Little wonder, then, that these physicians with ever-dwindling reimbursements and increasing overhead costs have little incentive to perform sigmoidoscopic examinations.

Equally vexing is that many of these health maintenance organizations also refuse to allow trained internist/gastroenterologists to perform colonoscopies on their own patients because of a corporate dictum that physicians cannot be listed on their patients' plans as practicing both primary care and a specialty. To be obligated to refer patients requiring such procedures to "pure" specialists is not only insulting but unbearably time-consuming. Many patients resent the inconvenience as well. This aggravation is . . . [Full Text of this Article]

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