Five Thirty Eight’s Katherine Hobson has a good piece on colorectal cancer screening and the cost control challenge:
The United States Preventive Services Task Force says the net benefit for screening adults age 50-75 is “substantial,” adding that colorectal cancer is the second-leading cause of cancer death in the country. But as of 2012, just 65 percent of eligible adults were being screened as recommended, and almost 28 percent had never been screened….Included on the list are two cheap, at-home poop tests intended to be done annually: the guaiac-based fecal occult blood test (gFOBT) and a more sensitive test called the fecal immunochemical test, or FIT….Of the two, Richard Wender, a physician and chief cancer control officer of the American Cancer Society, said the FIT is preferable, both because it’s more accurate and because it requires only one poop sample and no changes in diet.3 It costs about $25 or less and when done every year, theUSPSTF’s models estimate, it will avert 20-23 deaths from colorectal cancer per 1,000 people screened….
Colonoscopy is the most popular test in the U.S. In addition to its polyp-removing ability, if you have a negative test, you don’t have to come back for another 10 years. 4 ….Based on the available evidence and its modeling, the USPSTF estimates it reduces deaths from colorectal cancer by 22-24 per 1,000 people screened….It’s expensive, running upward of $1,000. (The test is covered without cost sharing as preventive care under the Affordable Care Act.)
Besides being a good opportunity to embed one of my favorite Scrubs scenes below the fold, why is this important?
This illustrates cost saving challenges.
For individuals with no suspicious results, the cost of the poop tests are $25 per year. The cost of a colonoscopy is $100 per year (amortized over 10 years). The cost of a suspicious result is $1,025 for the poop test plus a colonoscopy to confirm and cut polyps while there is no marginal cost of to a colonoscopy only screening if there are suspicious results. As long as most people in any given year don’t have suspicious poop blood tests, the insurance companies pay out less money on net than they would for colonoscopies.
PPACA requires that insurers pay 100% of the cost of a clinically effective preventive screening. Some insurers could conceivably move to a regime where they pay 100% of the cost of the poop blood test and 100% of a follow-up colonoscopy if there are clinical indicators for a follow-up but put a first line colonoscopy into regular cost sharing. If they really want to get ambitious, they could split some of the cost savings of a screening versus a scope with the member by knocking off deductible dollars or sending a cash back check for $20 or $30.
The big challenge is that this would be a signficant change in the culture and expectation of practice. People of a certain age expect to get a colonoscopy. We don’t expect to poop into a box and put that box in the car to hand to a technician. Doctors do not think of that is typical either. Their quality metrics are to get people screened for colorectal cancer without much concern as to how they are screened. Most of the prescribing docs won’t actually file a claim for the screening as that is the job of a specialist, so they have no real incentive either way to go one route or another. Finally in a shared savings arrangement, the cheaper but more frequent screening system could have significant negative impacts in the first year or two of expenses as more people are screened so total lab expenses would go up without compensating declines in net colonoscopy spend.