Cutting out coinsurance for patients undergoing colonoscopy after a positive stool test could improve patient life-years, according to new research.
Although the full effect of Medicare’s January 2023 policy waiving cost sharing for colonoscopy after a positive stool-based colorectal cancer screening test remains uncertain, researchers estimated that if the waived cost of a follow-up colonoscopy increased adherence by 15%, then the resulting colonoscopies would extend the lives of the average-risk population by up to 20%. Furthermore, any uptick in CRC screening is expected to yield savings in healthcare spending, according to the researchers.
“Policies and efforts to increase both total screening participation and follow-up colonoscopy rates are paramount to improving public health,” noted the researchers, led by A. Mark Fendrick, MD, the director of the University of Michigan Center for Value-Based Insurance Design, in Ann Arbor (Cancer Res Commun 2023;3[10]:2113-2117). “Policies that remove cost barriers to completing CRC screening may increase rates of screening participation, potentially improving economic and clinical outcomes.”
The effects of the federal policy are yet to be seen, but state-level policies have revealed mixed results. In Oregon, where a similar intervention was rolled out in 2017, there was a 6% increase in the odds of receiving any CRC screening, but there was no change in screening behavior in Kentucky, where cost sharing for colonoscopies after a positive stool test was waived in 2016 (JAMA Netw Open 2022;5[6]:e2216910).
In the current analysis, Dr. Fendrick and his co-investigators used a validated simulation model to project the federal policy’s effects. The model included 2 million average-risk individuals who received a mix of recommended CRC screening strategies or no screening at all. The hypothetical individuals were between 65 and 75 years of age and were screened with colonoscopy every 10 years, a fecal immunochemical test (FIT) every year or a multitarget stool DNA (mt-sDNA) test every three years.
The model’s base-case scenario used data from a U.S. longitudinal claims database study and assumed screening rates of 45.3% with initial colonoscopy and 24.4% for an initial stool-based test, leaving 30.3% of the population unscreened (JAMA Netw Open 2021;4:e2122269). Based on real-world data on rates of follow-up colonoscopy, in the base case, the model presumed 71.5% of patients followed up to colonoscopy after a positive mt-sDNA test and 46.7% after a positive FIT (Am Board Fam Med 2021;34:61-69). Health outcomes were estimated based on the natural history of CRC, type of screening test used, initial screening test adherence, follow-up colonoscopy adherence and age of the population.
According to the analysis, the base-case model was associated with 128 life-years gained per 1,000 screened individuals, compared with an unscreened population. The total screening and treatment costs were $7,938 per person.
Comparative scenarios assumed an increase in the overall screening rate from 0% to 15% (5% increments) and an increase in the follow-up colonoscopy rate from 0% to 15% (5% increments). Assuming an absolute increase of 15% in follow-up colonoscopies after a positive test, the investigators estimated 26 additional life-years gained per 1,000 individuals—a 20% increase relative to the base-case scenario. Total screening and treatment costs would be cut by $128 per person in this case, according to the analysis.
Furthermore, an economic analysis determined that any increase in overall screening or follow-up colonoscopy should make waiving coinsurance a cost-saving measure. The researchers also estimated that the cost of a quality-adjusted life-year would be reduced by roughly $13,000 if there is a 15% increase in follow-up colonoscopy after a positive FIT or mt-sDNA test.
A Popular Opinion
For Aasma Shaukat, MD, the findings are “intuitive,” she told Gastroenterology & Endoscopy News. “Cost sharing creates barriers to patients getting the necessary colonoscopy after an abnormal stool test,” she said. “All GI societies have advocated for removing cost sharing.”
Dr. Shaukat, the Robert M. and Mary H. Glickman Professor of Medicine at the NYU Grossman School of Medicine, in New York City, noted that she and her co-authors highlighted the removal of cost sharing in the most recent iteration of the American College of Gastroenterology clinical guidelines on colorectal cancer screening (Am J Gastroenterol 2021;116[3]:458-479). “Our position is that screening is a continuum,” she said. “If the initial test is abnormal, the colonoscopy is part of that screening episode and should be no cost to the patient.”
Regarding Medicare’s new rule change to drop cost sharing, Dr. Shaukat said, “We hope all payors will follow.”
—David Wild and Meaghan Lee Callaghan
This research was funded in part by Exact Sciences, the maker of the mt-sDNA test Cologuard. Dr. Shaukat reported no relevant financial disclosures.
This article is from the December 2023 print issue.