What are the Barriers to CRC Screening?

Waiving copayments for colonoscopy examinations to detect colorectal cancer (CRC) increases the number of patients that undergo screening, according to a study published in the July issue of Clinical Gastroenterology and Hepatology.

Colonoscopy is a recommended, cost-effective method of CRC screening that appears to reduce mortality, yet only half of Americans older than 50 have been screened. One barrier to screening is cost—people in health insurance plans that require large co-payments are less likely to undergo screening colonoscopy. Reducing this cost sharing might therefore increase screening rates.

Shabnam Khatami et al. analyzed colonoscopy incidence among 50- to 64-year-old beneficiaries of the University of Texas Select Health Plan, before and after the plan waived the co-payment for this examination. They found that soon after co-payments were waived, the incidence of colonoscopy increased from an expected incidence of 8.0% to 9.5%, an absolute increase of 1.5%, and an 18% relative increase (see figure).

Colonoscopy incidence before (2002–2008) and after the colonoscopy copayment waiver (2009). After the copayment was waved, the incidence of colonoscopy was higher than expected, based on prior trends.

This statistically significant, but modest, increase in uptake appeared to result directly from the co-payment waiver, rather than any larger trends in screening for cancer or other disorders. The authors conclude that patient cost is a major barrier to screening—the co-payment for colonoscopy screening can be $750 or more.

Khatami et al. point out that to address financial barriers and increase CRC screening, the Patient Protection and Affordable Care Act (ACA) mandates that insurers “not impose any cost-sharing requirements for [preventive] services that have in effect a rating of ‘A’ or ‘B’ in the current recommendations of the United States Preventive Services Task Force.” For CRC screening, the US Preventive Services Task Force recommends colonoscopy every 10 years for individuals age 50–75 at average risk for CRC. The authors say that the ACA legislation has therefore mandated waiver of co-payments for screening colonoscopies.

Khatami et al. admit that it is not clear whether cost is the primary reason that patients don’t undergo screening—other factors, such as time away from work and test invasiveness, could have larger roles.

In an editorial that accompanies the article, Spencer Dorn and A. Mark Fendrick point out that the study lacked a control group, yet they state the findings indicate that the ACA’s cost-sharing provision will lead more Americans to undergo screening colonoscopies. They also mention that the Texas Select Health Plan widely marketed the co-payment waiver, which might have bolstered the increase in useage.

Khatami et al. recognize that waiving co-payments is costly to insurers. The total outlay by the insurer for the 2358 patients who would have been expected to undergo a colonoscopy without the co-payment waiver would have been $2,358,000. With the co-payment waiver, the insurer picked up the full cost for 2590 patients—at a new total cost of $4,532,500. An additional $2,174,500 was therefore spent to detect an estimated 18 patients with advanced neoplasia ($120,806 per neoplasia detected) and prevent 1 patient from developing cancer ($2,174,500 per cancer prevented).

Although these numbers are rough estimates, the authors conclude that waiving co-payments is moderately effective in increasing colonoscopy uptake and also expensive.

They propose that additional strategies, beyond removing financial disincentives, are required to optimize CRC screening, such as improving patient knowledge of screening through outreach programs and getting more physicians to recommend CRC screening.

Read the article online.
Khatami S, Xuan L, Roman R, et al. Modestly increased use of colonoscopy when copayments are waived. Clin Gastroenterol Hepatol 2012;10: 761–766.e1.

Read the accompanying editorial.
Dorn SD, Fendrick AM. Waiving cost sharing for screening colonoscopy; free, but not clear. Clin Gastroenterol Hepatol 2012;10: 767–768.

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About Kristine Novak, PhD, Science Editor

Dr. Kristine Novak is the science editor for Gastroenterology and Clinical Gastroenterology and Hepatology, both published by the American Gastroenterological Association. She has worked as an editor at biomedical research journals and as a science writer for more than 12 years, covering advances in gastroenterology, hepatology, cancer, immunology, biotechnology, molecular genetics, and clinical trials. She has a PhD in cell biology and an interest in all areas of medical research.
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