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.
p.a.
Just had my scope yesterday. 3 polyps. My health ins says they cover 1/year. I was shocked. Thankfully I’ll do 3-5 yrs between. Prep no fun. Good info on the home tests, tks.
raven
I go for my two year scope in 2 weeks, they found some polyps on the last one so they moved me up. The week after I go for hernia repair and it looks like a $200 copay for each. This is under BCBSga.
JPL
My ex received treatment for colon cancer. Both his mother and sister had breast cancer, and because of the family history, my sons have been advised to have their first colonoscopy at forty. My older son will be forty in November, and hopefully the insurance company doesn’t refuse payment.
Wag
@JPL:
Your son meets all requirements for early screening. The insurance company will pay. If they put up a stink you don’ PCP can call and get prior authorization
Richard Mayhew
@Wag: Yep, pre-auth for the colonoscopy should be easy enough as they are fairly cheap and infrequent.
laura
I’ve got the paper test in the mail last week. The spouse keeps saying I should be studying for the test.
Easy peasy and in the mail.
satby
I’m a colonoscopy refusenik. I knew one of the (thankfully rare) people who ended up dying from one when it nicked the bowel and she died of perotinitous (yeah, that’s spelled wrong). I also react very badly even to light anesthesia, getting shocky even on valium. But I have no reservations about the poop tests, and think they should be used more.
They never seem to mention that not every polyp becomes cancerous, but they include polyps removed as if they all will to goose the prevention stats.
raven
@satby: Ever know anyone who died in a car wreck?
JaneE
I have been doing the annual poop tests for several years – Kaiser orders them automatically each year. This year I got a bad result, and a colonoscopy was ordered for that reason. No cost for any of it on my Senior Medicare plan.
satby
@raven: No. Lots who were injured, including me twice.
The main objection I have is my allergies to anesthesia, a tooth extraction put me into shock once, and it’s happened every time I’ve gone under since, but at least they can be prepared for it now. And if there is an alternative, non-invasive method to perform the same screening with statistically the same effectiveness, that’s the one for me.
satby
@JaneE: And at that point it becomes a diagnostic test, and not a mass screening. Where it makes more sense.
HRA
@satby:
I agree and I am the same way with even light anesthesia along with the once use of a valium many years ago. For years I have noticed there is always one popular surgery or process that is currently prevalent in the medical field. I refused to have 1 child’s tonsils yanked when she was 2 years old and took her to a pediatrician who was an allergy specialist. After 6 years of working on her juvenile asthma, she was cured and still has her tonsils. This is my guide.
raven
@satby: drive on
satby
@HRA: I’m allergic to morphine derivatives too, so the after surgery is a special joy.
@raven: s’cool, we’re all different.
JGabriel
Katherine Hobson @ 538:
Popular?
I’m not sure that being the most widely prescribed surgical procedure means that people like it.
Elly
Had my first colonoscopy in June and was all clear (which was what I expected, but still…). Before going in to see my PCP for the referral, I did some pretty extensive research on the alternatives because I really, really wanted to avoid it if I could, but in the end (no pun intended), I convinced myself that the “gold standard” test was the way to go for me, as well as my husband (who is also due but was equally apprehensive, so I figured it would be easier for him if I went first).
FWIW, my overall reaction was “not that bad.” This is possibly because I was prepared for the absolute worst w/respect to the prep, so ended up over-preparing for reactions (nausea, etc.) that never occurred. Mind you, I can’t say it was the best experience of my life, but for me, it was more “inconvenient/annoying” than awful.
TaMara (HFG)
@satby:
@raven:
I’m with satby. Here are the stats for 2011
I’m betting there were no such complications from the poop test. Just because a doctor recommends it, doesn’t mean it needs to happen. I was in a terrible car accident and saw 5 different doctors for various injuries and each one recommended a surgery/treatment based on their specialty that turned out to be unnecessary. Took the 6th doctor and of all things a lawyer to figure out I had a serious spine injury causing all my symptoms.
So I’m skeptical in all things and research any treatment a doctor says is “necessary”.
Miss Bianca
So, Richard…I have insurance thru’ work, so I am finally facing getting a colonoscopy done. Are you really saying that the procedure should be 100% covered? (I know it’s supposed to be, but somehow I can’t quite bring myself to believe it.)
Can one do the “poop in a box” procedure for the first screening, or does that have to be a colonoscopy?
p.a.
I got shown pictures. Was too loopy to ask if I they were available for download. Is there a TMI tag for threads?
p.a.
@Miss Bianca: I’ve had polyps but never an indication of bleeding.
JaneE
@satby: Kaiser actually offers the option to the patient – you can have a colonoscopy every 10 years or the poop test every year. They gave me a sigmoidoscopy for my 50th birthday. After that experience I preferred the poop test, but with a positive result there wasn’t a choice in the matter. Now that I have a good colonoscopy, I get to forego any tests for 10 years. Yeah!
David J. Littleboy
The numbers in the article are wildly off. There are less than 20 colon cancer deaths per 100,000 population per year. Although that’s for the whole population, and colon cancer is only for us older folks. This Scientific American blog quotes a claimed number of _ONE_ life saved for 1000 colonoscopies at the cost of _FIVE_ serious complications.
http://blogs.scientificamerican.com/cross-check/why-i-wont-get-a-colonoscopy/
The consensus now seems to be that PSA testing does no good. I expect that the consensus on colonoscopies will go the same way, at least for people with no family history of related cancers.
dww44
@JGabriel: Agreed;I’ve had probably more of them than most folks on here. About 5 of them over the last 10 years or so, as one who suffers from diverticular disease. They almost always find polyps, which was the case last year. The prep is still the absolutely pits and by far the worst thing about the process. I’ve had issues with the anesthesia in the past but not so much for the last 3 or so. Wake up alert and not groggy.
Percysowner
My dad died of colon cancer, so my previous doctor was extra cautious. We did the Colonoscopy when I hit 55 AND we did annual poop tests. I moved a couple of years ago, and my new doctor is willing to rely on the colonoscopy alone. Basically I got used to taking my poop to the doctor once a year, it was no big deal.
Tee
True Poo story…had my first colonoscopy when I was 19. Ulcerative colitis whoopee. Life was grand until I hit 26…got engaged and started planning my wedding. Symptoms flair up GI says, well we need to scope you soon its been about 3 since we took a look…No go. So the day I scheduled is the day I leave to go to Orlando to meet my inlaws. And because I had to stop frequently we drove from Buffalo south. And ran into my favorite West Virginia town “Barium Springs”. I know now to guard my days after with a big sword….and an insane chihuahua. I go next fall. I figure with all the pieces and parts they have take out over the years they could build a gerbil at least!
satby
@TaMara (HFG): I think the complication I really didn’t need to know about was “gas explosion”. Can you imagine being the doctor that has to go out and tell a family that a “routine procedure” caused an explosion inside their loved one?
Richard Mayhew
@Miss Bianca: work insurance is funky. Talk to HR or the insurance company and get their answer in writing
sheila in nc
I know this is during work hours but I really need to respond to the people who don’t like the usual prep. Like Tee, I’m a longtime colonoscopy participant (40+ years of Crohn’s disease). I can’t keep the horrible GoLytely stuff down long enough to do the job. Here’s the Best Prep Evah: an 8.3 oz bottle of Miralax divided into two 64-oz bottles of Gatorade (any flavor EXCEPT RED). Follow the usual timing directions but drink the Miralax/Gatorade instead. Works like a charm and MUCH easier to get down.
J R in WV
@TaMara (HFG):
Thanks for that link, I think. ;-)
I had one some years back, Dr said after I was “very clean”. First thing I remember afterwards I was tying my shoes… fully dressed in the hall with wife and the Dr.
Feeling really good! Whatever they used made me very happy, glad it isn’t available at the store. It really wasn’t bad, even the “prep”, compared to a real GI problem.
Not planning to do it again, I have mild IBS but no one in my family ever had colon cancer.