Background: A consensus has emerged that average-risk adults 50 years of age or older should be screened for colorectal cancer (CRC). Objectives: To describe health plans' coverage policies, guidelines, and organized programs to promote CRC screening.
Study Design and Methods: Review of data from the National Cancer Institute Survey of Colorectal Cancer Screening Practices, administered to a national sample of health plans in 1999-2000. The survey inquired about coverage policies for fecal occult blood testing, sigmoidoscopy, colonoscopy, and double-contrast barium enema; the nature of any guidelines the plan had issued to its providers on CRC screening; and systems for recruiting patients into screening and for tracking and reporting the results of screening and follow-up procedures.
Results: Of 346 eligible health plans, 180 (52%) responded. Nearly all health plans covered at least 1 CRC screening modality. Plans were most likely to cover fecal occult blood testing (97%) and least likely to cover colonoscopy (57%). Sixty-five percent had issued guidelines on CRC screening to providers. One quarter had a mechanism to remind patients that they are due for CRC screening, but fewer had systems for prompting providers, contacting noncompliant patients, or tracking completion of screening.
Conclusions: Health plans have the ability to provide organizational infrastructure for a broad range of preventive services to well-defined populations. However, few health plans had all 3 essential CRC screening delivery components—coverage, guidelines, and tracking systems—in place in 1999-2000.
(Am J Manag Care. 2004;10:273-279)
Despite consensus among expert groups in the United States that average-risk adults 50
years of age or older should be screened for colorectal cancer (CRC),1-3 national data reveal
that CRC screening rates are lower than those for breast and cervical cancer by nearly one half or
more.4 A complexity of factors involving patients, providers, and the healthcare delivery system
contribute to the underuse of CRC screening by older adults in the United States.5,6 Because
more than half of the US population is enrolled in health plans and many of these organizational entities
are able to deliver preventive services to defined populations, health plans are a potentially important
vehicle for increasing CRC screening rates nationwide.7,8 However, data are lacking to describe
the extent to which health plans systematically provide CRC screening as a preventive service to their
We evaluated data from the National Cancer Institute Survey of Colorectal Cancer Screening
Practices, a comprehensive survey of primary care and specialty physicians and health plan medical
directors that was designed to provide current, nationally representative data on CRC screening in the
United States and to identify barriers to screening in community practice.9 Herein we describe
health plans' coverage policies, use of guidelines for CRC screening, and implementation of systems for CRC
screening delivery and monitoring.
We surveyed a nationally representative sample of health plans in 1999-2000, using a
comprehensive database of US health plans obtained from SMG Marketing Group, Inc, as the sampling
frame.10 The study population was defined as health plans offering medical/surgical or
full-service products. Plans providing only Medicaid coverage were excluded because their coverage and
services are likely to be oriented primarily to a specific population (ie, children and women of
childbearing age) for which CRC screening has little relevance. The corporate parents of local plans also
were ineligible for the survey.
The target population for the survey comprised 1916 local plans. Health plans were
organized into 3 main strata for sample selection. The first stratum contained all plans listed in the
sampling frame database as having > 1 000 000 members (n = 24). The second stratum contained plans with
< 1 000 000 members and for which 1 medical director was responsible for more than 1 plan (n = 935). The
third stratum contained all remaining plans in the target population (n = 606). All plans in the first
stratum were selected with certainty. For each medical director represented in the second stratum, 1 plan
was randomly selected. This procedure was adopted to ensure adequate representation of very large plans,
and to avoid the respondent burden entailed in the receipt of multiple surveys by those medical directors
who manage multiple health plans. After sorting by US Census region (Northeast, North Central, South, West)
and plan size, a random sample was drawn from the third stratum. The survey's final sample size of 346
health plans was designed to provide estimates of population proportions within ±6% at a 95%
Medical directors of study plans were sent an advance mailing in the fall of 1999 that
included a cover letter describing the objectives of the survey, letters of support from 3 medical
societies and the US Surgeon General, and a postcard with a stamped return envelope on which medical
directors were asked to verify their contact information and indicate their preferred mode of response to
the survey (ie, mail, fax, telephone, or secure Internet Web site). Medical directors who responded to the
advance mailing were sent a subsequent mailing that included the mail or fax version of the questionnaire
or instructions on how to complete the survey by telephone or Internet, depending on their stated
preference. Approximately 6 weeks later, medical directors who did not respond to the advance mailing were
sent a followup mailing containing the mail version of the questionnaire. A second follow-up mailing of the
questionnaire was sent by express mail to nonrespondents in February 2000. Telephone follow-up of
nonrespondents was undertaken in March and early April 2000. The survey took approximately 20 minutes to
complete; no monetary response incentive was provided.
Because of the trend toward diversification of health plans into multiple model types,
medical directors representing a plan comprising more than 1 model type were asked to respond for the
plan's predominant model type. Survey questions regarding plan benefits for preventive services were
specific to "patients other than Medicare beneficiaries" because the Medicare program provides a
standardized benefit package for beneficiaries who are enrolled in health plans. More details on the survey
can be found at: http://healthservices.cancer.gov/surveys/colorectal. The study received approval from the
institutional review boards of the National Cancer Institute and Abt Associates, Inc.
We used descriptive statistics to examine health plans' coverage policies and use of
guidelines for CRC screening and implementation of systems for CRC screening delivery and monitoring. We
used contingency tables with chi-square tests to assess selected plan characteristics that might be
associated with coverage policies, guidelines, and organized programs to promote CRC screening.
Characteristics of interest included ownership (for-profit vs not-for-profit), model type (group/staff vs
network/independent practice association vs preferred provider organization/point-of-service plan/other),
accreditation (yes vs no), and method of primary care physician compensation (capitation vs other). A
sample weight that accounted for the probability of selection into the sample as well as a slightly higher
rate of nonresponse among for-profit plans was assigned to each respondent. Sampling weights were applied
in the statistical analyses to permit generalization of results to the population of local health plans in
the United States that provide full-service or general medical/surgical coverage.
A total of 180 health plan medical directors responded to the survey (response rate =
52%). Characteristics of responding plans are shown in Table 1.
Coverage of Preventive Services, Including Colorectal Cancer Screening Modalities
Most medical directors indicated that their plans provided coverage for selected office
and preventive care services, including routine acute care physician visits, screening mammograms, prostate
cancer screening with the prostate-specific antigen (PSA) test, and CRC screening with fecal occult blood
testing (FOBT), flexible sigmoidoscopy, colonoscopy, and double-contrast barium enema (DCBE) (Table
2). For CRC screening with FOBT, very few plans (<1%) restricted their coverage to patients
designated as high risk. However, for more invasive and expensive CRC screening procedures, plans were more
likely to restrict coverage to high-risk patients. For example, 35% of the 152 plans that covered CRC
screening with colonoscopy did so only for high-risk patients. The same was true of 17% of the 153 plans
that covered DCBE and 9% of the 172 plans that covered sigmoidoscopy. In 85% of covering plans, patients
incurred an out-of-pocket charge for a routine acute care physician visit. This requirement was less common
for screening procedures, however, with slightly more than 50% of covering plans assessing out-of-pocket
charges for sigmoidoscopy or colonoscopy, 44% for PSA testing, and <40% for mammography, FOBT, or DCBE.
Use of Guidelines or Protocols for Colorectal Cancer Screening
Sixty-five percent (n = 128) of plans had issued guidelines to providers on the topic of
CRC screening, with slightly more than half recommending more than 1 CRC screening modality. Ninety-six
percent of these guidelines covered asymptomatic, average-risk patients. Most (88%) were adopted from
guidelines developed elsewhere, primarily those of the 1996 US Preventive Services Task Force.11
Of the plans that had disseminated CRC screening guidelines to providers, most covered
FOBT and sigmoidoscopy, whereas relatively few covered colonoscopy or DCBE (Table 3). For those
modalities included in plan guidelines, nearly all plans (≥87%) specified starting ages and screening
intervals. Considerably fewer (≤20%) specified an age at which screening could be discontinued or the
provider types that should conduct screening with the modality. Few plans (≤28%) included in their
guidelines specific recommendations for the diagnostic evaluation of positive FOBT, sigmoidoscopy, or DCBE
screening tests. Of the plans that had issued guidelines that included sigmoidoscopy, colonoscopy, or DCBE,
the modality covered was almost universally delivered within the plan rather than through out-of-plan