In managed care, “value” drives our business. We are constantly in pursuit of new technologies, procedures, and strategies that deliver the highest quality care and greatest benefit while keeping costs affordable for our members. As part of this, we regularly advocate for preventive care services known to improve outcomes for patients and deliver long-term gains for our members.
Screening for cervical cancer is a perfect example of how preventive care services offer the best outcome and value for our members. Since the introduction of the relatively inexpensive Pap test, cervical cancer rates have declined steadily and deaths have dropped by 50%. The test is covered by every public and private payer, and for good reason.
On the other hand, while colonoscopies also are covered and highly effective at finding cancer and early-stage polyps, the preparation involved in this procedure makes it unwelcome for many as a screening tool for colorectal cancer (CRC).
As a result, although national guidelines call for men and women at average risk for the disease to begin screening at age 50 for CRC, by some estimates, compliance is a mere 38%. So although the benefit is clear, the fact that so many people avoid CRC screening because they don’t want to get a colonoscopy undermines its value.
The low rates of screening compliance mean that in more than half of all cases, CRC is not detected until the late stages when treatment is difficult and expensive, and survival rates are low. CRC will claim close to 50,000 lives this year, making it the second-leading cause of cancer-related death in the United States.
The good news is that there are more screening options available now—including several non-invasive choices, such as the stool-DNA test (Cologuard) and virtual colonoscopy. Further, health regulators are taking action to broaden patient access to these tests while rewarding providers, payers, and health systems for leading the effort to get more Americans tested.
Specifically, the National Committee for Quality Assurance updated its Healthcare Effectiveness Data and Information Set (HEDIS)
with new guidance on CRC screening. HEDIS quality measures are used by more than 90% of health plans to promote evidence-based healthcare and quality service to patients by assessing the performance of health plans on multiple measures.
The new HEDIS guidelines give doctors, health systems, and health plans greater incentive to offer and cover multiple screening methods, including newer options. Providers who increase the number of patients screened for CRC through June 2017—by whatever method the patient is willing to comply with—will receive higher quality ratings during their 2017 HEDIS audit and be eligible for quality-of-care bonuses.
The HEDIS measures come on the heels of updated guidelines issued in June by the US Preventive Services Task Force (USPSTF). Unlike previous guidelines, which assessed individual tests based on analysis of benefits and harms, the new recommendation gives an “A” rating to screening in general for all adults aged 50 to 75 who are at average risk. This means that newer methods now are considered on par with colonoscopy. Per the Affordable Care Act, all screening modalities included in the USPSTF guidelines must be included in the preventive services package of all US healthcare insurers with no associated patient out-of-pocket expenses—meaning no copays and deductibles.
The new HEDIS and USPSTF guidelines represent a collective push by regulators to promote value-based preventive care. In addition, they align with recommendations from other preeminent organizations, including the American Cancer Society (ACS) and CMS, which have covered newer options like stool-DNA since it was approved by the FDA.
Physicians Plus is committed to doing our part to get as many people screened for CRC as possible. As part of this pledge, we include stool-DNA under our benefit plans. Stool-DNA is designed to detect both blood and altered DNA from cancerous or precancerous cells shed into the stool as it passes through the colon. Members can complete the test in the comfort of home without any preparation and send it back to the lab for analysis via UPS. Those with a positive result are referred for a diagnostic colonoscopy, and we are rewriting our plans to ensure that this second test also is covered in full. Members with a negative result should continue to participate in a screening program at an interval and with a method that is appropriate for them based on conversations with their primary care practitioner.
Our evaluation of stool-DNA found clear benefit in offering it as a convenient, noninvasive and cost-effective alternative to colonoscopy. Not only does stool-DNA cost less (at $649 it’s about 11% of the cost of a colonoscopy), but the test also is effective in finding cancer. Clinical data from a 10,000 patient pivotal study published in the New England Journal of Medicine
found that the test has a 92% sensitivity with 87% specificity.
What’s even more impressive is that patient compliance with stool-DNA is nearly 70%— approximately 30 percentage points higher than colonoscopy. That equates to more patients who will be screened as recommended and many more who have the potential to catch their cancer earlier and whose lives may be spared.
For us, this innovation in CRC screening hits at the heart of what managed care is all about and represents the very definition of value in healthcare.