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The American Journal of Managed Care July 2015
Low-Value Care for Acute Sinusitis Encounters: Who's Choosing Wisely?
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Risa Lavizzo-Mourey, MD, MBA, president and CEO, The Robert Wood Johnson Foundation
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Shivan J. Mehta, MD, MBA; Daniel Polsky, PhD; Jingsan Zhu, MBA; James D. Lewis, MD, MSCE; Jonathan T. Kolstad, PhD; George Loewenstein, PhD; and Kevin G. Volpp, MD, PhD
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The Value of Colonoscopic Colorectal Cancer Screening of Adults Aged 50 to 64
Kathryn Fitch, RN, MEd; Bruce Pyenson, FSA, MAAA; Helen Blumen, MD, MBA; Thomas Weisman, MD, MBA; and Art Small, MD
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The Value of Colonoscopic Colorectal Cancer Screening of Adults Aged 50 to 64

Kathryn Fitch, RN, MEd; Bruce Pyenson, FSA, MAAA; Helen Blumen, MD, MBA; Thomas Weisman, MD, MBA; and Art Small, MD
Screening commercially insured individuals for colorectal cancer is a high-value service, costing less per year of life saved than breast or cervical cancer screening.
Colonoscopies, cancer diagnoses, and non-cancer costs were assumed to occur at the beginning of the year. Mortality was assumed to occur at the end of the year. Future life expectancies were tabulated using mortality rates that varied by age and sex, stage, and duration of CRC.

The model follows individuals for up to 15 years (for the cohort that turned age 50 years in 1998) and reaches a steady state for spending and cancer incidence in 2013. At this steady state, all ages in the 50-to-64-year-old cohort have been subject to the chosen screening scenario. For each scenario, costs and future life expectancy were tabulated for each individual alive in 2013. Under our assumption that cost trends equal discount rates, for any given screening scenario, all spending would remain constant after 2013, as would the number of cancer cases by stage and the population. Consequently, for cost and cost-benefit analysis, we simply tabulated results for 2013. Neither inflationary adjustments nor discounting was applied or necessary.

RESULTS

Cost/Benefit Analysis

We present the results of the simulation model in Table 4, calibrated to a typical health plan with 100,000 commercial members, which would include 23,000 members aged 50 to 64 years. Compared with no screening, 50% adherence (our baseline) with the recommendations for colonoscopy (age 50 and 60 years) would cost $11,562 per life-year saved and result in an additional 4 individuals alive in 2013 who are aged 50 to 64 years. Annual spending for colonoscopies would be $4.07 million and would yield 252 future life-years saved. Increasing colonoscopies to 70% would increase life-years saved to 348 and would result in 7 more individuals alive than would be the case with no screening. In the screening scenarios, the life-year calculation considers the individuals who are alive and those who will not develop CRC because of screening, as well those whose earlier diagnosis will reduce their mortality.

Sensitivity tests are shown in Table 4. Increasing or decreasing cancer costs by 10% produced costs per life-year saved of $10,758 or $12,778, respectively. Increasing or decreasing colonoscopy costs by 25% produced costs per life-year saved of $15,853 or $7684, respectively. Reduced or improved screening effectiveness produced costs per life-year saved of $14,816 or $9583, respectively.

Colorectal Cancer Screening Versus Other Cancer Screenings

Table 5 compares the cost per life-year saved of well-established cancer screenings with that of CRC screening. We applied medical inflation adjustments to bring the published figures for cervical, breast, and lung cancer up to the price levels associated with our 2013 estimate for colorectal cancer.15  This was necessary because prominent studies of the cost effectiveness of cancer screening were conducted more than 10 years ago.

As shown, the cost per life-year saved projected to 2013 dollars was $50,162 to $75,181 for cervical cancer, $31,309 to $51,274 for breast cancer, and $19,805 for lung cancer. In the baseline scenario, the 2013 estimate for the cost per life-year saved was $11,768 for colorectal cancer.

DISCUSSION

We used actuarial techniques to study the value to commercial payers of screening and prevention of CRC using colonoscopy. We found that the cost per life-year saved, assuming that 70% of the population was screened, was $11,768, which is comparable to our estimate for cost per life-year saved for lung cancer screening with low-dose CT scanning.16,17

We applied sensitivity testing to our model for several inputs. We found that cost per life-year saved, if the costs of colonoscopy were 25% lower than our baseline scenario, would be $7684, while it would be $15,853 if the costs of colonoscopy were 25% higher. We also found that cost per life-year saved, if the cost of cancer care varied by 10% either way from baseline, would be $10,758 to $12,778. Additionally, changing the effectiveness of screening yielded estimates of cost per life-year saved of $9583 to $14,816.

Previous studies of cost-effectiveness of colorectal screening have also found that screening for CRC is cost-effective compared with no screening. The cost-effectiveness of CRC screening has improved over time, with newer studies showing cost per life-year gained ranging from $19,000 to actually being cost-saving, while older studies have suggested a range of $13,000 to $32,000 cost per life-year gained.18

In older studies, the choice of optimal testing strategy was very sensitive to variation in the costs of the screening tests. In 2009 dollars, the costs for colonoscopy in US studies ranged from $460 to $1570. Four studies using Medicare costs used $533 as the cost of colonoscopy18; a study from 2000 that analyzed a mixed commercial/Medicare population used a blended rate derived from Truven Health MarketScan Research Databases and Medicare 5% sample claim data and described the range as $779 to $1192.19 Another study from 2000 chose $1570, based on information from a regional HMO.20  The incremental cost of polypectomy in US studies ranged from $162 to $480 for Medicare-derived cost,18 and from $442 to $786 for costs in the regional HMO.20 Some studies included the costs of treatment of the most common serious complication of colonoscopy—perforation—and those estimates ranged from $342 to $50,193; some models did not include perforation. Cost of care for CRC was also variable across studies, with some assuming that cost did not vary by stage; others input actual costs from HMO or Medicare, depending on state of disease and type of care.21

Our approach to costs was to use actual costs of medical care based on a database of claims paid by commercial health insurers in 2011. We captured all costs on the day of the screening colonoscopy, not simply the professional component of the procedure. Likewise, we based the costs of treatment of CRC diagnosed at the various SEER stages (local, regional, distant) on actual claims data. Furthermore, we placed the costs of CRC prevention, screening, and treatment in the context of the total spending by commercial health insurers. We did not consider the societal impact of life-years saved, such as productivity, taxes, or benefits. We did tabulate life-years saved beyond age 65, but we did not consider that screening the population aged 65 years or less will reduce the burden of CRC on the federal Medicare program.

Limitations

Our methodology and model have several limitations. No single source provided all necessary data, so we relied on multiple sources that may be confounding. For example, we applied sojourn times between CRC stages from the literature, but the studies were not based solely on people aged 50 to 64 years. Additionally, for the cost of CRC treatment, we assigned CRC stage based on treatment. Because some patients may not receive guideline-concordant treatment, this may lead to some level of stage misclassification.

We used SEER data for incidence and mortality estimates by age and sex, and these data include individuals who may not have commercial insurance. Any differences in population incidence and mortality for CRC by source of healthcare funding would not be accounted for.

While statistics on the risk reduction of many interventions exist from randomized controlled trials, no such figures are available for the stage shift or incidence reduction associated with full adherence to the colonoscopy regimen. The “best practice” incidence rates we developed were based on mathematical processes applied to the historical changes in CRC incidence rates, which we associated with the implementation of CRC screening.

For ease of modeling, we considered only colonoscopies, but other modalities are also recommended, including screening for fecal occult blood, visualization with sigmoidoscopy, or virtual colonoscopy with low-dose CT. We assumed the current reported CRC adherence rate of about 50%, which is defined to include screening modalities other than colonoscopy and a fairly loose definition of adherence. It is likely that truly effective screening is lower than 50%, which could mean the opportunity for reducing incidence and stage shifting is larger than we report. We note that the ability of colonoscopy to both reduce incidence of CRC and to detect CRC earlier means our results could be seen as showing somewhat greater impact than if other methods were used.

Our findings are based on a model that has reached a “steady state,” which has advantages in transparency in that it avoids the need for inflationary or present value (discounting) adjustments. It is also relatively clear for its application to payers; however, it has disadvantages in that it tabulates only future life-years saved (including life-years after age 65 years), not life-years saved in the past. It also does not consider the past investment needed to produce the “steady-state” results, only the ongoing costs. This is, in effect, a “snapshot analysis” that parallels typical health plan annual fiscal reporting.

Our scenarios assume that screened individuals obtain colonoscopies at ages 50 and 60 years. Of course, in reality, people do not always get screened on schedule. We made no explicit allowance for the many variations that can occur that could reduce colonoscopy effectiveness, such as inadequate bowel preparation, polyps that were missed by the colonoscopist, or complications from colonoscopy. Some of these variations are implicitly captured by our model’s calibration to the 2007-2009 incidence rates and the assumption that those rates reflect about 50% adherence to recommended CRC screening.

Some individuals with adenomas are diagnosed with villous type where the recommendation for additional screening is 3 years versus the 5-year recommendation for nonvillous type. Because the incidence of villous adenoma is not reported by age in the literature, we assumed a 5-year surveillance screening colonoscopy for every adenoma detected at the age 50 years colonoscopy screening. This could cause our CRC screening costs to be somewhat underestimated. However, along with 3-year screening there would likely be reduced CRC costs with earlier detection of colon cancer. The cost per life-year saved ($11,768; again, assuming 70% of the population was screened), is lower than most estimates of cost per life-year saved for breast and cervical cancer.22-24

CONCLUSIONS

CRC is a disease associated with substantial medical and economic burden, and it is in large part preventable or diagnosable at a localized stage with screening colonoscopy and resection of adenomas. In our investigation of CRC screening for the US population aged 50 to 64 years, using actual screening and treatment costs, we found that both the cost of screening and the cost per life-year saved compare favorably with published rates for other cancer screenings. Under the Affordable Care Act (ACA), preventive services including colonoscopy are considered essential health benefits for fully insured groups, including group and individual products offered on or off the healthcare exchanges, and require no patient cost sharing. While some of the self-insured population covered under Administrative Services Only plans may not be subject to the same ACA requirements and obligations as fully insured groups, employers utilizing these arrangements should note the overall relative value of screening and consider the enhanced benefits of encouraging colorectal cancer screening among employees. In this context, commercial insurers, as well as employers, should continue to consider CRC screening with colonoscopy to be of substantial value.

 
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