As Economy Worsens, Financial Factors May Hinder CRC Screening

Even as screening rates for colorectal cancer (CRC) remain down as a result of low patient awareness of benefit or their choice to forego a potentially unpleasant procedure, that low rate may decrease further because of the worsening national economic situation. The reasons for this decrease are varied.

A comprehensive review of more than 100 studies conducted between 1998 and 2009 found that high out-of-pocket costs, lack of health insurance, and low household income were some of the reasons people did not get screened.¹ Lead author Debra Holden, PhD, acknowledged that access to care is only part of the problem; the study, which was funded by the Agency for Healthcare Research and Quality, emphasized the need for policy-level interventions to improve screening.

A second recent study found that despite expanded Medicare coverage for CRC screening, the procedure was still underused for a number of reasons, including lack of supplemental health insurance.²

In addition, as new technologies for CRC screening are developed, financial obstacles related to whether these new technologies are covered by insurers may hamper screening. Computed tomographic colonography (CTC) can be used for CRC screening, but the Centers for Medicare & Medicaid Services has so far denied coverage, saying “the evidence is inadequate to conclude that CT colonography is an appropriate colorectal cancer screening test”.³ A study of 68 patients surveying their willingness to pay for CTC found that they were not willing to pay when not covered by insurance.⁴ What they were willing to pay ($244 mean, $150 median) is well below the currently charged procedural rate (between $500 and $1500). But because the CTC test is less invasive, there is thinking in some quarters that it could increase screening rates, especially for those at higher risk of disease.⁵

Legislative Remedies
Legislation to cover CTC as a colon cancer screening technique was introduced by Rep Danny Davis (D-IL) on May 28, 2010 (HR 5461), and this is now under review by House subcommittees. Another, more general policy remedy to address cost barriers was introduced in the last session of Congress. Rep Kay Granger (R-TX) authored and introduced legislation intended to make grants that provide CRC screening to individuals aged 50 years or older or who are at high risk for such cancer. The legislation would also develop and disseminate public information and education programs for the detection and control of CRC and promote the benefits of receiving screenings through this program. Called the Colorectal Cancer Early Detection, Prevention, and Treatment Act (HR 1189), the legislation was introduced February 25, 2009, and has been referred to committee as the first step in the deliberative process.

References

1. Holden DJ, Jonas DE, Porterfield DS, et al. Systematic review: enhancing the use and quality of colorectal cancer screening. Ann Intern Med. 2010; 152:668-676.
2. Doubeni CA, Laiyemo AO, Young AC, et al. Primary care, economic barriers to health care, and use of colorectal cancer screening tests among Medicare enrollees over time. Ann Fam Med. 2010; 8:299-307.
3. Centers for Medi care & Medicaid. Decision memo for screening computed tomography colonography (CTC) for colorectal cancer (CAG-00396N). May 12, 2009. www.cms.gov/mcd/viewdecisionmemo.asp? from2=viewdecisionmemo.asp&id=220&. Accessed September 13, 2010.