UM researchers measure the cost of follow-up examinations after free cancer screening


As the White House puts cancer prevention and early treatment at the center of its renewed Cancer Moonshot initiative, recent research from the University of Michigan offers insights policymakers could use to ensure more cancers are diagnosed earlier and inequalities are reduced.

The research relates to the part of the Affordable Care Act that makes certain cancer screenings and other preventive measures available to patients free of charge. This provision is specifically designed to prevent financial obstacles such as co-payments and insurance plan deductibles from getting in the way of detecting early signs of trouble.

But what if the results of the free initial exam are abnormal and more scans or tests are needed to determine if it really is cancer?

The incidence and potential cost of this side of cancer screening are the focus of recent studies by UM researchers and their colleagues, who have measured the costs patients incur for necessary follow-up screening after receiving a free screening for colon, cervical, lung, or breast cancer .

“For those who have an abnormal initial cancer screening test, there is no point in putting up a barrier for that person to complete the diagnostic process,” said A. Mark Fendrick, MD, who helped lead the new studies and UM’s center leads for value-based insurance design. “The primary goal of cancer screening is to identify those people who might benefit from early detection.”

He and the teams behind the recent studies aimed to inform policies that could remove financial barriers to increasing the number of people — particularly women and members of underserved populations — who follow up on abnormal test results. Failure to complete the screening process can allow the cancer to progress, potentially leading to poorer patient outcomes and high medical costs.

Colorectal Cancer Prevention

The two new colorectal cancer screening studies were published in January Reports on preventive medicine and December one JAMA network open.

Many average-risk adults choose to use stool-based screening tests, e.g. B. those that look for blood or DNA markers of colon cancer because they require less time and preparation than a screening colonoscopy and they can be done at home. These options, as well as screening colonoscopy, are available at no cost. Clinical guidelines state that those who test positive on a stool test need a follow-up colonoscopy.

the JAMA network open examined how often patients are billed for such a follow-up colonoscopy and what the patients actually paid out of pocket. It is data from nearly 88,000 people with private insurance or Medicare coverage who underwent a chair-based test.

A total of 16% of them subsequently underwent a colonoscopy. During this colonoscopy, almost 60% of the group had at least one polyp removed because it could be cancerous or precancerous.

More than half of privately insured patients and 78% of Medicare participants had to pay out of pocket for their follow-up colonoscopy. It averaged around $100, regardless of what type of insurance the patients had. Those who had polyps removed paid more than those who didn’t.

the preventive medicine Study based on simulation using patient data suggests follow-up colonoscopies after positive stool tests could save up to four times as many years of life from colorectal cancer and prevent twice as many deaths compared to the same number of people who have colonoscopies as the first colorectal screening test to have. This is because those who have a colonoscopy after an abnormal stool test have a higher risk of actually developing cancer than those who have a primary screening colonoscopy.

The studies helped formulate a new federal rule requiring private health insurance plans to pay for follow-up colonoscopies at no cost to the patient, effective May 31, 2022.

This is an extremely important policy that could increase screening uptake, improve equity and ultimately save lives, which are stated goals of the Cancer Moonshot. Removing a cost barrier starting this spring could help hundreds of thousands more people avoid the dilemma of deciding whether they can afford to follow up on their first positive colorectal screening test. However, the new rule does not apply to Medicare beneficiaries and does not apply to other types of cancer where screening is fully covered for some or all people: breast, lung and cervical cancer.”

A. Mark Fendrick, Physician of General Internal Medicine, Michigan Medicine – University of Michigan

Fendrick and colleagues published three studies documenting the frequency of follow-up and costs for patients with these cancers:

breast cancer

The UM team and colleagues from the University of Washington have looked at the follow-up costs of women with worrisome findings on their screening mammograms. Their results were published in 2021 JAMA network open.

Screening mammograms for certain women are free of co-payments since the Affordable Care Act provision was enacted. But between 2010 and 2017, the study shows, women who received additional imaging and biopsies after their screening mammograms faced ever-increasing costs of their own.

The study is based on data from 325,900 women between the ages of 40 and 64 with occupational health insurance who underwent 418,378 additional imaging tests or breast procedures following screening mammography.

Almost all had a second mammogram, called a diagnostic mammogram, after the screening scan. From there, many did more scans and even biopsies to remove a bit of tissue for examination to see if they had cancer.

Those who later had a biopsy paid the most out of their own pocket, increasing from an average of $91 in 2010 to $152 in 2017, regardless of whether they had an ultrasound or MRI before the biopsy – Had imaging.

lung cancer

A team led by UM radiologist Ruth Carlos, MD, and Fendrick documented the cost of follow-up exams for patients whose screening CT scan showed signs of possible lung cancer, and the results were published last fall in the Journal of American College of Radiology released. Such scans are fully covered for people who meet criteria for a specific level of past and current tobacco use.

In 2021, the US Preventive Services Task Force recommended expanding the populations eligible for CT screening for lung cancer. The changes were made to reduce inequalities in cancer screening among women and people of Black, Indigenous or Hispanic origin.

Overall, 7.4% of patients who had lung cancer screening CT had at least one follow-up invasive procedure. Over half of them were asked to pay something, sometimes hundreds or even thousands of dollars out of their own pocket, depending on the specific tests required to complete the screening process.

cervical cancer

In a 2022 article published in Obstetrics & Gynecology, Fendrick worked with obstetrician-gynecologist Michelle Moniz, MD, M.Sc., and others to investigate what women paid out-of-pocket for a type of cervical exam called colposcopy. A colposcopy, which is done after a Pap smear, HPV test, or routine cervical exam shows abnormal results, may include a biopsy or other procedures.

Women who had a no-op colposcopy paid an average of $112, while those who had cells removed for further testing paid an average of $155. Those who had additional procedures faced hundreds of dollars more in costs—and those costs rose sharply over the 13 years studied. By 2019, a woman who had additional care beyond a biopsy could face a total bill of almost $1,000.

“The recently released federal policy to eliminate cost sharing for follow-up colonoscopy after a commercially insured individual receives a positive, noninvasive test result is an important step forward,” said Fendrick. “However, there is still work to be done and evidence to support comparable guidelines to eliminate the expense of follow-up testing for the other three cancers for which initial screening tests are fully covered.”


Michigan Medicine – University of Michigan

Magazine reference:

Fendrik, AM, et al. (2021) Out-of-pocket expenses for colonoscopy after noninvasive colorectal cancer screening in US adults with commercial and Medicare insurance. JAMA network open.


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