The Business Group on Health, a healthcare policy advocate for large employers, surveyed its members last year about their benefit plans and healthcare strategies.
One of the data points that stood out is that the employers identified cancer as the largest share of their healthcare costs, and that 13% of them are seeing more late-stage cancer diagnoses, with 44% saying they expect to see that figure increase. President Joe Biden had just signed the Inflation Reduction Act into law which, in part, allows Medicare to negotiate certain prescription drug prices, generating debate about how the bill could affect the development of cancer treatments by pharmaceutical companies.
All of this should serve to remind us of one simple idea: let’s focus on screenings to prevent as many people as possible from even needing cancer drugs.
The impact of early detection
Colorectal cancer (CRC) is a good example of what’s possible when we focus on early detection. The American Cancer Society estimates that more than 153,000 cases of CRC will be diagnosed in the U.S. this year and that it will kill more than 52,500 people. But as sobering as those statistics may be, the five-year survival rate for CRC is as high as 90% if caught in its earliest stages, according to the American Cancer Society.
Colonoscopy allows for the detection and removal of slow-growing polyps that can eventually turn into cancer, a procedure the American Society for Gastrointestinal Endoscopy (ASGE) considers the “gold standard” for CRC screening. Other options exist for those who are unwilling or unable to undergo a colonoscopy, including an annual at-home fecal immunochemical test (FIT).
The U.S. Preventive Services Task Force (USPSTF) in 2021 lowered the recommended screening age for those at average risk from 50 to 45, and the Affordable Care Act required private insurers and Medicaid to cover the procedure with no out-of-pocket expenses. The change comes during a period when CRC cases have been increasing in people younger than 50.
More recently, the Centers for Medicare and Medicaid Services (CMS) approved rule changes that helped improve access to preventive screenings for more people. Medicare will now cover colonoscopies beginning at age 45 and eliminate cost-sharing for what are now deemed preventive colonoscopies following a suspicious or questionable FIT test.
The cost of cure vs. prevention
While we can debate how the cost of a colonoscopy can vary from state to state, what leaves little room for debate is the comparison between treating CRC and preventing it. Consider that the Centers for Disease Control and Prevention reports that the average cost to treat a newly diagnosed Medicare CRC patient can range anywhere from $40,000 to $80,000 depending on the stage and that the total annual costs for CRC care measures roughly $24 billion. A colonoscopy, recommended every 10 years starting at 45 for average-risk patients, is typically a few thousand dollars and would result in very little time away from work as compared to having cancer treatments. These are cost considerations that must be factored in as well when we think about total costs to society.
Prevention is less costly on a per-patient basis, but sometimes patients avoid it because of low awareness or even nominal costs, like co-pays for preventative care. Other factors, as well, may steer patients away from practicing preventive measures like having a screening colonoscopy. We need to consider and address logistical issues around CRC prevention such as finding a ride home after your procedure.
Barriers to prevention
Most endoscopy facilities in the United States require that patients have someone to drive them home after a procedure that uses sedation such as a colonoscopy. Studies have shown that something as simple as a lack of a ride home affects up to 41% of people referred for colonoscopy and contributes to a lack of follow-up after an abnormal FIT test. It’s often the case that the patient lacks family or friends who can take time off work to drive them home, highlighting the need to develop non-emergency medical transportation ride-share programs.
Preventive screenings face other pressures, including a legal challenge in Texas to a component of the Affordable Care Act that requires insurers to cover preventive services without cost sharing. While the plaintiffs in the case attacked the preventive care mandate in moral opposition to things like birth control and PrEP drugs, legal challenges like this run the risk of affecting millions of Americans in need of other forms of preventative healthcare like colorectal cancer screenings.
The federal judge in that case ruled that preventive care coverage was unconstitutional because members of the USPSTF are not appointed by the president and confirmed by the senate. The ruling would likely apply to recommendations made after 2010, including lowering the recommended screening age for colorectal cancer and revised lung cancer screening guidelines.
Other barriers to colonoscopy have included no usual source of care, inadequate insurance coverage and out-of-pocket expenses, issues that more greatly affect those with fewer financial resources – the very population meant to benefit from the ACA. Access to preventive care like CRC screenings should not be available based solely on socio-economic status or be hindered by unproductive debate.
As more preventative tools come to market, will we get our preventive care strategy to a good place? Diagnostic tools and methods continue to evolve and improve, such as being able to screen for lung cancer at the outer peripheries of the lungs, where cancer can be diagnosed at its earliest stages. But lung cancer screening rates remain low despite changes to USPSTF guidelines that make more at-risk patients eligible for preventive screenings.
Regardless of the type of cancer or advancements in their treatments, education centered on prevention remains a critical component to improving patient outcomes. While improving quality-of-life should be enough to drive the message of prevention, perhaps ongoing debates over what to do about rising healthcare costs can help focus more attention on the importance of investing an ounce to prevent disease, before having to pay pounds to cure it.
Paul Skodny is Executive Director, Health Economics and Market Access at Olympus Corporation of the Americas.