New research indicates that mailing colorectal cancer screening kits to Medicaid enrollees is a cost-effective way to boost screening rates. The findings are published early online in CANCER, a peer-reviewed journal of the American Cancer Society (ACS).
Colorectal cancer is one of the most commonly diagnosed cancers, but routine screening (such as colonoscopies and at-home stool testing) can identify cases early, when treatment is most effective. Despite recommendations that adults undergo regular screening from ages 50 to 75 years, more than one-third of eligible Americans are not up to date with screening. Strategies to boost screening in these adults include mailing screening reminders and mailing fecal immunochemical test (FIT) kits, which detect blood in stool samples.
To estimate and compare the costs and effectiveness of these two strategies in low-income Medicaid-insured populations, a team led by Alison Brenner, PhD, MPH, and Stephanie Wheeler, PhD, MPH, of the University of North Carolina at Chapel Hill’s Lineberger Comprehensive Cancer Center, developed a simulation model of 35,000 Medicaid-insured adults aged 52 to 64 years who were overdue for colorectal cancer screening to project costs and benefits over time associated with receiving either a mailed reminder or a mailed reminder plus a FIT kit. These simulations were based, in part, on a randomized trial conducted by these investigators comparing these strategies in the Medicaid population.
Over the course of one year, the number of colorectal cancer screenings, including both FITs and screening colonoscopies, was higher for the mailed reminder plus FIT alternative (23.2 percent) than for the mailed reminder-only alternative (15.8 percent).
The mailed reminder plus FIT alternative saved costs compared with the mailed reminder-only alternative from the Medicaid/state perspective because some patients who received only the reminder would schedule a more costly colonoscopy, which Medicaid must reimburse, rather than a FIT.
From the health clinic/facility perspective, the mailed reminder plus FIT alternative required an additional cost of only $116 per person screened over the mailed reminder-only alternative. This cost falls within the range of what decision-makers would typically be willing to pay for an additional person to be screened for colorectal cancer.
“By investing in sending the test kits with the reminder letters, health departments are expected to successfully screen more individuals for colorectal cancer at relatively low incremental costs, and Medicaid organizations are expected to actually save costs per additional person screened,” said Dr. Wheeler. “This analysis provides strong evidence that health departments and payers like Medicaid can substantially improve colorectal cancer screening in low-income and medically underserved populations at a reasonable cost, even given limited budgets, through the implementation of mailed FIT programs.” Dr. Wheeler noted that medically underserved populations are more likely to die from colorectal cancer than other groups and extending screening to them in an efficient manner may help address this disparity.
The findings are especially timely considering the recent need for alternatives to face-to-face visits with physicians during the COVID-19 pandemic. “Many aspects of preventive health care have moved to virtual delivery or mailed outreach delivery for the time being, and it is quite likely that some of these services will never fully return to in-person, visit-based delivery,” said Dr. Brenner. “Decision-makers critically need guidance on how to allocate resources for virtual or mailed outreach care delivery.” This study provides such guidance for one important preventive service: colorectal cancer screening.
An accompanying editorial states that “it is time for incentives and laws that motivate payers to cover full screening costs and evidence-based programs to increase screening toward a goal of at least 80% colorectal cancer screening in every community.”