Tuesday, May 6, 2008

Consumer Directed Health Plans, Cancer Screening, Colonoscopies and Disease Management

In the latest Annals of Internal Medicine is a noteworthy report on the impact of the adoption of a Consumer Directed Health Plan (CDHP) on cancer screening. Many readers may recall that CDHPs are both admired and reviled for helping consumers put "skin in the game."

Performed at the award winning Harvard Pilgrim Health Care, the study examined HEDIS rates for mammograms, paps and colon cancer screening over the year before and the year after for just over 3100 persons who were switched into a CDHP. The rates were compared to persons who remained in a standard HMO. The CDHP had first dollar coverage for mammograms, paps and fecal occult blood testing but not colonoscopy, flexible sigmoidoscopy or double contrast barium enema. To the authors’ credit a sensitivity analysis restricted the sample to members who were less likely to have had a previous colorectal cancer screening.

Mammogram and pap smear rates were no different in the two groups. In the control group, the colonoscopy rate went up, while in the CDHP, it dropped. In the meantime, the covered fecal occult blood test went up, giving the authors the reasonable impression that the enrollees in the CDHP “switched” from the expensive colonoscopy to the less expensive (and covered) occult blood test. The degree of change in screening rates in absolute terms was no more than three percentage points.

So, are Consumer Directed Health Plans bad for colon cancer screening? The Disease Management Care Blog doesn’t necessarily so:

  • What’s wrong with health care consumers making an informed decision to switch from gold plated screening to just OK screening? Lines have to be drawn somewhere.
  • 7.1% of the CDHP patients apparently agreed that colonoscopy screening was necessary and took advantage of it, versus 9.6% of the persons with first dollar coverage. It’s not like colonoscopy rates caved in.
  • The CDHP went to the Harvard Pilgrim Health Care HarvardPilgrim.org web site and looked for the information that helps consumers decide where the best colonoscopies were (defined as having a low complication rate, performed by expert providers with emergency back-up) at the best price. It can’t find it. This is Boston and New England after all, and the DMCB doubts there are any colonoscopy centers that are willing to post quality measures or pricing. Lacking a transparent market that helps consumers decide if they are getting value for the money, should the study findings be all that surprising?
  • Maybe persons who are actually paying for the test were more willing to ask about the trade-offs in complication rates vs. the benefit.
  • This study was performed in an integrated delivery system, which may not make it generalizable to much of the real world. For example, the Disease Management Care Blog doubts very much that Harvard Pilgrim was willing to use its purchasing clout to steer patients to colonoscopy providers offering the best quality at the lowest price. A free standing insurer and/or an employer-based plan may not hesitate to do that. If a transparently and competitively priced colonoscopy option was in network, the impact of high out of pocket expense could be lessened. Insurance underwriters recognize the level of risk from preventable colon cancer, but another role of large purchasers of medical services should be to find the best retail price for their enrollees. See the prior post on risk vs. retail.
  • If the price of colonoscopy is what is getting in the way of higher cancer screening rates, perhaps the answer is not adjusting the benefit package of a CDHP. Rather, the answer may include finding a way to lower the price of a colonoscopy. In addition to jawboning the providers for better contracting terms, the Disease Management Care Blog found this other way to offer the service at a lower price.
  • Finally, other patient support interventions such as this and this may help overcome patient reluctance to undergo screening. Note both fit nicely with the type of interventions already available in population-based wellness, health promotion and disease management programs. In fact, many disease management vendors are already out there promoting cancer screening under a variety of insurance benefit designs. They are probably doing a very good job at it too. Does anyone have any data to share?
By the way, kudos to Harvard Pilgrim for conducting the study. We need more real world research like this to inform public policy.

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