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| Testing for hidden early lung cancer |
More than 54,000 former and current tobacco users who looked like they were free of cancer were randomly assigned to a yearly cheapo chest x-ray vs. a yearly pricey low-radiation-dose CAT scan. Over 5 to 7 years of follow-up, the CAT scan was better at picking up early lung cancer (119 cases) which translated into a small but statistically significant survival advantage of 62 lives saved per 100,000 patient years.
Does this mean that Medicare, Medicaid and all commercial insurers should "cover" a baseline and yearly follow-up screening CAT scan for tobacco smokers at risk for lung cancer? According to actuary Bruce Pyenson and colleagues writing in the latest issue of Health Affairs, the answer may be yes.
The Disease Management Care Blog thinks the answer may still be no.
Is it being a heartless curmudgeon? Read on and decide for yourself.......
In the Health Affairs article, the authors assumed current and former tobacco smokers comprise about 30% of persons aged 50-64 years. They further assumed that about 50% of persons at risk would agree to the CAT screening exam. Based on prior studies, they estimated that 21% of the baseline scans and 7% of the follow-up yearly scans would require additional testing and figured lung cancers would be present in 0.6% and 0.2% of the baseline and follow-up scans. They used a fee rate of $247 per screening for both the scan and included the cost of a counseling session on smoking cessation.
Spread over a population, the cost of the screening would amount to 76 cents per member per month (PMPM). On a nationwide basis, there would be 130,000 additional lung cancer survivors. The cost per life-year saved in 2012 dollars would range between $11,708 and $26,016. To put things in perspective, it costs more per life-year saved to use current screening approaches to cervical cancer with pap smears (more than $50,000), colon cancer with colonoscopies ($18,000 to $29,000) and mammography ($31,000 to $51,000).
Much of the high costs of these other cancer screening procedures are the result of more persons being eligible for the testing. In the Health Affairs study, the only persons getting the scan are smokers who are at high risk.
What did the DMCB learn?
One important lesson in this study is that cancer screening is not free. It's too easy to assume that the early detection provided by mammography, colonoscopies and pap smears pays for itself. That's simply not true. What is true is that cancer screening is good value, but it'll still cost you for each life saved.
The second lesson is that good value still represents incremental cost. As a result, the 76 cents PMPM is in addition to the money already being spent by health insurers. While the extra pennies doesn't seem like a lot of money, the health insurance dollar is comprised of coverage of similarly priced goods and services, and all those pennies are continuing to add up. The DMCB thinks we're getting to the point where the U.S. would need to ask what coverage of which service should be cut to pay for lung cancer screening.
Both of these issues make it unlikely that insurers will willingly include coverage of screening CAT scans in their health insurer benefit. They can also argue that it would be highly unusual to decide to cover a new screening procedure based on a single study that hasn't even been reviewed yet by the U.S. Preventive Health Services Task Force.
Last but not least, the DMCB is willing to bet that there won't be much consumer demand for coverage by insurers because of bias against the victims of tobacco-associated illnesses as well as the argument that smokers should self-pay based on the comparative cost of a year's worth of cigarettes.
It remains to be seen if, under their ability to define a minimum insurance benefit as part of the Affordable Care Act, the Feds will require lung cancer screening.
Stay tuned!
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