Free screening colonoscopies for uninsured, high-risk CRC patients may help in early detection of cancer

For uninsured patients who are at a high risk for colorectal cancer (CRC), performing free screening colonoscopies can identify cancer at an earlier stage and appears to be cost neutral from a hospital system perspective, according to study results published online in the Journal of the American College of Surgeons ahead of print publication.

In the United States, the impact of CRC totaled $7.49 billion in 2000 and is expected to increase to $14.03 billion by 2020. Even after expansion of insurance coverage from the Affordable Care Act, some Americans and unregistered residents will still not receive health care coverage and will be unable to access resources for better health, which ultimately leads to worse outcomes and higher total costs for these patients if the disease is detected at a later stage. To help prevent this scenario, a research team led by surgeons from the University of Louisville (Kentucky) School of Medicine sought to determine if it would be cost-effective to provide free screening colonoscopies to a group of uninsured patients.

Lead study author Erica Sutton, MD, FACS, assistant professor surgery at the Hiram C. Polk Jr. Department of Surgery at the University of Louisville, said her team partnered with two groups, the Kentucky Colon Cancer Prevention Project and Surgery on Sunday Louisville, Inc., to conduct this study. Patients were referred to these non-profit organizations by free clinics in Louisville or primary care doctors, and those considered at high risk for CRC were offered free screening colonoscopies. Patients were considered at increased risk if they had a positive family history, a history of inflammatory bowel disease, or visible blood in the stool.

"Our community wanted to address how we fight and prevent colon cancer," Dr. Sutton said. "This approach is compassionate, but we also wanted to look at the cost or cost savings that we can expect to see from conducting a program like this for the uninsured."

The investigators collected patient data from these colonoscopies over a 12-month period. During the study period, 682 uninsured patients between the ages of 24 and 77 were screened. Nine cancers were identified: three patients were found to have stage I tumors, two patients had stage II, three had stage III, and one had stage 0.

The incidence of CRC, which was 1.3 percent, was compared with a control group of uninsured patients from the Surveillance, Epidemiology, and End Results (SEER) registry, a U.S. cancer surveillance system designed to track cancer incidence and survival. Researchers used published estimates from SEER-Medicare data of health expenditures by CRC stage during the initial phase of care. Health care costs included all Medicare payments, private insurer payments, and patient copayments and deductibles for covered services. To compare overall costs between patients in the study and the SEER database, the average initial cost of care (up to one year) was weighted by the stage-specific incidence in each group.

Compared with patients in the SEER-Medicare database, the study's cohort included more early stage cancers, and subsequently had a marginally lower estimated per patient initial cost ($43,126 vs. $43,736), which suggests the program is cost neutral from a system perspective.

"From strictly a payer standpoint, we found that this program did not cost more than what we currently do without it," Dr. Sutton said. She added the patients with cancer continued to get annual screenings through the program and free follow-up treatments.

Since the team started this study in 2013, Dr. Sutton said, they have been able to expand the free screenings to all the hospitals in Louisville. She said the team wanted to provide a model to hospitals in other parts of the state, and those hospitals have expressed interest as well. The team hopes this study's findings can begin a more wide-reaching national conversation about improving access to health care services in areas of ongoing disparity.

"If we don't want colon cancer to exist, we need to set up controlled screening programs, and we aren't going to bankrupt our system by preventing cancer in this way," Dr. Sutton said.