Simple financial incentive may improve rate of colonoscopy screenings

Offering $100 to patients eligible for a preventive colonoscopy screening more than doubled the rate of screening when compared to a simple emailed request, according to new research from the Perelman School of Medicine at the University of Pennsylvania. Screening colonoscopies improve the chance of early detection and prevention of colorectal cancer, but tens of millions of Americans who should have preventive screenings fail to get them. The new study, published this week in Gastroenterology, suggests that a simple financial incentive may be able to persuade many of those holdouts to undergo this important medical procedure.

"Colonoscopy is challenging for patients, requiring a day off from work, a bowel cleansing preparation, and transportation, in addition to non-financial costs of anxiety and discomfort," said lead author Shivan J. Mehta, MD, an assistant professor of Medicine at the Perelman School of Medicine and associate chief innovation officer at Penn Medicine. "The improvement we saw in the rate of screening colonoscopies was statistically significant, and shows for the first time that a financial incentive can at least modestly boost that rate."

Colorectal cancers kill more than 50,000 people in the US every year - second only to lung cancers - despite the fact that the vast majority of potential colorectal tumors can be detected via colonoscopy and removed easily, usually at the precancerous stage. The U.S. Preventive Services Task Force has recommended screening colonoscopies every 10 years until the age of 75, for most healthy adults starting at age 50, and for adults with a strong family history of colorectal cancer starting earlier. Studies suggest that from one-third to more than one-half of eligible people fail to get screening colonoscopies.

The new study included 2,245 people between 50 and 64 years old. Following a behavioral economics technique called active choice, Mehta and colleagues sent an email to one subset of participants asking that they actively opt in or opt out of a screening colonoscopy. To another subset, the researchers sent an email with the same active choice message plus an inducement of $100 cash for a colonoscopy completed within three months. To a third group, the control group, the researchers sent an email with just a phone number for scheduling a screening colonoscopy.

Only 1.6 percent of the control group and 1.5 percent of the simple active choice group ended up receiving a screening colonoscopy within three months, compared to 3.7 percent of the group that was offered the $100 inducement. The rate of appointment scheduling was also more than double in the $100-inducement group (4.8 percent) compared to the control and active choice groups (2.1 percent and 2.0 percent, respectively).

Providing people with financial incentives to adopt healthier behaviors or follow medical guidelines is already becoming a standard practice among insurers and employers. Such incentives have been proven effective in some cases, for example in persuading people to cut back on smoking, to take their medications, and to lose weight.

Researchers have found it harder to persuade people to undergo colorectal cancer screening. For example, the Affordable Care Act of 2009 eliminated patient cost sharing for colonoscopies and other colorectal cancer screening procedures - up to a $500 value for some people - but did not lead to a wider adoption of these procedures.

The effectiveness of the inducement used in this study, he suggested, may have come from the relatively large amount of money offered as a cash reward, and the fact that it was offered along with easy access to scheduling for the procedure.

"Although a $100 incentive seems relatively large, this amount is comparable to what employers already offer for completion of health risk assessments or biometric screening activities," said Mehta, who also works with teams in Penn's Center for Health Incentives and Behavioral Economics and the Center for Health Care Innovation, to lead research looking at how health care systems can leverage behavioral economics, care redesign, and information technology to improve population health. "Based on the results, the approach could be applied by employers or insurers to improve existing efforts to reduce the burden of colorectal cancer."