July 21, 2020 -- Mailing fecal immunochemical test (FIT) kits to U.S. Medicaid patients could increase the rate of colon cancer screening and appears to be cost-effective, according to a modeling study published online July 20 in the journal Cancer.
Using results from a randomized trial, the study simulated the costs and benefits associated with mailed FITs with prepaid return envelopes compared with a mailed reminder alone for colon cancer testing in a population of 35,000 Medicaid patients overdue for screening. Looking over a year, researchers concluded that the anticipated number of colorectal cancer (CRC) screenings, including FIT and colonoscopies, would be higher for the group that had the fecal tests mailed directly (23.2%) than those just getting mailed a reminder about the need for screening (15.8%).
For health providers, mailing tests with a reminder versus sending a reminder alone is financially doable, with an incremental cost-effectiveness ratio of $116 per person screened for the reminder with FIT versus the reminder alone, researchers reported.
The researchers also looked at how the two different strategies would affect state and Medicaid costs and found that the rate of screening would be higher for mailed FIT kits with reminder, but costs would be lower because those who get a reminder alone may be more likely to get a screening colonoscopy, which is much more expensive. They estimated annual Medicaid/state costs of $1.4 million for a reminder with FIT, versus $1.45 million for a reminder alone.
"Our analysis showed that, regardless of whether Medicaid or clinics/facilities paid for programming to increase CRC screening, the mailed reminder + FIT intervention was the higher value approach," Alison Brenner, PhD, a research assistant professor at the University of North Carolina, and colleagues reported.
How to expand access to screening?
Researchers conducted the study to gather information about the costs associated with various strategies aimed at increasing the rate of colon cancer screening in lower-income populations covered by Medicaid, for use as an aid to health policymaking. Colon cancer screening is strongly recommended between the ages of 50-75 years of age in guidelines from the U.S. Preventive Services Task Force, the authors noted.
"Despite this evidence base, however, more than one-third of age-eligible Americans are not up to date with CRC screening, and subpopulation-specific studies indicate especially low screening among Medicaid and other low-income populations," Brenner et al wrote.
Annual fecal immunochemistry testing is accepted as an option for colon cancer screening and is more convenient and less expensive than colonoscopy. Consequently, it is preferred by people at lower income levels and has potential to boost participation in screening programs, the authors noted.
For the study, researchers used modeling to assess costs and benefits, using results from a randomized trial of 2,100 North Carolina-based Medicaid enrollees overdue for colorectal cancer screening as a guide. Enrollees were randomized to get the mailed kit and reminder or a reminder that indicated it was time for screening and instructions on how to get a mailed FIT kit, pick up a FIT kit, or undergo a colonoscopy.
"Although the interventions were FIT-based, enrollees may be more likely to initiate CRC screening by any modality as a result of being notified that they are overdue for screening," Brenner et al wrote.
Brenner and colleagues estimated that in their modeling for 35,000 enrollees, 2,598 more screenings would be conducted over a year if FIT kits were mailed with a reminder. Furthermore, the authors believe that the mailed FIT approach "can quickly reach thousands of age-eligible Medicaid enrollees who are overdue for screening and encourage substantial numbers" to get screened for colorectal cancer.
Who picks up the tab?
Multiple studies have shown that direct mailing of fecal tests significantly increases uptake in colorectal cancer screening -- by 22% on average, wrote Kaiser Permanente health researchers Dr. Beverly Green and Richard Meenan, PhD, in an accompanying editorial, which was also published July 20 in Cancer. Screening in turn increases the likelihood for early detection of polyps and better outcomes.
Organized mailed FIT programs can push colorectal cancer screening rates past 80%, "markedly decreasing mortality," but are unfortunately uncommon in the U.S., Green and Meenan wrote. The study just published showed that a mailed FIT program could save money, but this was simulated, and it's unclear how mailing costs would be absorbed by clinics in practice, the authors noted in the editorial. Furthermore, payment for confirmatory colonoscopies for positive FIT tests remains unclear.
"In any case, the analysis ... raises an important question: Who should pay for mailed FIT screening programs?" Green and Meenan wrote.
Savings gained through decreased morbidity and mortality could help motivate health plans to pick up the tab for better screening, and tracking of screening rates as a quality measure with associated performance incentives in Medicaid coverage could also spur adoption, they suggested.