As a component of corporate wellness programs, cancer screening provides one of the most direct and immediate health benefits. It requires only simple testing versus long term, sustained behavior modification and there is significant clinical and economic value in catching cancer early in its most treatable stage. As such, cancer screening has been an important benefit design consideration for employers for a number of years.
Yet despite efforts to increase use of recommended screening tests, participation rates have been less than ideal, such that the benefit of this valuable wellness component has not been fully realized. In this article, we report on the results from a pilot of an innovative, cost-effective program that has the potential to significantly increase cancer screening rates for employers.
Why Early Cancer Detection is a Vital Wellness Issue
Most cancers have few symptoms in their early stages. In general, symptoms don't appear until the cancer has grown and perhaps spread, when the cancer is more difficult to treat. However, the outlook for cancer survival and even cure can be very good if cancers are diagnosed early in their most treatable stage.
This is why many organizations have promoted the use of and compliance with cancer screening guidelines, including those from the US Preventive Services Task Force, the American Cancer Society, and numerous physician specialty organizations.
While diagnosing cancer early improves survival odds, it also reduces metastatic disease and the costs and morbidity associated with chemo/radiation therapy and necessary surgical treatment. Cancer has been reported to be the leading cause of long-term disability and the second leading cause of intermittent short-term disability for U.S. employers.
Towers Watson, National Business Group on Health, 2009/2010 Staying@Work ReportEarly detection of cancer provides the opportunity for curative treatment and can minimize the significant healthcare expense of late-stage disease. The cost of treatment in the last year of life for cancer patients under the age of 65 who die of breast, cervical, prostate or colorectal cancer ranges from $93,000 to $129,000.
The CEO Roundtable on Cancer reports that companies spend on average $3,000 in direct annual medical costs for employees without cancer vs. $16,000 for those with cancer. The National Business Group on Health states that the cost of cancer treatment is typically among the top three most costly conditions representing on average 12% of total medical expenses. The cost of late stage cancer care is also rising.
For example, according to the Colon Cancer Alliance, the cost of early diagnosis of colon cancer is about $30,000. In contrast, the treatment cost for delayed diagnosis ranges from $120,000 or more with newer available treatment options. This is largely a result of chemotherapy costs, which have risen by as much as 800% between 1996 and 2007.
Current Status of Cancer Screening
Colorectal cancer screening has perhaps the lowest participation rate of all screening tests, with nationally reported compliance rates of 54%, according to the Healthy People 2020 website (http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicid=5). Approximately one-third of all women still do not receive annual mammography.
Depending on health benefits costs and access to care, screening rates for individual employers are often even lower. In an effort to promote cancer screening, many employers have eliminated out-of-pocket costs for screening tests; healthcare reform legislation incorporates such first-dollar coverage as well.
This removes the financial barrier for employees to seek screening, but doesn't necessarily motivate them to get screened. Other factors that contribute to low cancer screening rates include lack of understanding the relative importance and value of cancer screening, perceptions regarding the testing process and options, as well as access and convenience concerns.
Midwest Employer Study
It is not difficult to appreciate that from an employer perspective, regular participation of employees and family members in recommended cancer screening represents a source of value. While employers may be aware of low compliance with one or more cancer screenings, few options have been available to meaningfully increase screening rates.
Recently, an innovative approach to increase cancer screening rates has been developed using individualized telephonic decision support. Our study, described below, evaluates the effectiveness of this program in an employer setting.
Employees and spouses aged 50 or older of a county government in the Midwest were given the opportunity to participate in a novel telephonic health outreach program designed to increase compliance with recommended cancer screening guidelines. The program was voluntary and communicated to employees by mail, email, benefits meetings and was an offering at an annual health fair.
Individuals could enroll onsite, by phone or on a dedicated website. The existing employer self-insured health benefits design had, for some time, provided first-dollar coverage for all recommended screening tests, so no financial barrier existed to individual compliance with testing.The telephonic intervention was provided by ScreenCancer, Inc. which utilizes an outbound call-center approach and comprehensive, tailored algorithms optimized for individual healthcare conversations.
The service provided assessment, education, test facilitation when requested, and follow-up to maximize completion of recommended testing. A dedicated call center Navigator was assigned to each participant throughout the program. Cancers included in the screening program were breast, cervical, prostate and colorectal.
Participants were contacted at home at times selected during enrollment. The initial call began with a review of each individual's personal risk factors and screening history. Depending on the information obtained, targeted educational information was provided along with a discussion of appropriate screening options.
For colorectal cancer, colonoscopy was stressed as the best option (and the only option for those at increased risk). If participants did not want colonoscopy, they were offered the option of an at-home fecal immunochemical test (FIT) sent directly to them.
Initial calls ranged from 10-15 minutes, and participants received up to three follow-up calls to answer questions and track and encourage completion of testing. The program ran for four months from the start of enrollment through the last call.
One hundred twenty eight individuals signed up for the program, with 12 not responding to initial outreach communications. Of the remaining 116, 68 (59%) were already compliant with all recommended cancer screening, leaving 48 (19 males and 29 females) who were due or past due for preventive care services, as shown in Figure 5. At the end of the program, 31 (65%) of these individuals successfully completed all of their recommended cancer screening services, bringing the overall compliance of the group to 85%.
The effectiveness of the Screen Cancer Navigator approach in increasing compliance with screening for specific cancer types is shown in Figure 6. Of the different types listed, compliance with recommended colorectal cancer screening demonstrated the largest increase, with a 27% relative improvement in overall screening compliance and a post-program compliance rate of 87%, well above the national average of 54% (Healthy People 2020).
A post-program survey was also conducted where participants were asked to rate their experience with the program on a scale of 1-5 (5 highest). The overall satisfaction rating was 4 out 5 with the results of individual categories.
Existing communication and education strategies to promote cancer screening have helped to increase awareness and understanding of the value of testing and early diagnosis, yet overall screening rates remain less than optimal. The recently released Healthy People 2020 goals include a targeted colon cancer screening rate of 70.5% among adults aged 50-75 years, and increases of 10% for both breast and cervical cancer screening rates.
The program used in this pilot is based on methods which have been shown to increase cancer screening in other settings. These include a study of more than 1400 patients enrolled in a one-on-one patient education program similar to the ScreenCancer Navigator that found patient adherence with prescribed use of a molecular colorectal cancer test increased from 29% to 73% (Bagshaw J, Bucher W, Am J Gastroenterology, 2006;101:S549).
Other studies including variations of telephone outreach to increase compliance also show significant increase in cancer screening rates vs. control groups. The approach used in this pilot was shown to be efficient at increasing cancer screening rates, likely due the use of a cancer-focused staff utilizing computerized decision-support algorithms and tracking capabilities. This efficiency also allows for a low per-enrollee cost.
Depending of the size of the company, the cost savings resulting from just diagnosing and treating one cancer at an early stage relative to delayed diagnosis may well cover the related program costs. Targeting only known non-compliant populations (established through HRAs, claims analysis, etc.) could further enhance cost-effectiveness. While the results obtained are significant, there are limitations of the pilot that deserve mention.
First, program participants represent a self-selected subset of the entire employee population. As a result, these individuals may well have been more receptive to changing their use of cancer screening services. It is unclear how other individuals who did not elect to participate in the program would have responded to a similar intervention.
Secondly, the enrolled population had a higher baseline compliance rate with cancer screening relative to national benchmarks. However, even with higher baseline compliance, the observed increase in colorectal cancer screening compliance in particular was significant.It should also be noted that while the program stressed colonoscopy as the best and primary option for enrollees who where non-compliant with colorectal cancer screening, many people elected to perform a FIT test instead with the understanding they would be testing annually.
A FIT test, also in recommended screening guidelines if done annually, it is a test collected at home and then mailed to a testing laboratory to check for the presence of fecal blood, potentially indicative of cancer. When requested by the participant, the program provided FIT test education, ordering, tracking, follow-up and reporting to both the participant and their physician. This likely accounts for the high compliance rates for this test when compared to previously reported results.
This pilot study has shown that significant increases in individual participation in cancer screening, and in particular for colon cancer, can be attained using personalized and efficient telephonic decision support. Based on these results and data from other studies, employers with less than desired compliance with preventive care services may want to consider adopting a similar technique to increase screening participation rates. Broader use of this approach will help to clarify the value to both employers and eligible individuals.
About the Authors
Bruce Sherman, MD, FCCP, FACOEM, is Director, Health & Productivity Initiatives with the Employers Health Coalition of Ohio, providing claims data analytics and health management strategies to employer members. Dr. Sherman is also consulting Corporate Medical Director, Whirlpool Corporation supporting the development of integrated, value-based health and productivity management strategies.
David Nikka is CEO of ScreenCancer, Inc. a company that provides programs to cost-effectively and significantly increase cancer screening rates for employers, insurers and other target populations. David has over 20 years of experience in healthcare, biotechnology, medical devices and human resources and can be reached at 339-223-0573 or firstname.lastname@example.org.