The United States Preventive Services Task Force has recommended lung cancer screening for at-risk groups since 2013, and updated again in 2021. This is a simple procedure involving a low dose of radiation used to take a CT image of the chest. If utilized by most eligible Americans, screening could reduce lung cancer mortality by up to 20%. We’re talking about potentially tens of thousands of lives saved per year.
Lung Cancer Screening: Free and Underutilized
Furthermore, the Affordable Care Act has mandated that health insurance companies cover screening for current and former smokers in certain age groups (50 to 80) with no cost-sharing since 2015. Despite being free and effective, screening is extremely underutilized. Recent data show that seven out of eight eligible adults do not receive their annual screening in a given year.
While lack of awareness about free screenings, difficulties in accessing screening centers, and fear associated with the screening process and results play a large role in this underutilization, cost is a factor that has been gaining attention.
How is cost a barrier when screening is free? As we know, health insurance is confusing. Many Americans have a sense of disillusionment when it comes to health care, with constant worries of unexpected bills due to the nuances of their coverage. Beyond the screening itself, what happens if the screening leads to a cancer diagnosis? The costs—in addition to the massive, scary life changes—that come with treating cancer make it easy to convince ourselves that we don’t need a screening.
In an article published in the October 2023 issue of Medical Care, Kris Wain and colleagues explored how potential costs can influence whether or not a person chooses to get a lung cancer screening. In particular, they compared screening rates among people enrolled in health plans with deductibles and without deductibles.
The Role of Deductibles
Health insurance plans without a deductible have become increasingly rare. Only about ten percent of Americans have no-deductible health plans. One-fourth of employers offer only high-deductible health plans. Even when given the option, individuals tend to forgo the no-deductible option due to higher premiums unless they anticipate high utilization of healthcare.
In theory, deductibles are supposed to prevent Americans from over-utilizing healthcare. Indeed, those with high deductibles use fewer healthcare services and incur savings associated with the fewer visits and procedures. However, these individuals also tend to utilize fewer preventive and medically necessary services. This leads to higher costs and worse health in the long run.
To explore how deductibles impact lung cancer screening, Wain and colleagues followed a cohort of middle-aged individuals enrolled in managed care organizations and eligible for lung cancer screening. In order to narrow in on the specific barriers to lung cancer screening and the role of deductibles, the authors examined three steps in the screening process: whether eligible patients received a primary care visit, if they received an order for lung cancer screening, and if they received the screening itself.
The authors found that there was a significant association between the presence of deductibles and each step they examined, seeing a reduction in primary care visits, screening orders, and screening rates. High deductibles only led to a slightly greater decrease compared to low deductibles, suggesting that it is mostly the presence of a deductible, rather than the amount of the deductible, that creates a barrier. In addition, it appears that each step of the screening process presents additional challenges that are further exacerbated by deductibles.
Barriers at Every Step
While most individuals went to their primary care provider at some point, those with deductibles were still less likely to do so. This could be because they prefer to use less healthcare or due to potential costs associated with the visit or follow-up care.
Regardless of plan type, only about 15% of eligible individuals who visited the doctor received a screening order. This percentage was even lower for those enrolled in plans with deductibles. This was the largest gap that the authors found and points to issues on both the patient and provider sides. Providers may not know their patients are eligible or may be hesitant to suggest screening if their patient’s insurance plan has a deductible. Even if providers suggest screening, patients may have fears about the costs and results of the screening that can lead to resistance. Providers may feel inadequately equipped to navigate these conversations.
When it comes to getting the screening itself, a little over half had their screening once the order was made. There was a seven-percentage-point decrease in screening associated with enrollment in deductible health plans. These participants may have additional cost-related concerns that arise, even after receiving an order. They may worry about expensive follow-up care, unexpected bills, or the cost of accessing imaging centers.
Based on these findings, it appears that we need to target barriers at each step of the process. We should direct some special attention towards those enrolled in deductible health plans. However, lung cancer screening is vastly underutilized regardless of health plan type. Thus, we need to make larger systemic changes across all health plans.
The Need for a Multifaceted Solution
Potential strategies to address this problem can and should involve providers, patients, electronic health systems, and insurance companies.
Arguably, the most effective approach would be working to increase the number of screening orders by providers. We need to educate providers on how to identify eligible patients and talk them through the screening process. For hesitant patients, providers may consider explaining how lung cancer is highly curable when caught early. Electronic health systems can assist by automatically identifying and notifying providers of eligible patients during visits. Following up with individuals who receive orders may also encourage them to follow through with the screening. This also provides the opportunity to address new concerns that may have arisen after their initial appointment.
The complexities of health insurance coverage create another barrier. Insurance does not cover certain types of initial visits, even though patients cannot obtain a screening order without one. To address this, eligible individuals should be able to get a screening order without a doctor’s visit or have automated orders tied to preventative care visits for which there is guaranteed coverage.
Lastly, educating patients through providers, insurance companies, and mass communication can motivate patients to seek screening. These organizations can help patients navigate insurance coverage for preventive services. They can also convey the importance of screening to those who have misconceptions or are unaware. Communication efforts have the power to rebuild trust and change people’s behaviors related to healthcare.
Regardless of the avenues we take, we must work to increase lung cancer screening rates. Otherwise, the 20% reduction in lung cancer mortality from widespread screening will forever remain an unattainable goal.
Sarina Attri
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- Health Plans With Deductibles See Lower Lung Cancer Screening Rates - November 22, 2023
Ben King
Isn’t this just one of many examples how single payer, publicly financed and privately delivered healthcare would ultimately reduce cost and improve outcomes?