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Elimination of cost-sharing for individuals who undergo noninvasive colorectal cancer (CRC) screening and need follow-up colonoscopy increased screening overall in one state but failed to move the needle in another, a cohort study found.

Compared with neighboring states, the policy was associated with a 6% greater likelihood of CRC screening in Oregon (OR 1.06, 95% CI 1.00-1.12) but screening remained flat following a similar policy in Kentucky (OR 1.00, 95% CI 0.96-1.05), reported Douglas Barthold, PhD, of the University of Washington in Seattle, and colleagues.

In Oregon, individuals were less likely to undergo colonoscopy as their initial screening test following the policy change versus before, representing an uptick in the use of noninvasive testing (OR 0.65, 95% CI 0.58-0.73), while no difference was seen in Kentucky (OR 0.97, 95% CI 0.89-1.07), the authors wrote in a research letter published in .

"Access to full coverage significantly increased overall CRC screening and use of noninvasive testing in Oregon but not Kentucky," the group concluded. "These findings suggest that the enactment of policies that remove financial barriers is merely one of many elements (e.g., health literacy, outreach, transportation, access to care) that may help to achieve desired cancer screening outcomes."

In accordance with the Affordable Care Act, patients at average risk for CRC are required to have several screening modalities covered by their insurance , Barthold's group noted. Despite this, out-of-pocket costs can still incur for those who test positive on initial non-invasive tests and require follow-up colonoscopy.

"Even with positive pre-colonoscopic testing indicating a potential risk of active cancer, patients will oftentimes not follow up with the necessary procedures to address the findings," said Allen Kamrava, MD, of Cedars-Sinai Medical Center in Los Angeles, who was not involved in this study. "Though not the unitary factor, costs are definitely a factor -- something that I have seen oftentimes myself, anecdotally, in my practice."

Several states -- California (2021), Kentucky (2016), and Oregon (2017) -- have enacted state-level policies to eliminate the financial disincentives of follow-up colonoscopies. For commercial insurers, a new federal guidance was issued in January that non-invasive CRC screening tests. Medicare is currently considering adopting a similar policy.

For their study, the researchers examined the MarketScan Commercial Claims and Encounters Database on 1,215,580 individuals ages 45 to 64 living in Oregon, Kentucky, and nearby states (Idaho, Washington; and Indiana, Tennessee, West Virginia; respectively) from 2012 to 2019. Included individuals had to be continuously enrolled in a self-funded insurance plan for 12 months. Analyses adjusted for age, sex, state, year, and healthcare plan, among other factors.

Mean age was 54.5 years, and 51.5% were women. Overall, 14.7% of the individuals underwent CRC screening, about two-thirds of which were colonoscopy. During the study period, the use of non-colonoscopy screening was slightly higher in Kentucky and its comparator states versus Oregon and its surrounding states.

Following the policy changes, "the odds of receiving a colonoscopy conditional on undergoing noninvasive CRC screening were not statistically different in Oregon or Kentucky," the authors noted.

Limitations to the data included the use of claims data, and that the researchers could not access screening test results.

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