Expanding CRC screening: Understanding the options and the costs to providers Paul Brown Kelly Kohler University of North Carolina 1

Two types of studies 1. Effectiveness/Cost effectiveness Addresses the question Should we screen for CRC and, if so, with what modality? Example: – 2002 review of colorectal cancer screening – Cost effective $10,000 to $25,000 per life year gain Conclusion Colorectal cancer screening with FOBT should be undertaken 2

2. Micro-level costing study Addresses the question How should we screen and what does it cost to screen? Focus on screening process – Recruitment, testing, relaying results, etc 3

CRC Screening Program Overview Identify Eligible Population Recruit and enroll Test Dispatch Results Normal Routine re-call Abnormal Diagnostic CS NormalPolypCancer Unclear Repeat FOBT/FIT Registry, EHRs, media ads, awareness campaigns Reminder letters, phone calls, Dr visits, etc. Phone calls, follow- up appointments, endoscopy referrals, case manager FOBT, colonoscopy, etc. 4

Costing study – Question is not “Should we screen”? – Question is “Should we increase our current efforts?” Relevant to the providers in the US – Most already doing some type of screening – Question What will it cost us to increase our efforts? What will the benefit be? 5

Issues Not looking at the total cost – Interested in marginal (additional) cost Actual expenditures not needed – Not an ‘audit’ of expenditures Identify resources Unit costs Overheads – “What cost could other providers expect to incur?” Sensitivity analysis Explore robustness of results to assumptions or areas of uncertainty 6

Example – Colorectal cancer screening (Lewis et al, 2008) Issue: – People not coming in for regular CRC screening Context – Hospital clinic with records of patients – Can access records, identify who is not up-to-date Intervention – Send letter signed by provider – Include decision aid (video tape) – Follow up phone calls to schedule appointment 7

Effectiveness 137 patients – identified from database as being eligible but not current for screening Sent materials 97 followed up with phone call – 55 contacted Final numbers screened – 20/137 intervention (15%) – 4/100 control group (4%) 8

Is the program “worth it?” Is the program effective? – Yes – Improved screening rates is good Will the clinic continue with the program? – “Will the clinic be willing to pay for the program?” 9

Cost of program 10 Item costQuantityCost Mail out postage$ mailed$ Mail back postage$ returned$ Video/DVD$ sent$ Materials$ sent$ Staff time$17.00 per hour9 hours$ Telephone * Staff time$17.00 per hour 5 minutes for each of 97 called $ minutes for each of 55 reached $ Sub total $1, Overhead80% $1, Total cost (per 137) $3, Cost per additional patient screened $205.68

Is the program “worth it?” Society $206 per person screened Look at benefit of having an additional person screened Prob of getting preventing CR Cost and benefit from getting CRC Etc. Organization Unlikely to realize long term benefits Net Revenue will depend upon Effectiveness Reimbursement Etc. 11

Net revenue – Each program 12 n = 137 No programWith program Effectiveness Original4.0% 0 Program0 15.0% Revenue Reimbursement$498 * Total Revenue$2,729$10,234 Cost Cost per test$300 $300 ** Program$0 $3,291 Total cost$1,644$9,456 Difference * from CMS **lose money > $338 $1,085$778

Comparing programs 13 n = 137 Effectiveness Original4.0% Program15.0% Revenue Reimbursement$498 Total Revenue$7,505 Cost Cost per test $300 Program$3,291 Total cost $7,812 Difference-$307

Motivation for costing study “How much will it cost to expand screening beyond our current efforts?” “What do the results depend upon? Confidence?” – Break-even/sensitivity analysis Level of effectiveness that need to be reached Level of reimbursement, Etc. 14

Break even analysis 15 Break even n = 137 Screening costReimbursementEffectiveness Original4.0% Program15.0% 16.1% Revenue Reimbursement$498$519$498 Total Revenue$7,505$7,814$8,255 Cost Cost per screen $280$300 Program$3,291 Total cost $7,505$7,814$8,255 Difference* from CMS$0

Motivation for costing study If hospital medical directors care about costs… – Can help overcome financial barrier – Profits or budgets? 16