According to the 2008 U.S. Preventive Services Task Force (USPSTF) recommendation statement on screening for colorectal cancer, colorectal cancer is the second-leading cause of cancer death in the United States and appropriate screening could save thousands of lives a year.
The USPSTF recommends colorectal screening for everyone between 50 and 75 years of age. There are several screening tests currently available and modeling conducted by the USPSTF suggests that any of three screening programs would be “equally effective in life-years gained, assuming 100% adherence to the same regimen for that period”:
1. Annual high-sensitivity fecal occult blood testing
2. Sigmoidoscopy every five years combined with high-sensitivity fecal blood testing every three years
3. Screening colonoscopy at intervals of 10 years
Although other screening programs are less expensive and less invasive, and effectiveness is dependent upon the experience and expertise of those performing the procedure, well-performed colonoscopies were assessed to have higher sensitivity and specificity for detecting colon cancer. This finding, along with Medicare and the Patient Protection and Affordable Care Act (ACA) mandating no cost-sharing for colonoscopies and increased public awareness, has greatly increased the number of colonoscopies performed each year.
As the number of colonoscopies performed has increased, so has the variance in total cost for the procedure. Allowed charges can vary by thousands of dollars depending on the provider, place of service, and other variables. Monitoring utilization and evaluating the charges for these procedures has become increasingly important for health plans striving to improve health while managing costs.
The 2013 version of the Milliman Health Cost Guidelines™ (HCG) grouper includes separate detail lines to track utilization and cost of facility, as well as professional costs associated with preventive colonoscopy.
Using illustrative data from three health plans, allowable charges and utilization counts for facility and professional services associated with preventive colonoscopy are shown in Figures 1 and 2 below. These data include claims for patients between the ages of 50 and 75. HCG 051b represents outpatient facility services and HCG P40b represents professional services for a preventive colonoscopy. Note that there could be related services submitted on separate claims that are not captured in these totals.
Utilization units are counted separately for the facility and professional services. The utilization count associated with professional services represents the total number of preventive colonoscopies because some procedures will be provided in an office setting and will not have a separate facility record.
To compare utilization rates and average allowable charges for preventive colonoscopies across the three plans, sum the allowable charges for both HCG detail lines but use only the professional unit counts to avoid double-counting of procedures, as shown in Figure 2.
This simple analysis compares the cost and utilization of preventive colonoscopies across three plans, but additional analyses comparing costs across places of service (e.g., office, ambulatory surgery center, and outpatient hospital) provide further insights into cost drivers associated with these procedures.
This article first appeared at Milliman MedInsight.