This Targeted Lung Cancer Screening Program Can Improve Health and Save Money

In 2018, there were 234,000 new cases of lung and bronchus cancer in the U.S. and 154,050 estimated deaths — the highest among all types of cancers. According to the Centers for Disease Control and Prevention, cigarette smoking is linked to 80 to 90 percent of lung cancer deaths in the U.S. and is the No. 1 risk factor for lung cancer. Additional risk factors include chemical substances like radon, family history of lung cancer, and diet.

Research has shown that low-dose computed tomographic screening (LDCT) can effectively decrease lung cancer mortality. In 2015, the National Lung Screening Trial Research Team clinically observed that LDCT reduced lung cancer mortality by 20 percent, compared to chest X-ray screening. LDCT is a screening technology that combines X-ray equipment with sophisticated computers to produce multiple, cross-sectional images of the inside of the body, providing detailed pictures of the lungs and using less ionizing radiation than a conventional CT scan. Despite its clinical advantages and cost-effectiveness, only 3.9 percent of the eligible population (262,700 among 6.8 million people) received LDCT screening in 2015.

In a recent study, David D. Kim and other researchers at Tufts Medical Center estimated the effects of risk-targeted incentive programs for LDCT on improving population health and increasing economic efficiency. Using individual-level data from 53,086 participants in the National Lung Screening Trial, they compared the effects of programs targeted to higher-risk people (including smokers, older people, and those with chronic illnesses) to the effects of untargeted programs. In this analysis, they calculated gained life years and the net monetary benefit, which is the difference between the monetary value of life-years gained and incurred health care costs, assuming that a year of life is worth $100,000.

Assuming that resources are limited, targeting populations with higher risk may be an efficient and productive approach to screening. This research by Kim et al. found that life-year gains among people in the highest-risk group were 2.9 times greater than the gains among those in the lowest-risk group over a lifetime (4,900 versus 1,700 life-years gained per 100,000 people screened). The authors found financial benefits as well. The net monetary benefit for LDCT screening exceeded the net monetary benefit for chest X-ray screening for all risk groups as a result of the averted lung cancer deaths. Compared to the untargeted incentive program, the additional lifetime health gains by the targeted program ranged from 2,470 (conservatively targeted case to higher-risk groups) to 6,600 (aggressively targeted case to higher-risk groups) life-years gained, with LDCT uptake increasing from 3,900 to 10,000 per 100,000 eligible people across all risk groups. The corresponding lifetime net monetary benefit gains ranged from $210 million to $560 million.

This study shows that risk-targeted incentive programs can improve population health and yield greater economic benefits compared to untargeted incentive programs. A greater challenge for policymakers, however, lies in designing programs to promote LDCT screening in higher-risk groups. As possible incentive programs, the authors suggested 1) provider-level financial incentives, such as a risk-targeted pay-for-performance program with certain LDCT referral goals, enabling physicians to receive financial bonuses from payers in Medicare commensurate with the proportion of higher-risk patients they referred to lung cancer screening; 2) financial incentives by health plans or employers, such as programs offering premium discounts or cash bonuses to people who voluntarily take annual LDCT screening; and 3) combining these with other initiatives including smoking cessation and individual counseling programs.

Policymakers should consider these incentive programs to promote LDCT screening and identify high-risk individuals. Low-dose computed tomographic screening is a win-win; reducing costs while improving outcomes. Today, electronic health records and validated risk-prediction models are readily available and, with these tools, individualized risk information can be used to identify who should be screened for lung cancer. Still, further research is needed to understand the low rates of LDCT in order to best design and implement cost-effective programs that improve health.

Article Source: Kim, David D.,  Joshua T. Cohen, John B. Wong, Babak Mohit, A. Mark Fendrick, David M. Kent, and Peter J. Neumann. “Targeted Incentive Programs For Lung Cancer Screening Can Improve Population Health And Economic Efficiency.” Health Affairs 38, no.1 (2019): 60-67.

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