Projected Clinical, Resource Use, and Fiscal Impacts of Implementing Low-Dose Computed Tomography Lung Cancer Screening in Medicare

Abstract

Purpose: The Centers for Medicare and Medicaid Services (CMS) recently issued a national coverage determination that provides reimbursement for low-dose computed tomography (CT) lung cancer screening for enrollees age 55 to 77 years with Ն 30 -pack-year smoking history who currently smoke or quit in the last 15 years. The clinical, resource use, and fiscal impacts of this change in screening coverage policy remain uncertain. Methods:We developed a simulation model to forecast the 5-year health outcome impacts of the CMS low-dose CT screening policy in Medicare compared with no screening. The model used data from the National Lung Screening Trial, CMS enrollment statistics and reimbursement schedules, and peer-reviewed literature. Outcomes included counts of screening examinations, patient cases of lung cancer detected, stage distribution, and total and per-enrollee permonth fiscal impact. Results:Over 5 years, we project that low-dose CT screening will result in 10.7 million more low-dose CT scans, 52,000 more lung cancers detected, and increased overall expenditure of $6.8 billion ($2.22 per Medicare enrollee per month). The most fiscally impactful factors were the average cost-per-screening episode, proportion of enrollees eligible for screening, and cost of treating stage I lung cancer. Conclusion:Low-dose CT screening is expected to increase lung cancer diagnoses, shift stage at diagnosis toward earlier stages, and substantially increase Medicare expenditures over a 5-year time horizon. These projections can inform planning efforts by Medicare administrators, contracted health care providers, and other stakeholders.

Lung Cancer Screening Inconsistent With U.S. Preventive Services Task Force Recommendations

“…25 In a simulation model of clinical, resource use, and fiscal impacts of implementing low-dose CT screening among high-risk individuals who were Medicare beneficiaries, low-dose CT lung cancer screening utilization was assumed to be about 70% after 5 years of implementation. 26 …”

Why cancer screening has never been shown to “save lives”—and what we can do about it

“…5 The cost of adopting CT screening for lung cancer by the Medicare population has been estimated to surpass $6bn a year. 46 To reduce costs, trials could target just the highest risk groups, with successful results prompting trials in lower risk groups. For example, the potential benefits of CT screening for lung cancer vary by age and smoking history of the participant.…”

The Cost-Effectiveness of High-Risk Lung Cancer Screening and Drivers of Program Efficiency

“…7 The sheer volume of LDCT scans required to screen the general population, with age and smoking history as the sole selection criteria, would have major budgetary impacts and could unnecessarily expose low-risk individuals to potential screening harm. 8,9 In addition, the U.S. Preventive Services Task Force selection criteria, which compromise NLST-like selection criteria, correlate poorly with the characteristics of patients with lung cancer, providing further reason to look beyond age, smoking history, and years of abstinence as predictive factors for selecting individuals for lung cancer screening. 10 Post-NLST research interests have thus focused on the use of risk prediction to select individuals according to additional risk factors with the aim of reducing the number needed to screen.…”