S266 Lifetime Impact of the Change in Modality as a Result of Eliminating Cost-Sharing for Follow-Up Colonoscopy After a Positive Stool Test for Colorectal Cancer Screening

Introduction: Most commercial insurance plans in the US will be required to cover a follow-up colonoscopy after a positive stool test with no patient cost-sharing as of January 1, 2023. In Oregon, a policy that eliminated patient cost-sharing significantly increased the overall uptake of CRC screening and shifted screening modalities from colonoscopy to non-invasive methods. We estimated the clinical and economic effects of these outcomes that may stem from the policy on a cohort of US average-risk individuals newly eligible for CRC screening. Methods: CRC-AIM, a validated microsimulation model for CRC, was used to simulate 2 million individuals undergoing CRC screening (colonoscopy every 10 years, annual fecal immunochemical test [FIT], triennial multi-target stool DNA [mt-sDNA]) from ages 45-75. Individuals who completed initial CRC screening were assumed to also complete follow-up colonoscopies. Outcomes were aggregated according to the current proportional distribution of different modalities. The baseline scenario represented the utilization of CRC screening prior to implementation of state-level policy (46% colonoscopy, 23% stool test, and 31% unscreened; derived from published literature). Scenarios 1-5 assumed 10% shift from colonoscopy to stool-test utilization with 1, 2, 5, 10, and 15% absolute increase in overall screening rate, respectively. Results: When 10% shift from screening colonoscopy to stool-test utilization was modeled, an increase in overall screening as low as 1%, compared to the baseline led to lower total costs, and cost per patient screened and higher quality adjusted life years (QALYs) (Table). LYG increased by at least 5% while ≥1,200 cases and ≥900 deaths were averted per 1 million individuals with a modest (5%) uptake in total screening. Total colonoscopies were 1.7% lower than the baseline at 15% increase to total screening. All scenarios that included the alternate screening modality distributions were less costly and more effective compared to the baseline, regardless of percent changes to total screening uptake (Figure). Conclusion: Based on this modeling analysis, policies that remove cost barriers to completing CRC screening can lead to shifts in test utilization patterns, increase overall participation rates, and improve both economic and clinical outcomes.Figure 1.: Incremental cost-effectiveness ratio by absolute percent increase in total CRC screening rate. Screening rates were assumed to increase as a consequence of waiving patient cost-sharing leading to a shift from screening colonoscopy to non-invasive methods. Negative ICER indicates that the scenario is less costly and more effective than the baseline. (CRC: colorectal cancer; ICER: incremental cost-effectiveness ratio; QALY: quality-adjusted life year) Table 1. - Estimated Outcomes in Baseline Scenario and Scenarios 1-5 Assuming 10% Absolute Reduction in Colonoscopy Utilization and Increased Overall Screening Rate. LYG, CRC cases, CRC deaths, total colonoscopies, and stool tests were calculated per 1000 individuals. Total costs and total QALYS were calculated per person Scenario % COLs % Stool Tests % Screened LYG CRC Cases CRC Deaths Total COLs Stool Tests Total Costs Total QALYs ICER Baseline 46 23 69 246.4 36.9 15.6 2298.0 3442.1 $6,901 16.8482 NA (1) 10% shift from COL to stool-test and 1% increase in screening 36 34 70 245.2 37.8 15.8 2051.6 5080.8 $6,628 16.8483 Less costly and more effective (2) 10% shift from COL to stool-test and 2% increase in screening 36 35 71 248.5 37.3 15.5 2066.4 5229.8 $6,629 16.8492 Less costly and more effective (3) 10% shift from COL to stool-test and 5% increase in screening 36 38 74 258.3 35.7 14.7 2110.8 5676.7 $6,632 16.8520 Less costly and more effective (4) 10% shift from COL to stool-test and 10% increase in screening 36 43 79 274.7 33.0 13.3 2184.8 6421.6 $6,638 16.8565 Less costly and more effective (5) 10% shift from COL to stool-test and 15% increase in screening 36 48 84 291.1 30.3 12.0 2258.8 7166.5 $6,644 16.8611 Less costly and more effective COL: colonoscopy; CRC: colorectal cancer; ICER: incremental cost-effectiveness ratio; LYG: life-years gained; NA: not applicable; QALY: quality-adjusted life year.