When a free cancer check finds something, could cost keep patients from following up?

Eleven years ago this month, the scans and exams that hold the most power to spot the early signs of cancer became available for free to many American adults.

Now, two new studies show that when those screening tests reveal potentially troubling signs, patients could face hundreds of dollars in costs for follow-up tests.

The studies, by teams from the University of Michigan and Duke University, could inform efforts to ensure that patients follow up on abnormal test results and don’t delay care due to cost. Such delays could lead to cancer going undiagnosed and progressing, potentially leading to worse patient outcomes and high medical costs.

The studies look at out-of-pocket costs billed to older adults who had CT scans to screen for lung cancer, and to women after an abnormal Pap smear or cervical exam.  

The first paper, led by radiologists Tina Tailor, M.D., from Duke and Ruth Carlos, M.D., M.S. of U-M’s Michigan Medicine, looks at what patients were billed for the lung biopsies and other invasive procedures used to follow up on an abnormal lung CT scan. It’s published in the Journal of the American College of Radiology.

In all, 7.4% of the patients who had a lung cancer screening CT went on to have at least one follow-up invasive procedure. While 20% of this group was diagnosed with lung cancer, the rate of procedures “downstream” of the screening CT is higher than what was seen in the clinical trials of this type of screening. Such studies established the value of lung CT screening in certain older adults and led to no-cost access in 2013.

Over half of the patients who had a procedure after their lung scan were asked to pay something, sometimes hundreds or even thousands of dollars out of their own pockets. Forty percent paid nothing for their follow-up care.

Now that more American adults are eligible for free lung cancer screening, due to new evidence about its ability to spot disease early, the authors say insurers may want to consider ways to reduce the cost burden on those with abnormal scans who need follow-up care to determine if cancer is present.

The second paper, published in the journal Obstetrics & Gynecology by a team led by U-M internal medicine professor A. Mark Fendrick, M.D., and OB-GYN assistant professor Michelle Moniz, M.D., M.Sc., looks at what women paid out of their own pockets for a type of cervical exam called colposcopy. Conducted after a Pap smear, HPV test or routine cervical exam gives abnormal results, a colposcopy can include a biopsy or other procedures.

Women who had a colposcopy without further procedures paid an average of $112, while those who had cells taken for further examination paid $155 on average. Those who had further procedures faced hundreds of dollars more in costs -- and this out-of-pocket cost rose sharply during the 13 years studied. By 2019, a woman who had additional care beyond a biopsy could expect to face a total bill of nearly $1,000.

“Costs much lower than these have been shown to prevent women from obtaining recommended healthcare,” said Moniz. “So it is high time we consider eliminating financial barriers to recommended care to prevent cancer.”

“The Affordable Care Act requires enhanced preventive care coverage for over 150 million Americans, including initial screening tests for breast, cervical, colorectal and lung cancer.” said Fendrick.  “Since screening for these cancers often requires multiple steps, health insurers should remove barriers that may create financial hardship or deter an individual from completing the screening process.”

Carlos, Fendrick and Moniz are members of the U-M Institute for Healthcare Policy and Innovation. Fendrick directs the Center for Value-Based Insurance Design.