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The Illinois General Assembly passed House Bill 3113 (HB 3113) on May 30, 2019; it mandates that no copayments or cost sharing of any kind be imposed by health insurers for annual skin cancer screening by any physician.1 House Bill 3113 easily cleared both Houses (114-1 in the House of Representatives and 58-0 in the Senate). The legislature sent the bill to the Illinois Governor on June 28, and he now has 60 days to sign or veto the bill. If he does nothing, the bill automatically becomes law. In their position paper in support of HB 3113, the Illinois State Medical Society argues that HB 3113 will be a public health benefit and “reduce skin cancer” (Illinois State Medical Society Legislative Action Hub). However, on the basis of current evidence (or lack thereof) of the benefits of skin cancer screening, HB 3113 is not sound public health policy and should not become law.
Copayments are a form of cost sharing in which patients pay a fixed amount for particular health care services. Copayments are intended to incentivize patients to reduce health care overuse. Ideally, copayments encourage patients to preferentially choose high-value over low-value services; however, copayments are blunt instruments that tend to reduce both high- and low-value care.2 The increasing prevalence of copayments and other forms of cost sharing is a growing problem as the burden of patient out-of-pocket costs is increasing across the United States, owing in part to a larger proportion of patients choosing or being compelled to choose high-deductible health insurance plans.3 As a result, public health advocates believe that efforts to reduce or eliminate copayments, specifically for high-value services, have the potential to encourage patients to seek high-value care.
In this vein, the Affordable Care Act requires insurers to cover, without any cost-sharing requirements, preventive health services with an A or B rating from the United States Preventive Services Task Force (USPSTF), an independent, nongovernmental panel of national experts in disease prevention and evidence-based medicine that develops recommendations for clinical preventive services. Services rated A or B are those that have been found by the USPSTF to have moderate to large confidence of a moderate or greater net benefit. Cancer-specific preventive services with an A or B recommendation include breast, cervical, colorectal, and lung cancer screening. Since the implementation of the Affordable Care Act, evidence suggests evidence-based cancer screening has increased in part through the elimination of copayments.4 This finding is encouraging, given that evidence-based early detection can save lives and can sometimes reduce the cost associated with detection of late-stage disease.
With respect to skin cancer screening, the USPSTF review published in 2016 reached a conclusion of insufficient evidence, a rating of I.5 Their systematic review found that sufficient studies have not yet been performed to assess whether screening can reduce mortality or morbidity compared with no screening (standard care). As such, the balance between harms and benefits cannot be reliably and accurately assessed.5 Despite the recommendation by the USPSTF, HB 3113 has been supported by the American Academy of Dermatology Association, the American Society of Dermatologic Surgery Association, the Illinois Dermatologic Society, and the Illinois State Medical Society. Although certain private health plans offer skin cancer screenings without copayments, HB 3113 is unprecedented in the United States in mandating copayment elimination for statewide skin cancer screening.
Because the magnitude of the benefit of population-based skin cancer screening remains largely unknown, the decision about whether to screen also requires careful consideration of potential harms, including overdiagnosis, false-positive test results, procedure-associated physical harms, and psychological harms. Overdiagnosis is the diagnosis of disease that would have otherwise never produced any symptoms or shortened the life of the person diagnosed. With respect to melanoma, there is accumulating evidence that an increasing number of detected melanomas are overdiagnosed. Although large screening initiatives have increased melanoma detection, none have shown clear reductions in advanced disease or mortality, which are the most important outcomes of a successful screening program.6 For example, in the Skin Cancer Research to Provide Evidence for Effectiveness of Screening in Northern Germany (SCREEN) study, the incidence rates of melanoma in the screened population were 162 per 100 000 compared with 24 per 100 000 in the unscreened population, with no long-term decrease in melanoma mortality.7,8 Similarly, in an ongoing quality initiative study in western Pennsylvania, incidence rates among screened individuals were 94 per 100 000, and 37 per 100 000 in the unscreened group, with no difference in the incidence of thick melanomas diagnosed.9 These findings suggest that the more one searches for melanoma, the more one will find it, and the association between increased screening and morbidity or mortality remains uncertain. This phenomenon is not unique to melanoma and has been a well-documented associated harm in other screening programs (breast, prostate, thyroid).
Apart from the uncertain benefits of population-based skin cancer screening, keratinocyte carcinomas (KCs) are by far the most common type of skin cancer, representing more than 97% of all skin cancers diagnosed in the United States. Increased screening will undoubtedly lead to a surge in diagnosis of KCs. In the German SCREEN study, the number of KCs detected increased by 47% for women and 34% for men.7 Keratinocyte carcinomas are rarely fatal, but they can be expensive to treat. Incentivizing skin screening examinations for asymptomatic, average-risk patients has the potential to increase these costs substantially, with uncertain morbidity or mortality benefit compared with current practice.
Paradoxically, HB 3113 may lead to increased cost to patients. The screening examination is only part of the potential cost to patients. Although the copayments may be waived for screening, what happens if a potential skin cancer is detected? Will associated diagnostic procedures (ie, biopsy and pathological examination) be covered without cost sharing? These are important questions for patients to ask ahead of time, and a lack of clarity about the answers could result in important financial burdens. For example, implementation of copayment elimination for colorectal cancer screening, a service well-proven to reduce morbidity and mortality, has suffered from a lack of clarity about downstream costs.10 Another worry is that screening low-risk people may crowd out patients in dermatology clinics with higher-risk presentations.
Given the uncertain magnitude of benefits and harms of skin cancer screening, an alternative approach to reduce the barrier to screening could be to offer it without copayments in the context of a trial to assess the effectiveness of the intervention (coverage with evidence development). In this way, patients who participate in a trial could have increased access to screening while society and payers benefit from gaining additional evidence to better assess whether population-based skin cancer screening saves lives or improves quality of life. Alternatively, if HB 3113 is ratified, the state could serve as an intervention group in a natural experiment to examine the effects of eliminating copayments on skin cancer incidence and mortality rates as well as the economic consequences from potentially increased health care use, with nearby similar states serving as a control group.
Manipulation of copayments can alter patient behavior and should be employed judiciously. The elimination of copayments may increase the chances of early detection of skin cancer, but it may also result in overdiagnosis, increased costs, physical/psychological harm, and false-positive results, and it may crowd out care of other disorders. We must be careful how we align incentives to promote the delivery of high-value, patient-centered care. Before implementing population-based interventions like this one, we should fully understand the harms and benefits. Entrusting nonphysician policymakers to evaluate medical evidence, provide recommendations, and decide on benefit design is problematic, regardless of how it aligns with one’s point of view. At this time, HB 3113 should be vetoed by the Governor of Illinois.
Corresponding Author: Adewole S. Adamson, MD, MPP, Division of Dermatology, Department of Internal Medicine, Dell Medical School, University of Texas at Austin, 1601 Trinity St, Stop Z0900, Austin, TX 78712 (firstname.lastname@example.org).
Published Online: August 16, 2019. doi:10.1001/jamadermatol.2019.2797
Conflict of Interest Disclosures: Dr Pignone is a former member of the US Preventive Services Task Force. No other disclosures were reported.
Disclaimer: The views expressed here are those of Dr Pignone and not necessarily those of the US Preventive Services Task Force. Drs Adamson and Pignone are employees of the University of Texas. The views expressed here are theirs alone and do not necessarily reflect those of the institution.
Meeting Presentation: This paper was presented at the Annual Meeting of the American Dermatological Association; August 16, 2019; Sarasota, Florida.
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Adamson AS, Pignone MP. Eliminating Copayments for Skin Cancer Screening—A Public Health Policy With Insufficient Evidence. JAMA Dermatol. Published online August 16, 2019. doi:10.1001/jamadermatol.2019.2797
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