Colorectal cancer (CRC) is a leading cause of cancer-related deaths in the United States. The risk of mortality is substantially increased for individuals who do not receive screening, and the Centers for Disease Control and Prevention has made it a goal to have 80% of individuals older than 50 years regularly screened. The trial by Mehta et al1 tests whether financial incentives can increase CRC screening rates for patients who are not up-to-date using mailed fecal immunochemical test kits. The authors find that no incentive—in the form of pharmacy gift cards given unconditionally, conditional on completion, or in a high-payoff lottery—fared better in increasing fecal immunochemical test response rates than simply mailing the test with no financial reward.
There have now been a number of randomized clinical trials on initiatives that attempt to increase compliance of CRC screening, with positive but somewhat varied results.2 It is clear, however, that outreach in the form of sending kits by mail has a positive effect and that pecuniary incentives seem to have little to no effect on increasing completion rates beyond simply sending the patient a test kit and a reminder. Mehta et al1 showed this held true whether or not the payment was conditional on actually returning the test. This corroborates results from similar trials on financial incentives for at-home CRC screening, yet it is still a puzzling finding. While arguments can be made about power and study design, it goes against literature that shows a positive effect of financial incentives and conditional cash transfers for preventive care.3,4
Colorectal cancer screening is far from the only domain in preventive care with low uptake rates, especially for underserved populations. Randomized clinical trials from the developing world have found high price sensitivity for preventive services, even when individuals value the service.5 In the United States, the passage of the Affordable Care Act required that these services be provided without cost sharing, yet only half of elderly and near-elderly US individuals are up-to-date on preventive services. There are likely many reasons for this, including lack of information, lack of health care access, mistrust of care and insurance providers, and the lack of tangible immediate benefits.
Many of these reasons are institutional and difficult to address, and the problem is compounded when examining disadvantaged populations. However, future studies in CRC screening outreach could address 2 outstanding questions. First, is there a cost-effective financial incentive that can achieve optimal levels of screening? While it is clear that some price point will overcome the barriers associated with CRC screening, overinclusion quickly becomes a concern. It has been typical in these studies to offer $5 to $10, and Mehta et al1 speculate that the amount required is $15 based on postintervention interviews. Wellness programs offered by employers have been shown to generate savings for encouraging preventive care, but the lack of evidence on specific amounts currently inhibits cost-benefit analyses.6
It is possible that there is no cost-effective way to provide financial incentives to bring patients into compliance with CRC screening, and targeted outreach will be the optimal approach for most care and insurance provider groups. Thus, the second question is how to best direct these efforts. Kaiser Permanente California has found it worthwhile to send more than half a million CRC screening kits annually, and the Department of Veterans Affairs maintains a reminder system that has led to high screening rates. With such large populations, small changes to drivers of health behavior such as framing, timing, and follow-up can be tested experimentally on a continuous basis.7 This could help develop evidence-based strategies for specific settings and populations at relatively low cost.
While CRC screening clearly has tremendous upside, many patients remain difficult to reach, particularly among disadvantaged populations. Small financial incentives have not been shown to work better than outreach alone, and it remains unclear if this strategy can be a part of long-term efforts to reach CRC screening goals.
Published: March 22, 2019. doi:10.1001/jamanetworkopen.2019.1168
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2019 Rose L. JAMA Network Open.
Corresponding Author: Liam Rose, PhD, Stanford Surgery Policy Improvement Research and Education (S-SPIRE) Center, Stanford University, 1070 Arastradero Rd, Stanford, CA 94305 (email@example.com).
Conflict of Interest Disclosures: None reported.
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