How to Ensure Affordable Medical Imaging and Diagnostics Through Health Plans | EBA

Most estimates of the cost-effectiveness of screening and diagnostic examinations are based on imaging costs in university health systems rather than affordability of examinations, which can now be provided quite widely in employer-sponsored health plans.

The widespread availability of more affordable quality screening and diagnostic exams nationwide—coupled with the lifestyle and health changes brought about by the pandemic and the disruption of COVID-19 in cancer screenings and imaging—has likely changed this equation. . Clearly, rigorous studies should be undertaken to reassess the cost-effectiveness.

But “cost effectiveness” also has a different equation in the employer health plan space, as time lost from work and work efficiency are also affected by employee health status. Even a four-week delay in cancer treatment is associated with a 6% to 13% higher risk of death, according to a 2020 study published in British Journal of Medicine. This elevation also results in more invasive and expensive therapy and time lost from the workplace.

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Colorectal cancer is the second leading cause of death in the United States. According to a review article published in January 2022 by Texas Tech University, by April 2021, rates of routine screening colonoscopies were 50% lower than before the pandemic, with a resulting 53% drop in colorectal cancer surgeries . The overall colorectal cancer screening deficit is estimated at 3.8 million cases in the US

With a three to four month lag in endoscopy centers, alternative screening methods such as fecal immunochemical stool DNA testing and technology should be considered in normal-risk individuals, although this would not preclude a colonoscopy if the results are positive. The economics of covering DNA testing for these individuals to catch disease at an early stage, even if the repeat screening interval is shorter than colonoscopy, needs to be reevaluated.

A screening mammogram is covered by most employer health plans, but a woman with a new breast lump is usually subject to a deductible and coinsurance for a diagnostic mammogram and ultrasound. Mergers and acquisitions in the radiology and ambulatory imaging facilities are dramatically increasing the cost of these exams. That means it’s not uncommon for out-of-pocket costs for these tests to exceed $1,000 at negotiated rates in self-funded employer health plans, a cost well over $400 half of Americans don’t have to spend on emergency health care. These numbers strongly suggest that employers should consider covering all breast imaging in their plan for free.

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Non-alcoholic fatty liver disease is a silent epidemic in the US, affecting 20% ​​of adults and 10% of children. It is an established risk factor for leading causes of death and impairment: cancer, cardiovascular disease and type 2 diabetes. Screening for fatty liver can be done in an accessible environment with a portable machine (at the workplace or in a nearby clinic) with abdominal ultrasound. In addition, lifestyle changes can reverse the disease and prevent long-term illness and costs.

The same ultrasound examination can detect tumors in the abdominal organs, fatty deposits in the kidneys as a precursor to diabetic kidney disease, and atherosclerotic disease of the aorta or aneurysm. And the most sensitive examination for quantifying cardiovascular risk is not the stress test. This is a computed tomography (CT) scan with a calcium result. The same portable ultrasound machine can be used to measure the thickness of a blood vessel layer in the neck to screen for those who need to undergo a CT scan to quantify their risk. Both carotid and calcium CT scans can be quite affordable for self-funded health plans to offer if members are appropriately directed to affordable providers.

When self-funded employers fulfill their fiduciary obligations and contract for services through affordable independent providers, rather than subjecting plan and members to sky-high negotiated rates at private equity-backed hospital systems and consolidators, the economics of health care change. Dollars that would instead be overspent can be diverted to detect early indicators or diseases and early cancers and redirected to increasing wages or improving other benefits.

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