Incorporating cost into shared decision making conversations
In 2015, Medicare began reimbursing doctors for lung cancer screening with CT in high-risk populations, after the National Lung Screening Trial (NLST) found an association between screening and reduced lung cancer mortality. However, because of the high rate of false positives and potential for overtreatment from these CT scans, the Centers for Medicare and Medicaid Services (CMS) requires doctors and patients to have a “shared decision making visit” to discuss the costs and benefits of screening before performing the scan.
Despite the best intentions of CMS, the shared decision making (SDM) requirement is not going as well as policymakers had hoped. A study last year found that the quality of these SDM conversations were very poor; most lasted less than one minute, did not include an explanation of potential harms, and did not use required decision aids.
Even when SDM conversations include a discussion of risks and benefits, providers may be still underestimating the potential harms of screening. The patient decision aid created by the Agency for Healthcare Research and Quality, “Is lung cancer screening right for me?” draws estimates of harm from the National Lung Screening Trial (NLST). According to the NLST, the rate of complications from invasive lung procedures was about 8-10%, or less than 1 in 1000 people screened, as illustrated by the decision aid. However, the real-world results of lung cancer CT screening may be different. In a recent analysis in JAMA Internal Medicine, researchers found that in a nationally representative sample of patients in the community, the rate of complications from invasive procedures to assess lung abnormalities was about 22-24%, more than twice the rate found in the NLST.
Another issue with the SDM decision aid is that financial cost is almost entirely left out of the equation. In the decision aid, there is only a description of the requirements for Medicare to cover lung cancer screening, and a brief mention of possible “additional costs for followup tests and/or treatments after the initial screening exam.” However, the financial costs of follow-up can be substantial, because of the possibility of complications from invasive diagnostic tests. These costs need to be included in conversations about screening.
According to the JAMA study, the financial cost of complications from invasive lung procedures ranged from $6,320 for minor complications to $56,845 for major complications on average. While Medicare may cover the care necessary to recover from complications, private insurance may not. Patients with high-deductible plans may find themselves with bills amounting to tens of thousands of dollars because of a screening they believed was covered by insurance. The fact that the financial harms are not included in the patient decision aid under the “Possible benefits and harms” section is irresponsible. Just as damaging are specialty societies and health news sources that tout this type of screening as a “no-brainer” without considering the potential financial costs.