LDCT lung cancer screening: An actuarial affirmation

The numbers are in, and they add up to a fire hose of data pushing Medicare to cover low-dose CT (LDCT) screenings for lung cancer in all beneficiaries who are at high risk.

Medicare has been considering paying for such screenings for some time, and a recent cost-benefit analysis by Milliman Inc., the Seattle-based actuarial consultancy, buttresses prior studies that established clinical efficacy, infrastructure availability and, now decisively, cost-effectiveness.

The Milliman data, published in the August issue of American Health and Drug Benefits, show that use of recommendations on lung cancer screening from the United States Preventive Services Task Force (USPSTF) stand to save tens of thousands of lives—and untold dollars—each year.

Lung cancer is far and away the most deadly form of cancer. This year it is expected to kill approximately 159,260 Americans, accounting for 27% of all cancer deaths. It also is one of the most expensive forms of cancer to treat. The National Institutes of Health estimates that $12.1 billion was spent on lung cancer treatments in 2010 alone. Meanwhile, NIH places the five-year survival rate for lung cancer at 53.5% for cases detected when the disease is still localized within the lungs. The survival rate plunges to just 3.9% for patients with metastasis to other organs—and only 15% of lung cancer cases are diagnosed at an early stage.

The Milliman analysis shows that close to 5 million high-risk Medicare beneficiaries would meet criteria for lung cancer screening in 2014. Using $241 as the average annual cost of LDCT lung screening per person screened, the report states, many high-risk patients could be screened annually at a cost of approximately $1 per member per month. Such screening would be “highly cost-effective, at [less than] $19,000 per life-year saved,” for the three years of screening recommended by the USPSTF for high-risk beneficiaries.

Comparable costing

“The cost to Medicare for an annual low-dose CT screening plus follow-up is approximately 11% lower than that for baseline screening, because of the lower rate of new nodules requiring near-term diagnostic evaluation relative to the initial baseline screening,” the authors write. “Assuming that 50% of the patients aged 55 to 80 years with ≥30 pack-years of smoking were screened, the Medicare cost spread across the Medicare population would be $1.02 per member per month, assuming no cost-sharing for the initial or annual screening LDCT or smoking-cessation session.”

This cost, the report points out, is lower than the Medicare cost for screening mammography.

As for methodology, Milliman drew data from Medicare costs, enrollment and demographics from 2012 CMS beneficiary files, forecasting the figures to 2014 based on CMS and Census Bureau projections. The authors applied standard life and health actuarial techniques to calculate the cost and cost-effectiveness of lung cancer screening. “The cost, incidence rates, mortality rates, and other parameters chosen by the authors were taken from actual Medicare data,” they write, “and the modeled screenings are consistent with Medicare processes and procedures.”

The authors acknowledge several limitations in their study design, including not taking into account “the likely positive effects of the smoking-cessation counseling built into each screening session or effects on productivity, taxes, disability, life insurance costs, or the likely additional costs incurred by Social Security programs because of survivorship from lung cancer.”

Amplification from the ACR

The American College of Radiology has signaled support for the Milliman analysis, issuing a news release pointing out that it reinforces the conclusions of a 2012 study published in Health Affairs that found low-dose CT lung cancer screening is cost effective in high-risk commercially-insured people.

ACR also noted other published data showing that the test is more cost-effective than automobile seatbelts/airbags, along with National Lung Screening Trial data presented to the National Institutes of Health confirming that the test is cost effective, particularly compared to other screening programs.

Ella Kazerooni, MD, chair of ACR’s lung cancer screening committee, said in a published statement: “CT lung cancer screening is cost-effective and significantly reduces lung cancer deaths. Published results show no undue or lasting patient anxiety from the screening process. It is time for Medicare to cover CT lung cancer screening.”

A ready fit?

Many private insurers already cover the screenings, and they will be covered without cost sharing starting January 1, 2015, by nongrandfathered commercial plans, the Milliman authors note.

Had all eligible Medicare beneficiaries been screened and treated consistently from age 55 years, approximately 358,134 additional individuals with current or past lung cancer would be alive in 2014, they conclude, adding that low-dose CT screening would fit well within the standard Medicare benefit, including its claims payment and quality monitoring.

“Furthermore,” they write, “low-dose CT screening has the ability to identify other disease states that are prevalent in the screened age-group and among smokers and former smokers, such as coronary artery disease, aortic aneurysms, other thoracic tumors, and upper abdominal tumors.”

The Milliman analysis, “Offering Lung Cancer Screening to High-Risk Medicare Beneficiaries Saves Lives and Is Cost-Effective: An Actuarial Analysis,” is available in its entirety online