Financial Incentives to Improve Colorectal Cancer Screening – Time to Cut our Losses

Commentary

Colorectal cancer (CRC) screening effectively reduces mortality from this second leading cause of cancer deaths in the United States (U.S.).¹ However, only 69% of eligible adults in the U.S. are up to date with CRC screening, with lower rates of screening for racial/ethnic minorities and individuals of lower socioeconomic status.¹ Therefore, evidence-based interventions to improve CRC screening adherence are needed, especially interventions that address these disparities. In this issue of JAMA Network Open, Facciorusso et al. present their systematic review and meta-analysis of randomized controlled trials (RCTs) to evaluate the benefit of financial incentives upon CRC screening uptake.² This study included RCTs of adults eligible for CRC screening who received various forms of financial incentives (fixed or lottery-based incentives, unconditional incentives, or conditional incentives upon screening completion) compared to no financial incentives (everyone receiving either CRC screening reminders or mailed outreach). The primary outcome of interest was CRC screening completion using recommended tests within 12 months of intervention. The authors identified 8 RCTs that met inclusion criteria, representing 110,644 patients (53,444 offered financial incentives and 57,200 not offered financial incentives). These U.S.-based studies, reported between 2014 and 2020, included screening with fecal occult blood tests (4 RCTs), colonoscopy (3 RCTs) or a menu of options (1 RCT). The economic interventions included fixed incentives of $5–20, lotteries with a 1:10 chance of winning $50–100, or a chance to enter a $500 prize raffle. Facciorusso et al. found that adding financial incentives is estimated to only modestly increase CRC screening such that for those undergoing stool-based screening, screening adherence would be expected to increase by 3.5% from a baseline of 30% to 33.5%.² More importantly, this study revealed that the magnitude of benefit from financial incentives decreased as the proportion of individuals of lower socioeconomic status, non-white participants, and those overdue for CRC screening increased - populations that are disproportionately impacted by CRC and where the need to improve CRC screening, is the greatest. Furthermore, these findings were not significantly impacted by the type or amount of intervention, or by the screening modality. Finally, among higher quality studies and in those that included only individuals not up-to-date with screening, there was no significant benefit of financial incentives.

Behavioral Economics principles suggest that financial incentives are useful when behavior change can reduce future health expenditures.³ For this reason, financial incentives have been explored to promote smoking cessation, physical activity, cancer screenings, and vaccinations – including COVID-19. There is evidence that financial incentives may work best at motivating behavior change when they are simple (one-time behavior change), tied to controllable outcomes, and reinforce what individuals already want to do.⁴ As Facciorusso et al. report, the benefit of financial incentives was significantly higher when CRC screening completion was assessed within 3 months of the financial incentive than when assessed at longer intervals, consistent with the theory that individuals already primed to complete CRC screening may be motivated to do so with a financial incentive. When it comes to financial incentives, size matters. Small incentives, as most frequently studied in the included RCTs, can sometimes backfire by decreasing intrinsic motivation and performance compared to no incentive at all.⁵ Rather than focusing on the intrinsic health benefits of screening, the incentive may cause some individuals to interpret the incentive as compensation for exposure to negative aspects of the screening test. Thus, those who receive a financial incentive may defer future screenings in the absence of these incentives. Conversely, large incentives could potentially be coercive, especially in CRC screening where the greatest need is among historically marginalized and underserved populations.⁴ So, while money may be a powerful motivator, the benefits of financial incentives might not be realized in CRC screening because it requires repeated screening tests over many years and the outcome of each screening episode is uncertain.

While Facciorusso et al. found little evidence to support financial incentives, other interventions have been demonstrated to consistently increase CRC screening uptake.⁶ These include but are not limited to implementation of mailed FIT outreach⁷ and patient navigation – which would assist individuals through the screening process beginning with the decision to complete screening and ending with a plan for follow-up of abnormal results or repeat screening. Implementation of these proven strategies are especially important considering the recent Grade B recommendation from the United States Preventive Services Task Force to begin CRC screening in adults ages 45 to 49.¹ As a result, an additional 20 to 22 million Americans are now eligible for CRC screening. While colonoscopy remains the primary modality for CRC screening in the U.S., increased demand for this limited resource may lead to increased adoption of population health strategies, including mailed FIT outreach. As screening behaviors of individuals 45–49 years old is unknown, financial incentives may be explored to incentivize screening in this population. However, based on the mounting evidence on this topic as summarized by Facciorusso et al., we would advise investigators to proceed with caution. Considering limited healthcare dollars, future resources might be best spent doubling down on interventions that have demonstrated efficacy and cost-effectiveness, such as mailed FIT⁷ and patient navigation. Doing so could be especially significant for racial/ethnic minorities, individuals of lower socioeconomic status, and other populations that have yet to realize the full benefit of CRC screening.

When it comes to CRC screening, there are multiple other areas that could benefit from financial investments. First, we need to ensure that when CRC screening is performed, it is of high-quality whether it is by FIT, colonoscopy, or another recommended modality. For example, ensuring timely completion of colonoscopy to evaluate an abnormal non-colonoscopic screening test would greatly reduce CRC-associated mortality. Unfortunately, adherence with these important follow-up procedures is highly variable, ranging from 30% to 82%.⁶ Second, we need to address persistent racial, ethnic, and socioeconomic disparities in CRC mortality due to inadequate screening. Third, efforts to improve underutilization of CRC screening will need to be coupled with strategies to address the potential harms from overutilization (e.g., screening those who are too frail to benefit). Facciorusso et al’s paper suggests that it is time we stop giving small financial incentives to individuals for questionable short-term benefits and begin making additional financial investments into practices that address known patient, provider, health system and policy barriers to screening. As the saying goes, ‘money isn’t everything’, but in CRC screening, investing in evidence-based strategies could be everything for those affected by this highly preventable and all too common disease.