Eliminating Cost Sharing Boosted Follow-Up Colonoscopy Rates

Removing patient cost sharing for follow-up colonoscopy after a positive stool-based test significantly increased procedure rates nationwide, according to a new study.1 The findings underscore how eliminating financial barriers can help close critical gaps in colorectal cancer (CRC) screening completion.

This retrospective cohort study is published in Current Medical Research and Opinion.

Removing out-of-pocket costs for follow-up colonoscopy led to an immediate and sustained increase in utilization. | Image credit: shevchukandrey - stock.adobe.com

“The elimination of cost-sharing for follow-up colonoscopy represents the combined effect of two coordinated federal actions: tri-department guidance applying to ACA [Affordable Care Act]-compliant and private insurance plans, and a CMS rule extending coverage to Medicare beneficiaries, both effective January 2023,” wrote the researchers of the study. “Our analysis demonstrates that these aligned policies were associated with an immediate and sustained increase in follow-up colonoscopy utilization after a positive stool-based test.”

Despite the Affordable Care Act’s mandate for no-cost CRC screenings, many patients still faced significant out-of-pocket costs for bowel preparation, particularly low-volume products preferred for tolerability.2 A recent analysis of more than 2.5 million prescription claims found that 53% of commercially insured and 83% of Medicare Part D patients incurred cost sharing, with median out-of-pocket amounts reaching up to $60. These unexpected expenses may create barriers to completing screening colonoscopies, potentially undermining national screening goals and exacerbating disparities in preventive care.

In this study, the researchers used a large, nationally representative health care claims database linked with laboratory data from January 1, 2022, to December 1, 2023.1 The study population included adults aged 45 to 75 years who underwent colonoscopy during this period.

The primary outcome was the rate of follow-up colonoscopy—defined as a diagnostic colonoscopy performed within 6 months of a positive stool-based test. To assess the impact of the federal policy eliminating patient cost sharing, the investigators used an interrupted time series design with a seasonally adjusted segmented autoregressive model to estimate changes in utilization before (January 2022 to December 2022) and after (January 2023 to November 2023) the policy’s implementation.

This approach allowed researchers to isolate the effect of the cost-sharing elimination while accounting for seasonal trends and underlying temporal patterns in screening behavior.

Among more than 10.8 million adults who underwent colonoscopy between January 2022 and November 2023, follow-up procedures after a positive stool-based test accounted for 3.59% of all colonoscopies before the cost-sharing policy change. Following implementation of the federal policy eliminating patient out-of-pocket costs in January 2023, there was an immediate and statistically significant 41.2% relative increase in follow-up colonoscopy utilization—an absolute rise of 1.48% (95% CI, 1.25-1.71; P < .001)—which was sustained through the end of the study period.

However, the researchers acknowledged several limitations. First, it focused only on follow-up colonoscopy after positive stool-based tests and did not assess effects on initial screening or other modalities. Second, the claims-based data set lacked information on patient, provider, and access-related factors that may have influenced adherence. Third, although follow-up rates increased after cost-sharing elimination, other factors—such as renewed preventive care efforts or broader system recovery—may have contributed. Lastly, the short study period and absence of a control group limited causal inference.

Despite these limitations, the researchers believe these findings suggest that removing financial barriers led to a meaningful and lasting improvement in completion of the CRC screening process, reinforcing the role of policy interventions in increasing adherence to evidence-based preventive care.

“A significant increase in follow-up colonoscopy utilization was observed following the elimination of consumer cost-sharing, coinciding with the implementation of coordinated federal policies across both commercial and Medicare populations,” wrote the researchers. “By removing financial barriers for all major payer groups, these policies support more complete colorectal cancer screening by facilitating completion of the diagnostic process following a positive stool-based test.”

References

1. Greene M, Le QA, Ozbay AB, et al. Completing the colorectal cancer screening process: impact of eliminating cost-sharing for follow-up colonoscopy. Curr Med Res Opin. 2025;1-8. doi:10.1080/03007995.2025.2577763

2. Steinzor P. Many still pay for colonoscopy prep despite ACA coverage mandate. AJMC®. June 20, 2025. Accessed October 23, 2025. https://www.ajmc.com/view/many-still-pay-for-colonoscopy-prep-despite-aca-coverage-mandate