Navigation and Clinician Payment Investments Enhance Colorectal Cancer Screening Benefits

ABSTRACT

Colorectal cancer (CRC) is the second leading cause of cancer-related deaths in the US, with nearly 40% of eligible individuals not current on lifesaving CRC screening. Although stool-based screening tests offer accessible initial options, the CRC screening process is incomplete without a follow-up colonoscopy after a positive result. Unfortunately, low follow-up rates—particularly among socioeconomically disadvantaged groups—undermine the potential health benefits. Recent policies eliminating patient cost sharing for follow-up colonoscopies address one critical barrier but fail to overcome the systemic obstacles that impede screening completion.

Patient navigation programs are a proven strategy to bridge these gaps. By addressing logistical, financial, and educational challenges, navigation services significantly improve follow-up colonoscopy rates. However, inadequate reimbursement has hindered their widespread implementation. Current funding models, including CMS’ Principal Illness Navigation services, fall short of supporting preventive care such as CRC screening.

To fully realize the potential of CRC screening, investments in patient navigation, enhanced clinician reimbursement for follow-up colonoscopies, and systemic reforms are essential. Modeling studies reveal a “win-win-win” scenario: Clinicians receive appropriate compensation for their critical role in follow-up care, payers achieve cost savings through efficient screening processes, and investments in navigation services help close disparities in CRC screening. Expanding navigation programs and incentivizing follow-up colonoscopies would increase screening rates, reduce disparities, and achieve population health gains. These investments represent a rare opportunity to align stakeholder interests, prevent CRC deaths, and advance health equity.

Am J Manag Care. 2025;31(8):In Press

Takeaway Points

Investing in patient navigation, stool-based screening (SBS), and clinician incentives ensures higher colorectal cancer screening rates, reduces disparities, cuts health care costs, and improves population health outcomes. Our practice and policy recommendations are as follows:

• Ensure screening completion: Support navigation programs to guide patients and improve screening completion rates.
• Address disparities: Fund services to improve health care equity for underserved populations.
• Maximize cost savings: Prioritize SBS tests with follow-up colonoscopy and fair reimbursement to reduce costs.
• Leverage win-win-win opportunities: Align strategies to benefit patients, clinicians, and payers, enhancing outcomes for all stakeholders.

Colorectal cancer (CRC) is the second leading cause of cancer-related deaths in the US.1 Despite robust evidence that CRC screening can save lives2,3 and is provided to insured individuals with no out-of-pocket cost, nearly 40% of the eligible US population is not up to date with CRC screening.1 The suboptimal utilization is driven by factors such as lack of awareness, the availability of multiple initial screening options, and systematic barriers to screening navigation, including that certain patients need to perform multiple steps to complete the screening process. Deepening the concern over this suboptimal uptake are the data reported in this issue of The American Journal of Managed Care showing persistent racial/ethnic differences in CRC screening, driven largely by demographic and socioeconomic factors.4

Many individuals choose to undergo initial stool-based screening (SBS) tests—fecal immunochemical test (FIT) and multitarget stool DNA (mt-sDNA)—that are administered at home. When a SBS test result is positive (7% of FITs and 16% of mt-sDNA tests),5 a follow-up colonoscopy is necessary for CRC screening to be considered complete; otherwise, premalignant colon polyps and early-stage cancers may not be detected and treated. This necessary second step after a positive SBS test adds complexity, as it requires coordination across various specialties and health care facilities.

Follow-up colonoscopy rates after a positive SBS test are alarmingly low, with one nationwide study from 2015-2021 reporting that only 43.3% of patients with a positive FIT completed the procedure within the recommended 90-day period and just 56.1% completed it within 360 days.6 This is particularly concerning among vulnerable individuals, such as those with lower socioeconomic status or from racial and ethnic minority groups, who not only have higher rates of SBS testing but also are significantly less likely to complete a follow-up colonoscopy.6

Cost as a Barrier to Receiving Follow-Up Colonoscopy After a Positive SBS Test

Among the many barriers individuals face to receiving a follow-up colonoscopy after an initial positive SBS test, much attention has been paid to patient out-of-pocket costs. Although the preventive services provision of the Patient Protection and Affordable Care Act (ACA) required that all nongrandfathered private health plans eliminate cost sharing for each of the initial CRC screening tests recommended by the US Preventive Services Task Force, many patients faced substantial out-of-pocket costs when undergoing follow-up colonoscopy after a positive SBS test.7 In response, the federal government issued new guidance requiring that commercial insurers eliminate cost sharing for diagnostic colonoscopy following an abnormal SBS test effective January 2023.7 The Medicare program followed suit several months later by including a similar policy effective January 2023.8

The elimination of cost sharing for follow-up colonoscopy should not be viewed as a panacea for optimizing the rate of completion of the CRC screening process. Examining the impact of legislation eliminating cost sharing for follow-up colonoscopy in Oregon and Kentucky, Barthold and colleagues reported that although access to full coverage significantly increased overall CRC screening, the rate of follow-up colonoscopy among individuals who received an initial positive SBS test did not increase.9 This and other research findings suggest that the implementation of policies that address structural (eg, lack of referral for follow-up) and communication (eg, health literacy) barriers is necessary to achieve desired cancer screening outcomes.10-12

Lack of Adequate Payment for Patient Navigation Services for Cancer Screening

Patient navigation programs incorporate streamlined referral processes, team-based care coordination, and access to support services such as transportation and financial assistance to improve receipt of health care and patient outcomes.13 In cancer care, navigation programs have addressed both patient- and system-level barriers and improved cancer screening completion by helping patients understand what clinical care they need, aid in decision-making, and address concerns or obstacles that may arise.14-18 For example, patient navigation programs targeting CRC screening have led to significant improvement in follow-up colonoscopy rates after a positive SBS test.19

Despite the reported positive impact of patient navigation programs in improving patient outcomes,20 their adoption has been limited, driven largely by inadequate financing.21 The cost of CRC screening navigation is not trivial; one 2018 study reported that between $548 and $725 in spending on patient navigation was needed to yield 1 additional screening completion compared with usual care.22 In 2024, CMS introduced Principal Illness Navigation (PIN) services to be provided by certified or trained ancillary care team members under the supervision of qualified providers.23 PIN services support a team-based care management model of care coordination, patient-centered assessments, health education, patient advocacy, peer support, access to community resources, social and emotional support, and behavioral change support. A significant limitation of PIN services lies in their narrow scope of reimbursement, which is currently restricted to care for patients diagnosed with cancer or other high-risk, serious illnesses. This constraint excludes services critical to guiding patients through cancer screening processes. The extension of PIN coverage to include the services necessary to complete the screening process could improve early detection and outcomes in cancer care.

Inadequate Supply of Colonoscopy to Meet CRC Screening Demands

Adding to the many challenges patients face in completing CRC screening is the separate issue of inadequate colonoscopy supply. The US has a current shortage of gastroenterologists that is expected to increase in the near future.24 The limited availability of endoscopists, combined with colonoscopy being the most frequently utilized initial CRC screening method, poses a significant challenge to achieving population-wide cancer screening goals.25

Endoscopy system redesign to prioritize and streamline access to follow-up colonoscopy after a positive SBS test is one potential avenue to ensure that these highest-value procedures are completed. Given the limited capacity, implementing such a fast track to colonoscopy with dedicated rapid-access appointments for individuals with a positive SBS result would require a shift to fewer screening procedures and more follow-up colonoscopies.

Guarantee Adequate Reimbursement for Patient Navigation Services and Follow-Up Colonoscopy

In addition to the well-established clinical benefits of increasing CRC screening, a strong economic case can be made for generous reimbursement of interventions aimed to ensure the completion of follow-up colonoscopy after positive SBS testing, including both patient-facing navigation programs and provider-facing components, such as increased payment for follow-up colonoscopy. Previous modeling studies showed that colonoscopy performed following a positive SBS test produces substantially more clinical benefit and revenue than when colonoscopy is performed as an initial CRC screening test.26

Given that current US colonoscopy capacity is likely fixed for at least the short term, strategies are needed that provide endoscopists with appropriate financial incentives to ensure that more follow-up colonoscopy examinations are accessible to all those who test positive with a SBS test (and fewer initial screening colonoscopies are performed). These higher payments for follow-up procedures have the potential to produce several clinical and economic advantages over the status quo, as modeling studies report that follow-up colonoscopies produce net CRC cost savings if reimbursement for the follow-up procedure is less than $6448 for commercial plans and $5652 paid by Medicare—significantly higher amounts than current payment levels.27

This approach of incorporating more initial SBS screening, patient navigation, and clinician incentives to perform more follow-up colonoscopy has the potential to (1) increase the number of individuals initially screened for CRC, (2) increase the number of individuals who complete the CRC screening process through follow-up colonoscopy, (3) decrease the total spending on CRC screening and treatment, (4) increase colonoscopy reimbursement while maintaining full capacity, (5) reduce the environmental impact of CRC screening (compared with colonoscopy screening, mt-sDNA testing substantially reduces carbon emissions),28 and most importantly (6) substantially improve the population health benefits due to CRC cases prevented (from polyp removal) and early detection of more treatable CRC cases.

This extremely rare win-win-win for patients, clinicians, and payers should compel stakeholders to further invest in patient navigation and other support services that facilitate completion of the overall CRC screening process, while simultaneously ensuring adequate access to, and generous reimbursement for, follow-up colonoscopy. Such investments are urgently needed, are feasible to implement, and will yield positive outcomes for all stakeholders.

Author Affiliations: School of Nursing (PJZ), Institute for Healthcare Policy and Innovation (PJZ), and Center for Value-Based Insurance Design (AMF), Ann Arbor, MI; Michigan Medicine, University of Michigan (AMF, JEK), Ann Arbor, MI; Department of Health Management and Policy, School of Public Health, University of Michigan (AMF), Ann Arbor, MI; Department of Internal Medicine, University of Michigan Medical School (AR), Ann Arbor, MI; VA Center for Clinical Management Research (AR), Ann Arbor, MI.

Source of Funding: This work was supported by the National Cancer Institute institutional training grant T32-CA-236621.

Author Disclosures: Dr Fendrick reports serving as a consultant to AbbVie, CareFirst BlueCross BlueShield, Centivo, Community Oncology Alliance, EmblemHealth, Employee Benefit Research Institute, Exact Sciences, Grail, Health at Scale Technologies,* HealthCorum, Hopewell Fund, Hygieia, Johnson & Johnson, Medtronic, MedZed, Merck, Mother Goose Health,* Phathom Pharmaceuticals, Proton Intelligence, RA Capital Management, Sempre Health,* Silver Fern Healthcare,* Teladoc Health, US Department of Defense, Virginia Center for Health Innovation, Washington Health Benefit Exchange, Wellth,* Yale New Haven Health System, and Zansors* (asterisks indicate equity interest); research funding from Arnold Ventures, National Pharmaceutical Council, Patient-Centered Outcomes Research Institute, Pharmaceutical Research and Manufacturers of America, and Robert Wood Johnson Foundation; and outside positions as co–editor in chief of The American Journal of Managed Care, past member of the Medicare Evidence Development & Coverage Advisory Committee, and partner at VBID Health, LLC. The remaining authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (PJZ, AMF, JEK, AR); drafting of the manuscript (PJZ, JEK); critical revision of the manuscript for important intellectual content (PJZ, AMF, JEK, AR); administrative, technical, or logistic support (PJZ); and supervision (PJZ, AMF, AR).

Address Correspondence to: Portia J. Zaire, PhD, RN, University of Michigan, 2800 Plymouth Rd, Bldg 14, Ste G100, Ann Arbor, MI 48109. Email: Pzaire@umich.edu.

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