As CT lung cancer screening wallows in unreimbursed limbo, pioneers are developing strategies to deliver screening to all patients. Lahey Hospital & Medical Center detailed its success with a free lung cancer screening program in an article in the May issue of Journal of the American College of Radiology.

Since the National Lung Screening Trial (NLST) demonstrated a 20 percent reduction in lung cancer mortality in 2011, practices across the U.S. have grappled with whether and how to offer lung cancer screening to high-risk individuals, i.e., adults ages 55 to 74 years, at least a 30 pack-year smoking history and current or former smokers.

Lahey Hospital in Burlington, Mass., convened a multidisciplinary committee—comprised of representatives from radiology, pulmonology, radiation oncology, medical oncology, internal medicine, administration, finance, philanthropy, business development and marketing—to design and implement a lung cancer screening program beginning Jan. 9, 2012.

“The most important and vexing decision we made during the conception of our screening program was whether to charge for the screening examinations,” wrote Brady J. McKee, MD, of Lahey Hospital, and colleagues.

Ultimately, the committee decided ethical responsibility called for equal access to screening for all high-risk individuals and implemented a free screening model that will stand until reimbursement is broadly established.  

Other key decisions in the implementation process included use of the PET/CT and CT scanners during regular daily downtime early in the day and late in the afternoon. The hospital also added a dedicated 40-hour overnight and weekend shift to meet expected capacity.

The initial screening exam is provided free of charge to patients, but all follow-up exams and interventions are billed to insurance, which creates revenue to support the program.

“By modeling our own situation, we estimated that in the first 2 years of our screening program, 60% to 80% of the revenue available to offset the cost of free screening would be derived from treating lung cancer. In years 3 to 10, the revenue derived from interval diagnostic LDCT [low-dose CT] follow-up of small pulmonary nodules and lung cancer treatment become equally important revenue sources,” wrote McKee et al.

The hospital also developed a standardized CT reporting system based on BI-RADS and engineered a comprehensive physician education and outreach program. Its policies require a referral by a primary care physician prior to a screening exam. The education campaign is centered on four key points:

• Setting the stage for effective informed consent;
• Dispelling the misperception that links lack of reimbursement with lack of recommendation or benefit to CT screening;
• Monitoring appointments in a process similar to mammography; and
• Making available a multidisciplinary team of physicians to offer management and treatment recommendations for patients with findings suspicious for malignancy.

Lahey Hospital created and shares a list of frequently-asked questions with all patients and communicates with patients by phone one or two days prior to and within three weeks after the exam.

“If a [lung cancer screening] program were implemented nationwide in the United States, CT lung screening has the potential to save ≥ 1,000 lives every month.”

Achieving this outcome, according to McKee et al, requires standardization of operations across screening sites, and the authors called on the American College of Radiology to develop a comprehensive practice guideline on lung cancer screening.

Finally, the authors acknowledged that lack of reimbursement presents a barrier to screening and recommended “a vigorous lobbying effort … to expedite reimbursement to eliminate the health care disparities this situation creates and make CT lung cancer screening equally available to all patients at high risk.”