Jim Kling

October 28, 2013

SAN DIEGO, California — An offer of a $50 gift card to Target increased colorectal cancer (CRC) screening in men by about 15% over a standard program. The effect was smaller than the sponsoring insurance company had hoped for, but further analysis of the data suggested that subpopulations were more likely to respond to the incentive. This suggests that different strategies could be required for different plan designs and member populations.

"People don't really offer gift cards to get health services done. We're trying to give patients that boost of motivation to get something done that in many cases they know they should do, but [have trouble] finding the time to do," Sandra Marinace, MPH, director of clinical program development at the health benefit company WellPoint, which carried out the program, told Medscape Medical News. Marinace presented the research here at the American College of Gastroenterology (ACG) 2013 Annual Scientific Meeting and Postgraduate Course.

State-by-state surveys show that between 25% and 44% of eligible adults do not undergo CRC screening. The researchers set out to determine whether a $50 gift card incentive would increase screening rates for men. They compared the gift certificate incentive with an educational outreach effort of a letter followed by an interactive voice recognition (IVR) telephone call.

The study included 23,524 men enrolled in Blue Cross Blue Shield of Georgia fully insured commercial insurance products. According to claims analysis, there was no evidence they had undergone CRC screening. The researchers randomly assigned the men to 2 quality improvement programs, and both groups received a Health Insurance Portability and Accountability Act (HIPAA)-compliant letter telling them they were overdue for CRC screening, followed 1 week later by a HIPAA-compliant IVR telephone call with the same message. One group of 4000 members (incentive group) also received a mailed offer of a $50 gift card if they completed CRC screening.

Among those in the incentive group, 2.2% redeemed the $50 gift card. As of July 1, 2012, 3690 members of the incentive group were noncompliant. Of those patients, 5.11% underwent CRC screening by the end of the year. Of the 17,874 members who received the standard letter and IVR, 4.48% completed CRC screening in the same period (2-tailed P-value, 0.09; odds ratio [OR], 1.152; lower confidence interval [LCI], 0.978; upper confidence interval [UCI], 1.355). Among members with health maintenance organization (HMO) coverage, the effect was more pronounced (2-tailed P-value, 0.006; OR, 1.606; LCI, 1.146; UCI, 2.252).

The results were less than Marinace had hoped for. "When we didn't see a bigger impact, we looked at what populations that it does work on. It seemed like there were certain characteristics that people had that made them more likely to respond — being healthier, having an HMO plan — and maybe you could tie that to characteristics that make them more likely to choose an HMO over a [preferred provider organization] or a consumer-directed health plan," Marinace said.

Healthier people might be more proactive about their health. "If you're a diabetic, are you more worried about colorectal cancer screening, or are you more worried about controlling your diabetes? It could be that people who are healthier...are more receptive to an incentive offer," she added.

In contrast, sicker people may be more likely to be getting screened anyway because they see their physician regularly and are receiving encouragement.

The study suggests that financial incentives might not be the best route, according to Sushovan Guha, MD, PhD, associate professor of gastroenterology, hepatology, and nutrition at the University of Texas Medical School at Houston, who attended the presentation. "What was striking to me was that only very few [individuals] availed themselves of the gift card," he told Medscape Medical News.

In fact, of the people who received the gift card offer and underwent screening, fewer than half actually claimed the gift card. "Maybe there are other things we need to look at. Is it time away from work, do they have some scheduling issues or conflicts with family issues like taking care of their kids? There are a lot of other things we need to look at, not just providing a $50 check. We need to identify certain age groups, certain ethnic groups, certain education background, look at this from an economic perspective, and see whether [a specific] population will benefit from incentive, or if they just might need a babysitter and they will be happy to come without an incentive. It's not one size fits all," said Dr. Guha.

Marinace is an employee of WellPoint, which implemented the program. Dr. Guha has disclosed no relevant financial relationships.

American College of Gastroenterology (ACG) 2013 Annual Scientific Meeting and Postgraduate Course: Abstract 20. Presented October 15, 2013.

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