Recently this cheery subject line appeared in my email inbox: Yes, Jennifer. There’s an easy way to screen for colon cancer and get a $25 Amazon gift card! The idea of an email solicitation—with a gift card incentive—for colon cancer screening seemed ludicrous. I deleted the email, and didn’t think about it again until…
A couple weeks later my mail carrier delivered a bulky envelope stamped Colorectal Cancer Screening Test Kit. What the heck?!? I’m not due for a colonoscopy until 2022, and I don’t make a habit of wearing out my welcome at the gastroenterologist’s office.
In the envelope was a generic cover letter from my insurance company (oops! I mean my health plan. Have you noticed this change in terminology? It’s a worthy subject for another day.) The letter contained such banalities as: We at Aetna care about your health. …achieve your health goals. …no cost to you. …feel good and live well. A piece of biodegradable paper and a tiny vial with an integral poop scoop were folded together with a pre-paid Business Reply Mail envelope. (No cost to me!) And there was the lab test request form.
The ordering physician was Faisal Saeed, but I don’t know any such doctor. All my identifying information—name, date-of-birth, address, phone number, gender—was on the form. Dr. Saeed seemed to know all about me, except for the fact that I had had a colonoscopy in 2012 and wasn’t due back for more than two years—the fact most pertinent to this lab test. The test request form indicated that LabCorp in North Carolina would analyze my poop at the request of BioIQ. I called Aetna on their member customer service line. (“Members.” Similar to a country club, but instead of a drink delivered poolside, I get a poop vial delivered by U.S. Mail.) Forty minutes and at least two levels of supervisors later, I had no answers. They seemed as baffled as I was. They couldn’t identify BioIQ, and they didn’t know Dr. Saeed. They didn’t seem to grasp why I was calling, as they asked for the umpteenth time, “What exactly is your complaint? Have we billed you incorrectly?” I hung up and looked elsewhere for answers.
BioIQ’s website states their goal is to “close gaps in care” by making convenient health screenings for critical diseases such as colon cancer widely accessible. To accomplish this, they partner with health plans, like Aetna, whose Star and HEDIS quality ratings improve when higher percentages of their “members” get routine testing. BioIQ accesses the data base of companies like Aetna, and handles the email marketing. They follow-up with the mailed lab request form and sample vial. Their technology platform connects a network of various labs, hospitals, pharmacies and health plans. This is a big numbers game, and the unique circumstances of individual “members” are irrelevant, as, evidently, is the patient-physician relationship. I may or may not need a screening, but it helps Aetna win participation points in the ratings system if I comply and scoop my poop into the vial.
These tiny poop samples are processed in a fecal immunochemical test (FIT). A single FIT screening detects about 75% of colorectal cancer, significantly less than the detection rate of a colonoscopy. Furthermore, some brands of FIT screenings are more effective than others, and a significant proportion of FIT screenings lead to false positives. However, FIT screenings are orders of magnitude less expensive than colonoscopies, and they are certainly less of a pain in the, uh, rear. To compensate for the low detection rate, patients are asked to have a FIT screening annually, as opposed to five to ten years between colonoscopies.
I want to be clear that a) I am in favor of health care innovation, particularly when it lowers costs as it improves the lives of people b) I understand that colonoscopies are invasive and expensive, and therefore not an option for many people c) I know that increased awareness and knowledge about our bodies, our symptoms, and our options saves lives. There is nothing inherently wrong with FIT screenings, as compared to colonoscopies, as long as patients understand the statistical trade-offs. There is nothing inherently wrong with a marketing campaign to increase awareness of the dangers of colon cancer and ways to lessen the risk of death from such a cancer. There is nothing inherently wrong with saving money.
But in my opinion, there are at least four things inherently wrong with this particular marketing scheme.
- The oft-repeated “No Cost To You!” is a lie. BioIQ is making money on this program or they wouldn’t be in business. Dr. Saeed is getting paid. LabCorp is taking a cut. I am paying for this test with my premium payments to Aetna. They’ve just hidden the costs of this particular test from me.
- Using a random doctor to “order” this test for me is, if not outright fraud, then borderline fraud. If any old doctor can order this specific test for this specific patient, then why aren’t FIT screenings available over the counter?
- While FIT screenings may be better than no screening at all, nowhere in the marketing material is there any explanation that a single FIT screening is only 75% accurate and may yield false positives. People who comply with this offer ought to know their options and the relative trade-offs.
- The Amazon gift card is the poisonous icing on this noxious cake. Aetna shouldn’t insult me by bribing me with $25 of my own money in the form of a gift card. Does Aetna really think I don’t understand that their revenue comes from my premiums? Instead of entering yet another unholy alliance—this one with Amazon—Aetna can reduce my premium by $25 and I’ll spend it where I darn well please.
Healthcare in the United States is a big snarl, too big a snarl to untangle in one blog post—or one blog site. This Aetna and BioIQ example is one tiny pixel in the much bigger picture. But I believe it is representative of the core reason for the distortion—the snarl—in the system: Consumers—you and I—are not driving this system. Rather, we are being driven.
