The Western Thoracic Surgical Association

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Where's the Money? Revenues associated with 3000 Lung Cancer Screens
*John Handy, Jr.1, Courtney Wood1, Erika Rauch1, Kevin Olson1, Roshanthi Weerasinghe1, Rachel Sanborn2, Micheal Skokan3
1Providence Cancer Center, Portland, OR;2Earle A Chiles Research Institute, Portland, OR;3The Oregon Clinic, Portland, OR

Objective: Since the National Lung Screening Trial (NLST), lung cancer screening (LCS) has been widely implemented but little is known about LCS finances. We describe revenues associated with screening and immediate downstream clinical activity.
Methods: A lung cancer screening (LCS) program began in November 2013 incorporating 7 hospitals (2 non-university tertiary and 5 community medical centers) and 3 free standing imaging centers. Candidates were referred by primary care providers (PCP). LCS was carried out using the Center for Medicare & Medicaid Services modified NLST eligibility criteria. Dedicated radiologists at the tertiary centers interpreted all LCS, assigning Lung RADS categories. Every Lung RADS 4 LCS was reviewed by the multidisciplinary thoracic disease conference, generating management recommendations. The program coordinator recorded all imaging, procedures, adverse events, pathology, staging and ensured follow up LCS. Clinical and administrative data bases were combined, examining 2013 - May 2017. Weighted average payment (to account for payer differences) and average total costs (direct + indirect) were analyzed. Downstream clinical activity was identified from the index event (LCS) and examining subsequent clinical encounters using relevant ICD10 codes (neoplasm, tobacco use, oncology, etc).
Results: 1950 people underwent initial CT screening, 1160 underwent follow up LCS, totaling 3110 scans. Payers comprised Medicare-65%, commercial-20% and Medicaid-14%. 55 cancers were diagnosed, including 40 non-small cell (stage I-26; stage II-5; stage III- 4 and stage IV-5), 6 small cell and 9 extra-thoracic cancers. Lung cancer detection rate was 2.3%. Intervention included additional imaging (CT, XR, PET, US, MRI, bone scan, mammogram) in 483 (15.5%) and 111 procedures (5.6%). Invasive diagnostic procedures included bronchoscopy (27), CT-guided biopsy (19) and ultrasound guided biopsy (18). 47 surgeries were performed (1.5%). Thoracic surgeries included thoracoscopic lobectomy (21), thoracoscopic wedge resection (6), thoracoscopic anatomic segmentectomy (4) and thoracoscopic pneumonectomy (1). Adverse event rate for procedures was 10.8% (0.6% of all screened patients). One lobectomy patient died, yielding a 2.1% surgical mortality.

LCS Revenues
EventsAverage Total CostAverage Total PaymentNet Margin
Additional imaging resulting from LCS483$129,492$187,13830.8%
Downstream clinical activity263$654,340$703,4487%

Of the downstream clinical activity, thoracic surgery contributed 34%, medical oncology 21%, general surgery 19%, and pulmonology 14%.
Conclusion: Beyond the substantial human and financial benefits of identifying curable early stage lung cancer, a low dose CT lung cancer screening program is profitable. 55% of payment results from downstream clinical activity while the LCS itself and additionally generated imaging generated 45%. This information can be used to allocate costs of a LCS program to clinical services and radiology.

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