Opportunity 

Colorectal cancer (CRC) is the second leading cause of cancer-related deaths among men and women in the United States. It is recommended that individuals begin regular screenings for CRC at the age of 45. Screening can prevent cancer by discovering precancerous polyps that can be removed before they turn into cancer. It can also find CRC early when treatment often leads to a cure.  

Patients have several options when it comes to completing screening. The most common are colonoscopy and FIT (fecal immunochemical test).  

Unfortunately, millions of people in the United States are not getting screened for CRC. 

Intervention  

We conducted multiple clinical trials to explore whether financial incentives can alter CRC screening rates. 

In one study, patients of an urban primary care practice received a letter from their physician with a mailed FIT kit and instructions. Participants were randomized into one of four arms that offered 1) no financial incentive, 2) an unconditional $10 incentive, 3) a $10 incentive conditional on FIT completion, or 4) a lottery incentive conditional on FIT completion. 

We also tested active choice with and without a financial incentive. Health system employees received an email stressing the importance of screening and were given a phone number to schedule a colonoscopy. In one intervention group, the email included an active choice to sign up, decline, or indicate that screening had already been completed. The second intervention group received the email with active choice options plus an offer of $100 to participate.  

In a third trial, which leveraged Way to Health, employees in the same health system as the prior study received an email describing the importance of CRC screening and were given a link to a web-based CRC risk assessment. Participants in the intervention groups were also offered a $10 loss-framed incentive to complete the risk assessment. All screening-eligible participants were given a phone number with direct access to colonoscopy scheduling, and those in the intervention group were offered an additional $25 for colonoscopy completion. 

Impact  

In the study with mailed FIT kits, roughly 24 percent of patients mailed back completed kits within two months of receiving them, and 29 percent did so within six months. However, the financial incentives had no impact, perhaps because of their low value.  

The $100 financial incentive in the active choice study led to a statistically significant increase in colonoscopy completion, but active choice alone did not improve screening rates. 

In the third study, risk assessment completion was 50 percent higher for participants offered the financial incentive, but the colonoscopy rate was not significantly different between groups. The completion rate was also lower than in the prior study with the $100 incentive. 

Results from these studies highlight that the framing and context of incentives can be just as important as the dollar value of incentives. Financial incentives are not likely to change people’s intentions to get screened, but if designed appropriately, they can nudge patients to complete who are already interested.