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McEvoy CS, Shah NG, Roberts SE, Carroll AM, Platz TA, Oxner CR, Butler RE, Ricca RL. Universal Healthcare Coverage Does Not Ensure Adherence to Initial Colorectal Cancer Screening Guidelines. Mil Med 2021; 186:e1071-e1076. [PMID: 33211098 DOI: 10.1093/milmed/usaa319] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 06/17/2020] [Accepted: 11/13/2020] [Indexed: 01/22/2023] Open
Abstract
INTRODUCTION Colorectal cancer is the second leading cause of cancer deaths in the USA, and screening tests are underutilized. The aim of this study was to determine the proportion of individuals at average risk who utilized a recommended initial screening test in a universal healthcare coverage system. MATERIALS AND METHODS This is a retrospective cohort study of active duty and retired military members as well as civilian beneficiaries of the Military Health System. Individuals born from 1960 to 1962 and eligible for full benefits on their 50th birthday were evaluated. Military rank or rank of benefits sponsor was used to determine socioeconomic status. Adherence to the U.S. Preventive Services Task Force guidelines for initial colorectal cancer screening was determined using "Current Procedural Terminology" and "Healthcare Common Procedure Coding System" codes for colonoscopy, sigmoidoscopy, fecal occult blood test, and fecal immunohistochemistry test. Average risk individuals who obtained early screening ages 47 to 49 were also identified. RESULTS This study identified 275,665 individuals at average risk. Of these, 105,957 (38.4%) adhered to screening guidelines. An additional 19,806 (7.2%) individuals were screened early. Colonoscopy (82.7%) was the most common screening procedure. Highest odds of screening were associated with being active duty military (odds ratio [OR] 3.63, 95% confidence interval [CI] 3.43 to 3.85), having highest socioeconomic status (OR 2.37, 95% CI 2.31 to 2.44), and having managed care insurance (OR 4.36, 95% CI 4.28 to 4.44). CONCLUSIONS Universal healthcare coverage does not ensure initial colorectal cancer screening utilization consistent with guidelines no does it eliminate disparities.
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Affiliation(s)
- Christian S McEvoy
- Department of Surgery, Naval Medical Center Portsmouth, Portsmouth, VA 23708, USA.,Health Analysis Department, Navy and Marine Corps Public Health Center, Portsmouth, VA, USA
| | - Nina G Shah
- Health Analysis Department, Navy and Marine Corps Public Health Center, Portsmouth, VA, USA
| | - Sarah E Roberts
- Health Analysis Department, Navy and Marine Corps Public Health Center, Portsmouth, VA, USA
| | - Anna M Carroll
- Health Analysis Department, Navy and Marine Corps Public Health Center, Portsmouth, VA, USA
| | - Timothy A Platz
- Department of Surgery, Naval Medical Center Portsmouth, Portsmouth, VA 23708, USA
| | - Christopher R Oxner
- Department of Surgery, Naval Medical Center Portsmouth, Portsmouth, VA 23708, USA
| | - Ralph E Butler
- Department of Surgery, Naval Medical Center Portsmouth, Portsmouth, VA 23708, USA
| | - Robert L Ricca
- Department of Surgery, Naval Medical Center Portsmouth, Portsmouth, VA 23708, USA
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2
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Bitler MP, Carpenter CS, Horn D. Effects of the Colorectal Cancer Control Program. HEALTH ECONOMICS 2021; 30:2667-2685. [PMID: 34342362 PMCID: PMC8497428 DOI: 10.1002/hec.4397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 03/19/2021] [Accepted: 06/24/2021] [Indexed: 06/13/2023]
Abstract
Although colorectal cancer (CRC) screening is highly effective, screening rates lag far below recommended levels, particularly for low-income people. The Colorectal Cancer Control Program (CRCCP) funded $100 million in competitively awarded grants to 25 states from 2009-2015 to increase CRC screening rates among low-income, uninsured populations, in part by directly providing and paying for screening services. Using data from the 2001-2015 Behavioral Risk Factor Surveillance System (BRFSS) and a difference-in-differences strategy, we find no effects of CRCCP on the use of relatively cheap fecal occult blood tests (FOBT). We do, however, find that the CRCCP significantly increased the likelihood that uninsured 50-64-year-olds report ever having a relatively expensive endoscopic CRC screening (sigmoidoscopy or colonoscopy) by 2.9 percentage points, or 10.7%. These effects are larger for women, minorities, and individuals who did not undertake other types of preventive care. We do not find that the CRCCP led to significant changes in CRC cancer detection. Our results indicate that the CRCCP was effective at increasing CRC screening rates among the most vulnerable.
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Affiliation(s)
| | | | - Danea Horn
- Department of Agricultural and Resource Economics, UC Davis
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Abstract
BACKGROUND The strain on public resources to meet the healthcare needs of populations through publicly-provided health insurance programmes is increasing and many governments turn to private health insurance (PHI) to ease the pressure on government budgets. With the goal of improving access to basic health care for citizens through PHI programmes, several high-income countries have developed strong regulations for PHI schemes. Low- and middle-income countries have the opportunity to learn from this experience to optimise PHI. If poorly regulated, PHI can hardly achieve an adequate quantity or quality of population coverage, as can be seen in the USA where a third of adults younger than 65 years of age have no insurance, sporadic coverage or coverage that exposes them to high out-of-pocket healthcare costs. OBJECTIVES To assess the effects of policies that regulate private health insurance on utilisation, quality, and cost of health care provided. SEARCH METHODS In November 2019 we searched CENTRAL; MEDLINE; Embase; Sociological Abstracts and Social Services Abstracts; ICTRP; ClinicalTrials.gov; and Web of Science Core Collection for papers that have cited the included studies. This complemented the search conducted in February 2017 in IBSS; EconLit; and Global Health. We also searched selected grey literature databases and web-sites. SELECTION CRITERIA: Randomised trials, non-randomised trials, interrupted time series (ITS) studies, and controlled before-after (CBA) studies conducted in any population or setting that assessed one or more of the following interventions that governments use to regulate private health insurance: legislation and licensing, monitoring, auditing, and intelligence. DATA COLLECTION AND ANALYSIS Two review authors independently assessed study eligibility, extracted data, and assessed risk of bias and certainty of the evidence resolving discrepancies by consensus. We planned to summarise the results (using random-effects or fixed-effect meta-analysis) to produce an overall summary if an average intervention effect across studies was considered meaningful, and we would have discussed the implications of any differences in intervention effects across studies. However, due to the nature of the data obtained, we have provided a narrative synthesis of the findings. MAIN RESULTS We included seven CBA studies, conducted in the USA, and that directly assessed state laws on cancer screening. Only for-profit PHI schemes were addressed in the included studies and no study addressed other types of PHI (community and not for-profit). The seven studies were assessed as having 'unclear risk' of bias. All seven studies reported on utilisation of healthcare services, and one study reported on costs. None of the included studies reported on quality of health care and patient health outcomes. We assessed the certainty of evidence for patient health outcomes, and utilisation and costs of healthcare services as very low. Therefore, we are uncertain of the effects of government mandates on for-profit PHI schemes. AUTHORS' CONCLUSIONS Our review suggests that, from currently available evidence, it is uncertain whether policies that regulate private health insurance have an effect on utilisation of healthcare services, costs, quality of care, or patient health outcomes. The findings come from studies conducted in the USA and might therefore not be applicable to other countries; since the regulatory environment could be different. Studies are required in countries at different income levels because the effects of government regulation of PHI are likely to differ across these income and health system settings. Further studies should assess the different types of regulation (including regulation and licensing, monitoring, auditing, and intelligence). While regulatory research on PHI remains relatively scanty, future research can draw on the rich body of research on the regulation of other health financing interventions such as user fees and results-based provider payments.
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Affiliation(s)
- Nkengafac Villyen Motaze
- Centre for the Development of Best Practices in Health (CDBPH), Yaoundé Central Hospital, Yaoundé, Cameroon
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- National Institute for Communicable Diseases (NICD), A Division of the National Health Laboratory Service (NHLS), Johannesburg, South Africa
| | - Primus Che Chi
- Health Systems and Research Ethics, KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Pierre Ongolo-Zogo
- Centre for the Development of Best Practices in Health (CDBPH), Yaoundé Central Hospital, Yaoundé, Cameroon
| | - Jean Serge Ndongo
- Centre for the Development of Best Practices in Health (CDBPH), Yaoundé Central Hospital, Yaoundé, Cameroon
| | - Charles S Wiysonge
- Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town , Cape Town, South Africa
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4
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Preston MA, Ross L, Chukmaitov A, Smith SA, Odlum ML, Dahman B, Sheppard VB. Health Insurance Coverage Mandates: Colorectal Cancer Screening in the Post-ACA Era. Cancer Prev Res (Phila) 2020; 14:123-130. [PMID: 32917646 DOI: 10.1158/1940-6207.capr-20-0028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 07/30/2020] [Accepted: 09/02/2020] [Indexed: 11/16/2022]
Abstract
Building a culture of precision public health requires research that includes health delivery model with innovative systems, health policies, and programs that support this vision. Health insurance mandates are effective mechanisms that many state policymakers use to increase the utilization of preventive health services, such as colorectal cancer screening. This study estimated the effects of health insurance mandate variations on colorectal cancer screening post Affordable Care Act (ACA) era. The study analyzed secondary data from the Behavioral Risk Factor Surveillance System (BRFSS) and the NCI State Cancer Legislative Database (SCLD) from 1997 to 2014. BRFSS data were merged with SCLD data by state ID. The target population was U.S. adults, age 50 to 74, who lived in states where health insurance was mandated or nonmandated before and after the implementation of ACA. Using a difference-in-differences (DD) approach with a time-series analysis, we evaluated the effects of health insurance mandates on colorectal cancer screening status based on U.S. Preventive Services Task Force guidelines. The adjusted average marginal effects from the DD model indicate that health insurance mandates increased the probability of up-to-date screenings versus noncompliance by 2.8% points, suggesting that an estimated 2.37 million additional age-eligible persons would receive a screening with such health insurance mandates. Compliant participants' mean age was 65 years and 57% were women (n = 32,569). Our findings are robust for various model specifications. Health insurance mandates that lower out-of-pocket expenses constitute an effective approach to increase colorectal cancer screenings for the population, as a whole. PREVENTION RELEVANCE: The value added includes future health care reforms that increase access to preventive services, such as CRC screening, are likely with lower out-of-pocket costs and will increase the number of people who are considered "up-to-date". Such policies have been used historically to improve health outcomes, and they are currently being used as public health strategies to increase access to preventive health services in an effort to improve the nation's health.
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Affiliation(s)
- Michael A Preston
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, Virginia. .,Department of Health Behavior and Policy, Office of Health Equity & Disparities Research, VCU Massey Cancer Center, Virginia Commonwealth University, Richmond, Virginia
| | - Levi Ross
- Department of Health Science, The University of Alabama, Tuscaloosa, Alabama
| | - Askar Chukmaitov
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, Virginia
| | - Sharla A Smith
- Department of Population Health, University of Kansas School of Medicine-Wichita, Wichita, Kansas
| | | | - Bassam Dahman
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, Virginia
| | - Vanessa B Sheppard
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, Virginia.,Department of Health Behavior and Policy, Office of Health Equity & Disparities Research, VCU Massey Cancer Center, Virginia Commonwealth University, Richmond, Virginia
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5
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Braun AL, Kässner A, Syrogiannouli L, Selby K, Bulliard JL, Martin Y, Guessous I, Tal K, Del Giovane C, Zwahlen M, Auer R. Association between colorectal cancer testing and insurance type: Evidence from the Swiss Health Interview Survey 2012. Prev Med Rep 2020; 19:101111. [PMID: 32426215 PMCID: PMC7226870 DOI: 10.1016/j.pmedr.2020.101111] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 02/18/2020] [Accepted: 04/26/2020] [Indexed: 11/17/2022] Open
Abstract
Colonoscopy and FOBT are both recommended for colorectal cancer screening. Colonoscopy costs much more, so test choice might be linked to insurance type. Private insurance and low deductibles were associated with more colonoscopies. FOBT, which is cheap, was not associated with private insurance.
Both colonoscopy and fecal occult blood test (FOBT) are commonly used for colorectal cancer (CRC) screening, but colonoscopy costs much more than FOBT. Swiss insurance offers high or low deductibles and choice of basic or private insurance. We hypothesized that high deductibles and basic insurance discourage colonoscopy, but do not change FOBT rates. We determined the proportion of patients tested for CRC in Switzerland (colonoscopy within 10 years, FOBT within 2 years), and determined associations with health insurance type. We extracted data on 50–75-year-olds from the Swiss Health Interview Surveys of 2012 to determine colonoscopy and FOBT testing rates (n = 7335). Multivariate logistic regression models estimated prevalence ratios (PRs) of CRC testing associated with health insurance type (deductible and private insurance), adjusted for socio-demographic factors (age, gender, education, income) and self-rated health. The weighted proportion of individuals tested for CRC within recommended intervals was 39.5%. Testing with colonoscopy was significantly associated with private insurance (PR 1.85, 95% CI: 1.46–2.35) and low deductible (PR 2.00, 95% CI: 1.56–2.57). Testing with FOBT was significantly associated with deductible (PR 1.71, 95%CI:1.09–2.68) but not with private insurance. About 60% of the Swiss population was not current with CRC testing. After adjusting for covariates, private insurance and low deductible was significantly associated with higher prevalence of CRC testing, indicating that waiving the deductible could increase CRC screening uptake and reduce health inequality.
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Affiliation(s)
| | - Anja Kässner
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Switzerland
| | | | - Kevin Selby
- Center for Primary Care and Public Health (Unisanté), University of Lausanne, Switzerland
| | - Jean-Luc Bulliard
- Center for Primary Care and Public Health (Unisanté), University of Lausanne, Switzerland
| | - Yonas Martin
- Institute of Primary Health Care (BIHAM), University of Bern, Switzerland
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Idris Guessous
- Unit of Population Epidemiology, Department of Community Medicine and Primary Care and Emergency Medicine (UEP), Geneva University Hospitals, Switzerland
| | - Kali Tal
- Institute of Primary Health Care (BIHAM), University of Bern, Switzerland
| | - Cinzia Del Giovane
- Institute of Primary Health Care (BIHAM), University of Bern, Switzerland
| | - Marcel Zwahlen
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Switzerland
| | - Reto Auer
- Institute of Primary Health Care (BIHAM), University of Bern, Switzerland
- Center for Primary Care and Public Health (Unisanté), University of Lausanne, Switzerland
- Corresponding author at: Institute of Primary Health Care (BIHAM), University of Bern, Mittelstrasse 43, CH-3012 Bern, Switzerland.
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6
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Song LD, Newhouse JP, Garcia‐De‐Albeniz X, Hsu J. Changes in screening colonoscopy following Medicare reimbursement and cost-sharing changes. Health Serv Res 2019; 54:839-850. [PMID: 30941767 PMCID: PMC6606542 DOI: 10.1111/1475-6773.13150] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVES To compare existing algorithms for classifying screening vs diagnostic colonoscopies and to quantify the increase in screening colonoscopy rates when Medicare began reimbursement in 2001 and when the Affordable Care Act (ACA) eliminated cost-sharing. DATA SOURCES Twenty percent random sample of fee-for-service (FFS) Medicare claims, 2000-2012. STUDY DESIGN Using recent administrative codes as tarnished gold standards, we examined the sensitivity and specificity of five published algorithms for classifying colonoscopies and calculated annual screening colonoscopy rates. We estimated the change in rates after Medicare began reimbursement and used difference-in-differences analysis to estimate the effects of eliminating cost-sharing by comparing states with and without a mandate to cover screening colonoscopy prior to the ACA. FINDINGS Model-based algorithms have higher sensitivity (0.53-0.99) than expert-based algorithms (0.35-0.39), but lower specificity (0.43-0.65 vs 0.79-0.88). All algorithms detected increases in screening from both Medicare's reimbursement change (range: 24-93/10 000) and the 2011 cost-sharing change (range: 1.1-34/10 000). Difference-in-difference estimates of the ACA's effect varied from 51 to 155 tests per 10 000 depending on the algorithm. CONCLUSIONS Screening colonoscopy rates increased after eliminating cost-sharing in 2011, but the increase's size varied depending on the algorithm used to classify the indication. Improvements are needed in Medicare coding for screening.
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Affiliation(s)
- Lina D. Song
- PhD Program in Health PolicyThe Graduate School of Arts and SciencesHarvard UniversityCambridgeMassachusetts
- Health Policy Research CenterMongan Institute, Massachusetts General HospitalBostonMassachusetts
| | - Joseph P. Newhouse
- Department of Health Care PolicyHarvard Medical SchoolBostonMassachusetts
- Department of Health Policy and ManagementHarvard T.H. Chan School of Public HealthBostonMassachusetts
- The John F. Kennedy School of GovernmentHarvard UniversityCambridgeMassachusetts
- Faculty of Arts and SciencesHarvard UniversityCambridgeMassachusetts
| | - Xabier Garcia‐De‐Albeniz
- Health Policy Research CenterMongan Institute, Massachusetts General HospitalBostonMassachusetts
- Department of EpidemiologyHarvard T.H. Chan School of Public HealthBostonMassachusetts
| | - John Hsu
- Health Policy Research CenterMongan Institute, Massachusetts General HospitalBostonMassachusetts
- Department of Health Care PolicyHarvard Medical SchoolBostonMassachusetts
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7
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Gottschalk FCH. Why prevent when it does not pay? Prevention when health services are credence goods. HEALTH ECONOMICS 2019; 28:693-709. [PMID: 30815954 DOI: 10.1002/hec.3874] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 12/05/2018] [Accepted: 01/13/2019] [Indexed: 06/09/2023]
Abstract
This article identifies information asymmetries and the corresponding problem of overtreatment as a possible source of prevention and health disparities when patients differ with respect to their health risk. It analyzes preventive health behavior (primary prevention) and preventive health-care utilization (secondary prevention) in markets in which patients cannot determine whether they receive excessive secondary preventive treatment-that is, where health services are credence goods. The problem of overtreatment in such markets is considered as a possible pathway through which differences in health risk lead to disparities in primary and secondary prevention as well as the corresponding health outcomes. Patients with high health risks do not invest in primary prevention, because they anticipate to be provided with unnecessary secondary prevention. Patients with lower risks invest in primary but not in secondary prevention, resulting in health losses. Furthermore, when societal groups differ with respect to their exposure to overtreatment, and we consider socioeconomic status as a possible reason, we observe disparities in primary and secondary prevention as well as the resulting health outcomes, including the "social gradient." Several implications for empirical research are discussed.
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Affiliation(s)
- Felix C H Gottschalk
- Department of Management, Technology, and Economics (D-MTEC), Center of Economic Research (CER-ETH) ETH Zurich, Zurich, Switzerland
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8
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Smieliauskas F, Sharma H, Hurley C, de Souza JA, Shih YCT. State insurance mandates and off-label use of chemotherapy. HEALTH ECONOMICS 2018; 27:e55-e70. [PMID: 28726348 DOI: 10.1002/hec.3537] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Revised: 04/30/2017] [Accepted: 05/15/2017] [Indexed: 06/07/2023]
Abstract
Access to cancer drugs used off-label is important to cancer patients but may drive up healthcare costs with little evidence of clinical benefit. We hypothesized that state health insurance mandates for private insurers to provide coverage for off-label use of cancer drugs cause higher rates of off-label use. We used Truven MarketScan data from 1999 to 2007 on utilization of 35 infused chemotherapy drugs in private health plans in the United States, covering the period when eight states implemented off-label coverage laws. We studied trends in off-label use of drugs, distinguishing between appropriate and inappropriate off-label use according to drug compendia, and estimated difference-in-difference regressions of the effect of state laws on off-label use. We estimate 41% of utilization was off-label, including 17% of use conservatively defined as inappropriate. Trends show gradual declines in off-label use over time. We also find no discernable effect of state laws mandating coverage of off-label use of cancer drugs on utilization patterns under multiple empirical specifications. Our conclusion is that policymakers should consider shifting away from mandating coverage as a way to ensure access to drugs off-label and towards incentivizing adherence to clinical practice guidelines to improve the quality and value of off-label use.
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Affiliation(s)
| | - Hari Sharma
- Department of Public Health Sciences, University of Chicago, Chicago, IL, USA
| | | | - Jonas A de Souza
- Section of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Ya-Chen Tina Shih
- Section of Cancer Economics and Policy, Department of Health Services Research, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
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9
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Peterse EFP, Meester RGS, Gini A, Doubeni CA, Anderson DS, Berger FG, Zauber AG, Lansdorp-Vogelaar I. Value Of Waiving Coinsurance For Colorectal Cancer Screening In Medicare Beneficiaries. Health Aff (Millwood) 2017; 36:2151-2159. [PMID: 29200350 PMCID: PMC6067012 DOI: 10.1377/hlthaff.2017.0228] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Financial barriers to colorectal cancer screening persist despite the Affordable Care Act (ACA). Medicare beneficiaries may face 20 percent coinsurance for a screening colonoscopy when the procedure includes the removal of polyps or follows a positive fecal screening test. Using an established microsimulation model, we estimated that waiving this coinsurance would result in 1.7 fewer colorectal cancer deaths (a decrease of 13 percent) and $17,000 higher colorectal cancer-related costs (an increase of 0.6 percent) for the Centers for Medicare and Medicaid Services per 1,000 sixty-five-year-olds, assuming a 10-percentage-point increase in the rates of first colonoscopy screening, follow-up, and surveillance. If the rates did not change, waiving coinsurance would increase total costs by $51,000 (1.9 percent) per 1,000 sixty-five-year-olds. Estimated screening benefits were comparable when fecal testing was assumed to be the primary screening method. Moreover, waiving coinsurance would be cost-effective if the screening rate increased by 0.6 percentage points, assuming a willingness-to-pay threshold of $50,000 per quality-adjusted life-year gained. Thus, the waiver is likely to have a favorable balance of health and cost impact.
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Affiliation(s)
- Elisabeth F P Peterse
- Elisabeth F. P. Peterse ( ) is a PhD candidate in the Department of Public Health, Erasmus University Medical Center, in Rotterdam, the Netherlands
| | - Reinier G S Meester
- Reinier G. S. Meester is a postdoctoral researcher in the Department of Public Health, Erasmus University Medical Center
| | - Andrea Gini
- Andrea Gini is a PhD candidate in the Department of Public Health, Erasmus University Medical Center
| | - Chyke A Doubeni
- Chyke A. Doubeni is an associate professor in the Department of Family Medicine and Community Health, University of Pennsylvania Perelman School of Medicine, in Philadelphia
| | - Daniel S Anderson
- Daniel S. Anderson is a staff gastoenterologist in the Southern California Kaiser Permanente Group, in San Diego
| | - Franklin G Berger
- Franklin G. Berger is the George H. Bunch Professor in the Department of Biological Sciences and director of Center for Colon Cancer Research, both in the Jones Physical Sciences Center, University of South Carolina, in Columbia
| | - Ann G Zauber
- Ann G. Zauber is a member, attending biostatistician in the Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, in New York City
| | - Iris Lansdorp-Vogelaar
- Iris Lansdorp-Vogelaar is an associate professor in the Department of Public Health, Erasmus University Medical Center
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Xu WY, Dowd B, Abraham J. Lessons from state mandates of preventive cancer screenings. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2016; 17:203-215. [PMID: 25773049 DOI: 10.1007/s10198-015-0672-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Accepted: 02/09/2015] [Indexed: 06/04/2023]
Abstract
We use the 1997-2008 Medical Expenditure Panel Survey (MEPS) and variation in the timing of state mandates for coverage of colorectal, cervical, and prostate cancer screenings to investigate the behavioral and financial effects of mandates on privately insured adults. We find that state mandates did not result in increased rates of cancer screening. However, coverage of preventive care, whether mandated or not, moves the cost of care from the consumer's out-of-pocket expense to the premium, resulting in a cross-subsidy of users of the service by non-users. While some cross-subsidies are intentional, others may be unintentional. We find that users of cancer screening have higher levels of income and education, while non-users tend to be racial minorities, lack a usual source of care, and live in communities with fewer physicians per capita. These results suggest that coverage of preventive care may transfer resources from more advantaged individuals to less advantaged individuals.
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Affiliation(s)
- Wendy Yi Xu
- Division of Health Services Management and Policy, College of Public Health, The Ohio State University, Columbus, OH, USA.
| | - Bryan Dowd
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Jean Abraham
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, MN, USA
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11
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Hamman MK, Kapinos KA. Mandated coverage of preventive care and reduction in disparities: evidence from colorectal cancer screening. Am J Public Health 2015; 105 Suppl 3:S508-16. [PMID: 25905835 DOI: 10.2105/ajph.2015.302578] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES We identified correlates of racial/ethnic disparities in colorectal cancer screening and changes in disparities under state-mandated insurance coverage. METHODS Using Behavioral Risk Factor Surveillance System data, we estimated a Fairlie decomposition in the insured population aged 50 to 64 years and a regression-adjusted difference-in-difference-in-difference model of changes in screening attributable to mandates. RESULTS Under mandated coverage, blood stool test (BST) rates increased among Black, Asian, and Native American men, but rates among Whites also increased, so disparities did not change. Endoscopic screening rates increased by 10 percentage points for Hispanic men and 3 percentage points for non-Hispanic men. BST rates fell among Hispanic relative to non-Hispanic men. We found no changes for women. However, endoscopic screening rates improved among lower income individuals across all races and ethnicities. CONCLUSIONS Mandates were associated with a reduction in endoscopic screening disparities only for Hispanic men but may indirectly reduce racial/ethnic disparities by increasing rates among lower income individuals. Findings imply that systematic differences in insurance coverage, or health plan fragmentation, likely existed without mandates. These findings underscore the need to research disparities within insured populations.
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Affiliation(s)
- Mary K Hamman
- Mary K. Hamman is with the Department of Economics, College of Business Administration, University of Wisconsin-La Crosse. Kandice A. Kapinos is with the RAND Corporation, Arlington, VA
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