Mandated coverage for cancer-screening services: whose guidelines do states follow?

The State of State Biomarker Testing Insurance Coverage Laws

This Viewpoint discusses laws mandating insurance coverage of biomarker testing to broaden access to care for patients with cancer.

Autism spectrum disorder, politics, and the generosity of insurance mandates in the United States

The study of Autism Spectrum Disorder (ASD) in the United States has identified a growing prevalence of the disorder across the country, a high economic burden for necessary treatment, and important gaps in insurance for individuals with autism. Confronting these facts, states have moved quickly in recent years to introduce mandates that insurers provide coverage for autism care. This study analyzes these autism insurance mandates and demonstrates that while states have moved swiftly to introduce them, the generosity of the benefits they mandate insurers provide varies dramatically across states. Furthermore, our research finds that controlling for policy need, interest group activity, economic circumstances, the insurance environment, and other factors, the passage of these mandates and differences in their generosity are driven by the ideology of state residents and politicians–with more generous benefits in states with more liberal citizens and increased Democratic control of state government. We conclude by discussing the implications of these findings for the study of health policy, politics, and autism in America.

Medicare Cancer Screening in the Context of Clinical Guidelines: 2000 to 2012

OBJECTIVES

Cancer screening is a ubiquitous and controversial public health issue, particularly in the elderly population. Despite extensive evidence-based guidelines for screening, it is unclear how cancer screening has changed in the Medicare population over time. We characterize trends in cancer screening for the most common cancer types in the Medicare fee-for-service (FFS) program in the context of conflicting guidelines from 2000 to 2012.

MATERIALS AND METHODS

We performed a descriptive analysis of retrospective claims data from the Medicare FFS program based on billing codes. Our data include all claims for Medicare part B beneficiaries who received breast, colorectal (CRC), or prostate cancer screening from 2000 to 2012 based on billing codes. We utilize a Monte Carlo permutation method to detect changes in screening trends.

RESULTS

In total, 231,416,732 screening tests were analyzed from 2000 to 2012, representing an average of 436.8 tests per 1000 beneficiaries per year. Mammography rates declined 7.4%, with digital mammography extensively replacing film. CRC cancer screening rates declined overall. As a percentage of all CRC screening tests, colonoscopy grew from 32% to 71%. Prostate screening rates increased 16% from 2000 to 2007, and then declined to 7% less than its 2000 rate by 2012.

DISCUSSION

Both the aggressiveness of screening guidelines and screening rates for the Medicare FFS population peaked and then declined from 2000 to 2012. However, guideline publications did not consistently precede utilization trend shifts. Technology adoption, practical and financial concerns, and patient preferences may have also contributed to the observed trends. Further research should be performed on the impact of multiple, conflicting guidelines in cancer screening.

Insurance coverage mandates: Impact of physician utilization in moderating colorectal cancer screening rates

Precision public health requires research that supports innovative systems and health delivery approaches, programs, and policies that are part of this vision. This study estimated the effects of health insurance mandate (HiM) variations and the effects of physician utilization on moderating colorectal cancer (CRC) screening rates. A time-series analysis using a difference-in-difference-in-differences (DDD) approach was conducted on CRC screenings (1997-2014) using a multivariate logistic framework. Key variables of interest were HiM, CRC screening status, and physician utilization. The adjusted average marginal effects from the DDD model indicate that physician utilization increased the probability of being "up-to-date" vs. non-compliance by 9.9% points (p = 0.007), suggesting that an estimated 8.85 million additional age-eligible persons would receive a CRC screening with HiM and routine physician visits. Routine physician visits and mandates that lower out-of-pocket expenses constitute an effective approach to increasing CRC screenings for persons ready to take advantage of such policies.

When Guidelines Conflict: A Case Study of Mammography Screening Initiation in the 1990s

BACKGROUND

Cancer screening guidelines communicate important information to patients and physicians regarding the costs and benefits of screening. Currently, guideline recommendations from major organizations conflict regarding the age of mammography screening initiation. To understand current and future U.S. mammography screening patterns we study age-mammography patterns from the 1990s, another period of conflicting guideline recommendations.

METHODS

We examine mammography use rates by single year of age to understand compliance with guideline-recommended initiation ages in the 1990s. Mammography test use data was taken primarily from the 1991 to 2001 Behavioral Risk Factor Surveillance System. The analytic sample included all women 35 to 54 years of age.

RESULTS

We found a discrete 8.7-percentage point increase in mammography use precisely at age 40 and a much smaller 1.6-percentage point increase in mammography use at age 50. These findings varied by insurance status, with the insured experiencing a large, discrete increase primarily at age 40 and the uninsured experiencing notable discrete increases at ages 40 and 50.

CONCLUSION

Physicians and patients converged primarily on the age 40 mammography screening threshold during the 1990s. Prices, along with guidelines, were key determinants of the age of screening initiation, with the insured responding to age 40 coverage and cost-sharing reductions and the uninsured affected by guidelines and public funding tied to the age 50 threshold. The policy factors underlying these results, recent ACA coverage increases, and ACA cost-sharing requirements imply that a substantial number of women will continue to receive mammography screening in their 40s.

An Assessment of the Perceived Barriers and Strategies to Promoting Early Detection of Colorectal Cancer: A Practitioners' Perspective

Colorectal cancer (CRC) is the third most common type of cancer in the United States. Of the kinds of cancers that can be detected early, it is the only type of cancer that has not shown a decrease in mortality rates. The purpose of this study was to gather information on the perceived barriers to screening for CRC from a primary health care professionals' perspective and to compile a list of suggested strategies to reduce these barriers in Tompkins County, New York. A series of structured group meetings was conducted using a Nominal Group Process (NGP) method for data collection. The most common perceived barriers were (in descending order of importance) reluctance because of fear and/or embarrassment, cost, lack of knowledge, denial, lack of providers' support, and insufficient time. The important suggested strategies to promote screening were community education, health practitioners' support, reduction of cost, better screening, providing time, and social support.

How Effective is Population-Based Cancer Screening? Regression Discontinuity Estimates from the US Guideline Screening Initiation Ages

We estimate the marginal benefits of population-based cancer screening by comparing cancer test and detection rates on either side of US guideline-recommended initiation ages (age 40 for breast cancer and age 50 for colorectal cancer during the study period). Using a regression discontinuity design and self-reported test data from national health surveys, we find test rates for breast and colorectal cancer increase at the guideline age thresholds by 109% and 78%, respectively. Data from cancer registries in twelve US states indicate that cancer detection rates increase at the same thresholds by 50% and 49%, respectively. We estimate significant effects of screening on earlier breast cancer detection (1.2 cases/1000 screened) at age 40 and colorectal cancer detection (1.1 cases/1000 individuals screened) at age 50. Forty-eight and 73% of the increases in breast and colorectal case detection occur among middle-stage cancers (localized and regional) with most of the remainder among early-stage (in-situ). Our analysis suggests that the cost of detecting an asymptomatic case of breast cancer at age 40 via population-based screening is $107,000–134,000 and that the cost of detecting an asymptomatic case of colorectal cancer at age 50 is $473,000–485,000.

Effects of State Cervical Cancer Insurance Mandates on Pap Test Rates

OBJECTIVE

To evaluate the effects of state insurance mandates requiring insurance plans to cover Pap tests, the standard screening for cervical cancer that is recommended for nearly all adult women.

DATA SOURCES

Individual-level data on 600,000 women age 19-64 from the CDC's Behavioral Risk Factor Surveillance System.

STUDY DESIGN

Twenty-four states adopted state mandates requiring private insurers in the state to cover Pap tests from 1988 to 2000. We performed a difference-in-differences analysis comparing within-state changes in Pap test rates before and after adoption of a mandate, controlling for the associated changes in other states that did not adopt a mandate.

PRINCIPAL FINDINGS

Difference-in-differences estimates indicated that the Pap test mandates significantly increased past 2-year cervical cancer screenings by 1.3 percentage points, with larger effects for Hispanic and non-Hispanic white women. These effects are plausibly concentrated among insured women.

CONCLUSIONS

Mandating more generous insurance coverage for even inexpensive, routine services with already high utilization rates such as Pap tests can significantly further increase utilization.

Lessons from state mandates of preventive cancer screenings

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.

The role of family history of cancer on cervical cancer screening behavior in a population-based survey of women in the Southeastern United States

BACKGROUND

Our objective was to determine the association of self-reported family history of cancer (FHC) on cervical cancer screening to inform a potential link with cancer preventive behaviors in a region with persistent cancer disparities.

METHODS

Self-reported FHC, Pap test behavior, and access to care were measured in a statewide population-based survey of human papillomavirus and cervical cancer (n = 918). Random-digit dial, computer-assisted telephone interviews were used to contact eligible respondents (adult [ages 18-70] women in South Carolina with landline telephones]. Logistic regression models were estimated using STATA 12.

FINDINGS

Although FHC+ was not predictive (odds ratio [OR], 1.17; 95% confidence interval [CI], 0.55-2.51), private health insurance (OR, 2.35; 95% confidence interval [CI], 1.15-4.81) and younger age (18-30 years: OR, 7.76; 95% CI, 1.91, 3.16) were associated with recent Pap test behavior. FHC and cervical cancer screening associations were not detected in the sample.

CONCLUSIONS

Findings suggest targeting older women with screening recommendations and providing available screening resources for underserved women.

Are United States and Canadian cancer screening rates consistent with guideline information regarding the age of screening initiation?

OBJECTIVE

To understand whether US and Canadian breast, colorectal and prostate cancer screening test utilization is consistent with US and Canadian cancer screening guideline information with respect to the age of screening initiation.

DESIGN

Cross-sectional, regression discontinuity.

SETTING

Canada and the US.

PARTICIPANTS

Canadian and American women of ages 30-60 and men of ages 40-60.

INTERVENTIONS

None. Main Outcomes Measures Mammography, prostate-specific antigen (PSA) and colorectal cancer test use within the past 2 years.

METHODS

We identify US and Canadian compliance with age screening information in a novel manner, by comparing test utilization rates of individuals who are immediately on either side of the guideline recommended initiation ages.

RESULTS

US mammography utilization within the last 2 years increased from 33% at age 39 to 48% at age 40 and 60% at age 41. US colorectal cancer test utilization, within the last 2 years, increased from 15% at age 49 to 18% at age 50 and 28% at age 51. US PSA utilization within the last 2 years increased from 37% at age 49 to 44% at age 50 and 54% at age 51. In Canada, mammography utilization within the last 2 years increased from 47% at age 49 to 57% at age 50 and 66% at age 51.

CONCLUSION

American and Canadian cancer screening utilization is generally consistent with each country's guideline recommendations regarding age. US and Canadian differences in screening due to guidelines can potentially explain cross-country differences in breast cancer mortality and affect interpretation of international comparisons of cancer statistics.

Are U.S. cancer screening test patterns consistent with guideline recommendations with respect to the age of screening initiation?

BACKGROUND

U.S. cancer screening guidelines communicate important information regarding the ages for which screening tests are appropriate. Little attention has been given to whether breast, colorectal and prostate cancer screening test use is responsive to guideline age information regarding the age of screening initiation.

METHODS

The 2006 Behavioral Risk Factor Social Survey and the 2003 National Health Interview Surveys were used to compute breast, colorectal and prostate cancer screening test rates by single year of age. Graphical and logistic regression analyses were used to compare screening rates for individuals close to and on either side of the guideline recommended screening initiation ages.

RESULTS

We identified large discrete shifts in the use of screening tests precisely at the ages where guidelines recommend that screening begin. Mammography screening in the last year increased from 22% [95% CI = 20, 25] at age 39 to 36% [95% CI = 33, 39] at age 40 and 47% [95% CI = 44, 51] at age 41. Adherence to the colorectal cancer screening guidelines within the last year increased from 18% [95% CI = 15, 22] at age 49 to 19% [95% CI = 15, 23] at age 50 and 34% [95% CI = 28, 39] at age 51. Prostate specific antigen screening in the last year increased from 28% [95% CI = 25, 31] at age 49 to 33% [95% CI = 29, 36] and 42% [95% CI = 38, 46] at ages 50 and 51. These results are robust to multivariate analyses that adjust for age, sex, income, education, marital status and health insurance status.

CONCLUSION

The results from this study suggest that cancer screening test utilization is consistent with guideline age information regarding the age of screening initiation. Screening test and adherence rates increased by approximately 100% at the breast and colorectal cancer guideline recommended ages compared to only a 50% increase in the screening test rate for prostate cancer screening. Since information regarding the age of cancer screening initiation varies across countries, results from this study also potentially have implications for cross-country comparisons of cancer incidence and survival statistics.

Differential effectiveness in patient protection laws: what are the causes? An example from the drive-through delivery laws

In the mid-1990s, many states as well as the federal government began to regulate early postpartum hospital discharge. Length-of-stay patterns changed markedly in response, but effects were much greater in some states than others. In particular, laws directly empowering patients appeared more effective than laws requiring providers to follow practice guidelines. In addition, the effectiveness of regulation could potentially be influenced by state environment, such as managed care penetration as well as exposure to media attention and public pressure on the issue, though these factors alone were insufficient to cause general behavior change. Furthermore, the 1996 federal law had little effect beyond state laws, suggesting that it did not provide substantial benefits to women in self-insured plans exempted from state law regulation by the Employee Retirement Income Security Act. Findings from this study could provide lessons for similar patient protection initiatives.

A comparative analysis of mandated benefit laws, 1949-2002

OBJECTIVE

To understand and compare the trends in mandated benefits laws in the United States.

DATA SOURCES/STUDY SETTING

Mandated benefit laws enacted in 50 states and the District of Columbia for the period 1949-2002 were compiled from multiple published compendia.

STUDY DESIGN

Laws that require private insurers and health plans to cover particular services, types of diseases, or care by specific providers in 50 states and the District of Columbia are compared for the period 1949-2002. Legislation is compared by year, by average and total frequency, by state, by type (provider, health care service, or preventive), and according to whether it requires coverage or an offer of coverage.

DATA COLLECTION/EXTRACTION METHOD

Data from published tables were entered into a spreadsheet and analyzed using statistical software.

PRINCIPAL FINDINGS

A total of 1,471 laws mandated coverage for 76 types of providers and services. The most common type of mandated coverage is for specific health care services (670 laws for 34 different services), followed by laws for services offered by specific professionals and other providers (507 mandated benefits laws for 25 types of providers), and coverage for specific preventive services (295 laws for 17 benefits). On average, a mandated benefit law has been adopted or significantly revised by 19 states, and each state has approximately 29 mandates. Only two benefits (minimum maternity stay and breast reconstruction) are mandated in all 51 jurisdictions and these were also federally mandated benefits. The mean number of total mandated benefit laws adopted or significantly revised per year was 17 per year in the 1970s, 36 per year in the 1980s, 59 per year in the 1990s, and 76 per year between 2000 and 2002. Since 1990, mandate adoption increased substantially, with around 55 percent of all mandated benefit laws enacted between 1990 and 2002.

CONCLUSIONS

There was a large increase in the number of mandated benefits laws during the managed care "backlash" of the 1990s. Many states now use mandated benefits to prescribe not only what services and benefits would be provided but how, where, and when services will be provided.

Current cervical neoplasia screening practices of obstetrician/gynecologists in the US

OBJECTIVE

The purpose of this study was to determine cervical cancer screening practices of obstetrician/gynecologists in the US after recent revised guidelines.

STUDY DESIGN

Questionnaires were mailed to 355 randomly selected US obstetrician/gynecologists. Questions were structured as clinical vignettes.

RESULTS

Questionnaires were returned by 60% (213/355) of recipients; 185 were eligible. Seventy-four percent would begin screening virginal girls at age 18. Sixty percent would continue annual screening in a 35-year-old woman with 3 or more normal tests. Frequent screening is common in women after total hysterectomy for symptomatic fibroids and no history of dysplasia, and in 70-year-old women with a 30-year history of previous normal tests. Most (82%) use liquid-based cytology; 78% of female respondents would prefer it for themselves. Most (64%) would not adopt triennial Pap/HPV DNA screening, although 58% of women would choose it for themselves.

CONCLUSION

Most US obstetrician/gynecologists screen low-risk women often and indefinitely, despite national guidelines designed to minimize screening harms resulting from overtesting.

Making Policy When The Evidence Is In Dispute

Policymakers often struggle with medical issues that are the subject of fierce scientific debate. On closer examination, many of these debates are manifestations of conflicting perspectives and values as much as disagreements over the evidence. We summarize common factors underlying recent debates and outline a series of questions that can help disentangle questions of evidence from those of values. These questions focus on identifying the most important outcomes, evaluating the quality of evidence, and assessing the trade-offs involved. We then use four recent policy debates-involving prostate-specific antigen (PSA) screening, high-dose chemotherapy for breast cancer, antibiotic therapy for otitis media, and newborn hearing screening-to illustrate how this approach can help clarify areas of agreement and disagreement of the opposing sides.

Underuse of screening sigmoidoscopy and colonoscopy in a large cohort of US adults

OBJECTIVES

We examined the prevalence of endoscopy (sigmoidoscopy or colonoscopy) by indication and by demographic and lifestyle factors.

METHODS

We analyzed cross-sectional data collected in 1997 from participants aged 50 years and older in the Cancer Prevention Study (CPS) II Nutrition Cohort.

RESULTS

Fifty-eight percent of men and 51% of women reported ever having undergone endoscopy; only 42% of men and 31% of women reported endoscopy for screening rather than for disease diagnosis or follow-up. Prevalence varied by demographic and lifestyle factors.

CONCLUSIONS

Efforts to increase colorectal cancer screening need to target women, all persons aged 50-64 years, and those with colorectal cancer risk factors. Future studies should distinguish endoscopy for screening from procedures for disease diagnosis and follow-up to avoid overestimating screening compliance.

Perspectives on behavioral and social science research on cancer screening

The first section in the current article offered several themes that characterize behavioral and social science cancer screening research to date and are likely to be relevant for studying the adoption and utilization of future screening technologies. The themes discussed included the link between epidemiologic surveillance and the priorities of intervention, the "at-risk" perspective that often guides research on screening and initiatives to redress disparities, the need to monitor the diversification of personal screening histories, the range of intervention groups and study designs that can be tested, the importance of including key questions in population-level surveys and national health objectives, and the desirability of clarifying the characteristics of cancer screening that make it an attractive field of study in its own right. The second section commented on emerging areas in which more research will allow additional lessons to be learned. The other articles in the current supplement presented many more lessons in a variety of areas, and other authors are encouraged to write similar articles that help to identify general themes characterizing cancer screening research.

Cancer trial enrollment after state-mandated reimbursement

BACKGROUND

Recruitment of patients into cancer research studies is exceedingly difficult, particularly for early phase trials. Payer reimbursement policies are a frequently cited barrier. We examined whether state policies that ensure coverage of routine medical care costs for cancer trial participants are associated with an increase in clinical trial enrollment.

METHODS

We used logistic Poisson regressions to analyze enrollment in National Cancer Institute phase II and phase III Clinical Trials Cooperative Group trials and compared changes in trial enrollment rates between 1996 and 2001 of privately insured cancer patients who resided in the four states that enacted coverage policies in 1999 with enrollment rates in states without such policies. All statistical tests were two-sided.

RESULTS

Trial enrollment rates increased in the coverage and noncoverage states by 24.9% (95% confidence interval [CI] = 22.8% to 27.0%) and 28.8% (95% CI = 27.7% to 29.8%) per year, respectively, from 1996 through 2001. After implementation of the coverage policies in 1999 in four states, there was a 21.7% (95% CI = 3.8% to 42.6%) annual increase in phase II trial enrollment in coverage states, compared with a 15.6% (95% CI = 8.8% to 21.8%) annual decrease in noncoverage states (P<.001). After accounting for secular trend, cancer type, and race in multivariable analyses, the odds ratio (OR) for a phase II trial participant residing in a coverage versus a noncoverage state after 1999 was 1.59 per year (95% CI = 1.22 to 2.07; P =.001). In a multivariable analysis of phase III trial participation, there was a decrease in the odds of residing in a coverage state after 1999 (OR = 0.90, 95% CI = 0.84 to 0.98; P =.011).

CONCLUSION

State coverage policies were associated with a statistically significant increase in phase II cancer trial participation and did not increase phase III cancer trial enrollment.

Cancer screening estimates for U.S. metropolitan areas

OBJECTIVES

To provide estimates of breast, cervical, and colorectal cancer screening for metropolitan areas in the United States.

METHODS

Behavioral Risk Factor Surveillance System (BRFSS) data from 1997 to 1999 were reweighted and analyzed for 69 U.S. metropolitan areas for the receipt of a Papanicolaou (Pap) test (ages > or =18 years); mammography (ages > or =40 years); fecal occult blood testing and sigmoidoscopy (ages > or =50 years). Stratified analyses by demographics were performed for 25 metropolitan areas with populations of > or =1.5 million.

RESULTS

Metropolitan estimates ranged from 64.6% to 82.0% for mammography and from 77.2% to 91.7% for Pap tests. There was much greater variability in estimates for colorectal cancer screening, with a 3.6-fold difference in the range of estimates for fecal occult blood testing (9.9% to 35.2%) and a 2.5-fold difference for sigmoidoscopy (17.3% to 43.3%). In the 25 largest areas, prevalence of cancer screening was generally lower for persons with a high school education or less and for those without health insurance. Compared with women aged 50 to 64 years, mammography estimates were lower for women aged 40 to 49 years in 13 of the 25 metropolitan areas. Pap testing was less common among women aged > or =65 years, and colorectal cancer screening was less common for persons aged 50 to 64 years.

CONCLUSIONS

Estimates of cancer screening varied substantially across metropolitan areas. Increased efforts to improve cancer screening are needed in many urban areas, especially for colorectal cancer screening. The BRFSS is a useful, inexpensive, and timely resource for providing metropolitan-area cancer screening estimates and may be used in the future to guide local or county-level screening efforts.

Wellness general of the United States: a creative approach to promote family and community health

This article offers a creative approach to promote family and community health, beginning with the conversion of the office of Surgeon General of the United States into the Wellness General of the United States. The content ranges from federal initiatives to promote quality health research to individuals and families who will be the beneficiaries at medical clinics and community health programs. The proposal recommends changes to institutions and policies, including junk food taxes, the National Institutes of Health, the United States Preventive Services Task Force, the Healthy People 2010 initiative, the Health Plan Employer Data and Information Set, the Medicare Coverage Advisory Committee, state health mandates, local health plans, community medical clinics, and community health programs. The goal is to stimulate ideas and actions among policymakers, researchers, practitioners, educators, and students.

Cancer screening

Table 3 provides a summary of key recommendations for each cancer site discussed in this chapter. One of the unifying principles of cancer screening is that every clinician or group practice needs to define an explicit screening policy. Resources must then be devoted to implementing this policy, evaluating adherence, and improving performance.

Implementation of colorectal cancer screening: the challenge

Colorectal cancer is the second leading cause of cancer death among men and women in the United States, and its incidence is increasing in other developed countries throughout the world. Efficacious and cost-effectiveness screening measures exist for colorectal cancer, but successful implementation at a community level remains challenging. This article is a summary of recently published information on cost-effectiveness of colorectal screening, attempts to enhance acceptance and compliance by physicians and the public, and legislative efforts to ensure access to screening.

Barriers to screening for colorectal cancer

Rapidly growing interest in colon cancer screening is a crucial first step to identifying and reducing many of the barriers that impede population screening for this common disease. Promoting screening demands health care policy change to increase the percentage of Americans with insurance coverage that includes a colon cancer screening benefit. A systematic approach to screening with invitations that come from a clinician are likely to be the most effective way to prompt more individuals to be screened. Awareness campaigns and patient educational aids, including decision tools, implemented in multiple sites, such as worksites, community centers, health care systems, and physician offices, increase the percent of eligible Americans who understand their personal risk, the need for screening, and the options available to them.