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Wain K, Carroll NM, Honda S, Oshiro C, Ritzwoller DP. Individuals Eligible for Lung Cancer Screening Less Likely to Receive Screening When Enrolled in Health Plans With Deductibles. Med Care 2023; 61:665-673. [PMID: 37582296 PMCID: PMC10840830 DOI: 10.1097/mlr.0000000000001903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/17/2023]
Abstract
BACKGROUND In 2015, the Centers for Medicare & Medicaid Services and commercial insurance plans began covering lung cancer screening (LCS) without patient cost-sharing for all plans. We explore the impact of enrolling into a deductible plan on the utilization of LCS services despite having no out-of-pocket cost requirement. METHODS This retrospective study analyzed data from the Population-based Research to Optimize the Screening Process Lung Consortium. Our cohort included non-Medicare LCS-eligible individuals enrolled in managed care organizations between February 5, 2015, and February 28, 2019. We estimate a series of sequential logistic regression models examining utilization across the sequence of events required for baseline LCS. We report the marginal effects of enrollment into deductible plans compared with enrollment in no-deductible plans. RESULTS The total effect of deductible plan enrollment was a 1.8 percentage-point (PP) decrease in baseline LCS. Sequential logistic regression results that explore each transition separately indicate deductible plan enrollment was associated with a 4.3 PP decrease in receipt of clinician visit, a 1.7 PP decrease in receipt of LCS order, and a 7.0 PP decrease in receipt of baseline LCS. Reductions persisted across all observable races and ethnicities. CONCLUSIONS These findings suggest individuals enrolled in deductible plans are more likely to forgo preventive LCS services despite requiring no out-of-pocket costs. This result may indicate that increased cost-sharing is associated with suboptimal choices to forgo recommended LCS. Alternatively, this effect may indicate individuals enrolling into deductible plans prefer less health care utilization. Patient outreach interventions at the health plan level may improve LCS.
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Affiliation(s)
- Kris Wain
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO
| | - Nikki M. Carroll
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO
| | - Stacey Honda
- Center for Integrated Healthcare Research, Kaiser Permanente Hawaii, Honolulu, HI
- Hawaii Permanente Medical Group, Honolulu, HI
| | - Caryn Oshiro
- Center for Integrated Healthcare Research, Kaiser Permanente Hawaii, Honolulu, HI
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Funaro K, Niell B. Screening Mammography Utilization in the United States. JOURNAL OF BREAST IMAGING 2023; 5:384-392. [PMID: 38416907 DOI: 10.1093/jbi/wbad042] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Indexed: 03/01/2024]
Abstract
Breast cancer is the second leading cause of cancer mortality in adult women in the United States. Screening mammography reduces breast cancer mortality between 22% and 48%; however, screening mammography remains underutilized. Screening mammography utilization data are available from insurance claims, electronic medical records, and patient self-report via surveys, and each data source has unique benefits and challenges. Numerous barriers exist that adversely affect the use of screening mammography in the United States. This article will review screening mammography utilization in the United States, explore factors that impact utilization, and briefly discuss strategies to improve utilization.
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Affiliation(s)
- Kimberly Funaro
- H. Lee Moffitt Cancer Center and Research Institute, Department of Diagnostic Imaging, Tampa, FL, USA
| | - Bethany Niell
- H. Lee Moffitt Cancer Center and Research Institute, Department of Diagnostic Imaging, Tampa, FL, USA
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Christensen EW, Waid M, Scott J, Patel BK, Bello JA, Rula EY. Relationship between Race and Access to Newer Mammographic Technology in Women with Medicare Insurance. Radiology 2023; 306:e221153. [PMID: 36219114 DOI: 10.1148/radiol.221153] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Background Racial disparities in breast cancer mortality have been reported. Mammographic technology has undergone two major technology transitions since 2000: first, the transition from screen-film mammography (SFM) to full-field digital mammography (FFDM) and second, the transition to digital breast tomosynthesis (DBT). Purpose To examine the relationship between use of newer mammographic technology and race in women receiving mammography services. Materials and Methods This was a multiyear (January 2005 to December 2020) retrospective study of women aged 40-89 years with Medicare fee-for-service insurance who underwent mammography. Data were obtained using a 5% research identifiable sample of all Medicare fee-for-service beneficiaries. Within-institution and comparable-institution use of mammographic technology between Black women or women of other races and White women were assessed with multivariable logistic and linear regression, respectively, adjusted for age, race, Charlson comorbidity index, per capita income, urbanicity, and institutional capability. Results Between 2005 and 2020, there were 4 028 696 institutional mammography claims for women (mean age, 72 years ± 8 [SD]). Within an institution, the odds ratio (OR) of Black women receiving digital mammography rather than SFM in 2005 was 0.80 (95% CI: 0.70, 0.91; P < .001) when compared with White women; these differences remained until 2009. Compared with White women, the use of DBT within an institution was less likely for Black women from 2015 to 2020 (OR, 0.84; 95% CI: 0.81, 0.87; P < .001). Across institutions, there were racial differences in digital mammography use, which followed a U-shaped pattern, and the differences peaked at 3.8 percentage points less for Black compared with White women (95% CI: -6.1, -1.6; P = .001) in 2011 and then decreased to 1.2 percentage points less (95% CI: -2.2, -0.2; P = .02) in 2016. Conclusion In the Medicare population, Black women had less access to new mammographic imaging technology compared with White women for both the transition from screen-film mammography to digital mammography and then for the transition to digital breast tomosynthesis. © RSNA, 2022 Online supplemental material is available for this article. See also the editorial by Lee and Lawson in this issue.
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Affiliation(s)
- Eric W Christensen
- From the Neiman Health Policy Institute, 1891 Preston White Dr, Reston, VA 20191 (E.W.C., M.W., E.Y.R.); Health Services Management, University of Minnesota, St Paul, Minn (E.W.C.); Department of Radiology, SUNY Downstate Health Sciences University, Brooklyn, NY (J.S.); Department of Radiology, Mayo Clinic Arizona, Phoenix, Ariz (B.K.P.); and Department of Radiology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY (J.A.B.)
| | - Mikki Waid
- From the Neiman Health Policy Institute, 1891 Preston White Dr, Reston, VA 20191 (E.W.C., M.W., E.Y.R.); Health Services Management, University of Minnesota, St Paul, Minn (E.W.C.); Department of Radiology, SUNY Downstate Health Sciences University, Brooklyn, NY (J.S.); Department of Radiology, Mayo Clinic Arizona, Phoenix, Ariz (B.K.P.); and Department of Radiology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY (J.A.B.)
| | - Jinel Scott
- From the Neiman Health Policy Institute, 1891 Preston White Dr, Reston, VA 20191 (E.W.C., M.W., E.Y.R.); Health Services Management, University of Minnesota, St Paul, Minn (E.W.C.); Department of Radiology, SUNY Downstate Health Sciences University, Brooklyn, NY (J.S.); Department of Radiology, Mayo Clinic Arizona, Phoenix, Ariz (B.K.P.); and Department of Radiology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY (J.A.B.)
| | - Bhavika K Patel
- From the Neiman Health Policy Institute, 1891 Preston White Dr, Reston, VA 20191 (E.W.C., M.W., E.Y.R.); Health Services Management, University of Minnesota, St Paul, Minn (E.W.C.); Department of Radiology, SUNY Downstate Health Sciences University, Brooklyn, NY (J.S.); Department of Radiology, Mayo Clinic Arizona, Phoenix, Ariz (B.K.P.); and Department of Radiology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY (J.A.B.)
| | - Jacqueline A Bello
- From the Neiman Health Policy Institute, 1891 Preston White Dr, Reston, VA 20191 (E.W.C., M.W., E.Y.R.); Health Services Management, University of Minnesota, St Paul, Minn (E.W.C.); Department of Radiology, SUNY Downstate Health Sciences University, Brooklyn, NY (J.S.); Department of Radiology, Mayo Clinic Arizona, Phoenix, Ariz (B.K.P.); and Department of Radiology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY (J.A.B.)
| | - Elizabeth Y Rula
- From the Neiman Health Policy Institute, 1891 Preston White Dr, Reston, VA 20191 (E.W.C., M.W., E.Y.R.); Health Services Management, University of Minnesota, St Paul, Minn (E.W.C.); Department of Radiology, SUNY Downstate Health Sciences University, Brooklyn, NY (J.S.); Department of Radiology, Mayo Clinic Arizona, Phoenix, Ariz (B.K.P.); and Department of Radiology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY (J.A.B.)
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Titan AL, Baiu I, Liou D, Lui NS, Berry M, Shrager J, Backhus L. Eligibility for Lung Cancer Screening Among Women Receiving Screening for Breast Cancer. JAMA Netw Open 2022; 5:e2233840. [PMID: 36178692 PMCID: PMC9526079 DOI: 10.1001/jamanetworkopen.2022.33840] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Blurb: This cohort study assesses the number of women who were eligible for and underwent lung cancer screening among those who received mammograms at a single academic medical center.
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Affiliation(s)
- Ashley L. Titan
- Department of Surgery, Stanford University Hospital, Stanford, California
| | - Ioana Baiu
- Department of Surgery, Stanford University Hospital, Stanford, California
- Department of Cardiothoracic Surgery, Stanford University Hospital, Stanford, California
| | - Doug Liou
- Department of Cardiothoracic Surgery, Stanford University Hospital, Stanford, California
| | - Natalie S. Lui
- Department of Cardiothoracic Surgery, Stanford University Hospital, Stanford, California
| | - Mark Berry
- Department of Cardiothoracic Surgery, Stanford University Hospital, Stanford, California
| | - Joseph Shrager
- Department of Cardiothoracic Surgery, Stanford University Hospital, Stanford, California
| | - Leah Backhus
- Stanford School of Medicine, Stanford, California
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Effect of Out-of-Pocket Costs on Subsequent Mammography Screening. J Am Coll Radiol 2021; 19:24-34. [PMID: 34748732 DOI: 10.1016/j.jacr.2021.09.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 09/26/2021] [Accepted: 09/27/2021] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Although the Affordable Care Act eliminated cost sharing for screening mammography, a concern is that grandfathered plans, diagnostic mammograms, and follow-up testing may still lead to out-of-pocket (OOP) spending. Our study examines how OOP spending among women at their baseline screening mammogram may impact the decision to receive subsequent screening. METHODS The study included commercially insured women aged 40 to 41 years with a screening mammogram between 2011 and 2014. We estimated multivariate linear probability models of the effect of OOP spending at the baseline mammogram on subsequent screening 12 to 36 months later. RESULTS Having any OOP payments for the baseline screening mammogram significantly reduced the probability of screening in the subsequent 12 to 24 months by 3.0 percentage points (pp) (95% confidence interval [CI]: 1.1-4.8 pp decrease). For every $100 increase in the OOP expenses for the baseline mammogram, the likelihood of subsequent screening within 12 to 24 months decreased by 1.9 pp (95% CI: 0.8-3.1 pp decrease). Similarly, any OOP spending for follow-up tests resulting from the baseline screening led to a 2.7 pp lower probability of screening 12 to 24 months later (95% CI: 0.9-4.1 pp decrease). Higher OOP expenses were associated with significantly lower screening 24 to 36 months later (coefficient = -0.014, 95% CI: -0.025 to -0.003). DISCUSSION Although cost sharing has been eliminated for screening mammograms, OOP costs may still arise, particularly for diagnostic and follow-up testing services, both of which may reduce rates of subsequent screening. For preventive services, reducing or eliminating cost sharing through policy and legislation may be important to ensuring continued adherence to screening guidelines.
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Hathaway C, Paetsch P, Li Y, Wu J, Asgarian S, Parker A, Welsh A, Deverka P, Cohain A. Association of Breast Cancer Screening Behaviors With Stage at Breast Cancer Diagnosis and Potential for Additive Multi-Cancer Detection via Liquid Biopsy Screening: A Claims-Based Study. Front Oncol 2021; 11:688455. [PMID: 34222015 PMCID: PMC8241562 DOI: 10.3389/fonc.2021.688455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 05/12/2021] [Indexed: 11/21/2022] Open
Abstract
Purpose To evaluate mammography uptake and subsequent breast cancer diagnoses, as well as the prospect of additive cancer detection via a liquid biopsy multi-cancer early detection (MCED) screening test during a routine preventive care exam (PCE). Methods Patients with incident breast cancer were identified from five years of longitudinal Blue Health Intelligence® (BHI®) claims data (2014-19) and their screening mammogram and PCE utilization were characterized. Ordinal logistic regression analyses were performed to identify the association of a biennial screening mammogram with stage at diagnosis. Additional screening opportunities for breast cancer during a PCE within two years before diagnosis were identified, and the method extrapolated to all cancers, including those without recommended screening modalities. Results Claims for biennial screening mammograms and the time from screening to diagnosis were found to be predictors of breast cancer stage at diagnosis. When compared to women who received a screening mammogram proximal to their breast cancer diagnosis (0-4 months), women who were adherent to guidelines but had a longer time window from their screening mammogram to diagnosis (4-24 months) had a 87% increased odds of a later-stage (stages III or IV) breast cancer diagnosis (p-value <0.001), while women with no biennial screening mammogram had a 155% increased odds of a later-stage breast cancer diagnosis (p-value <0.001). This highlights the importance of screening in the earlier detection of breast cancer. Of incident breast cancer cases, 23% had no evidence of a screening mammogram in the two years before diagnosis. However, 49% of these women had a PCE within that time. Thus, an additional 11% of breast cancer cases could have been screened if a MCED test had been available during a PCE. Additionally, MCED tests have the potential to target up to 58% of the top 5 cancers that are the leading causes of cancer death currently without a USPSTF recommended screening modality (prostate, pancreatic, liver, lymphoma, and ovarian cancer). Conclusion The study used claims data to demonstrate the association of cancer screening with cancer stage at diagnosis and demonstrates the unmet potential for a MCED screening test which could be ordered during a PCE.
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Affiliation(s)
| | - Peter Paetsch
- Blue Health Intelligence, Chicago, IL, United States
| | - Yali Li
- Thrive, An Exact Sciences Company, Cambridge, MA, United States
| | - Jincao Wu
- Thrive, An Exact Sciences Company, Cambridge, MA, United States
| | - Sam Asgarian
- Thrive, An Exact Sciences Company, Cambridge, MA, United States
| | - Alex Parker
- Thrive, An Exact Sciences Company, Cambridge, MA, United States
| | - Alley Welsh
- Thrive, An Exact Sciences Company, Cambridge, MA, United States
| | | | - Ariella Cohain
- Thrive, An Exact Sciences Company, Cambridge, MA, United States
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Monticciolo DL. Current Guidelines and Gaps in Breast Cancer Screening. J Am Coll Radiol 2020; 17:1269-1275. [PMID: 32473894 DOI: 10.1016/j.jacr.2020.05.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 04/30/2020] [Accepted: 05/01/2020] [Indexed: 01/25/2023]
Abstract
Breast cancer is the most common nonskin cancer in women and the second leading cause of cancer death for women in the United States. Mammography screening is proven to significantly decrease breast cancer mortality, with a 40% or more reduction expected with annual use starting at age 40 for women of average risk. However, less than half of all eligible women have a mammogram annually. The elimination of cost sharing for screening made possible by the Affordable Care Act (2010) encouraged screening but mainly for those already insured. The United States Preventive Services Task Force 2009 guidelines recommended against screening those 40 to 49 years old and have left women over 74 years of age vulnerable to coverage loss. Other populations for whom significant gaps in risk information or screening use exist, including women of lower socioeconomic status, black women, men at higher than average risk of breast cancer, and sexual and gender minorities. Further work is needed to achieve higher rates of screening acceptance for all appropriate individuals so that the full mortality and treatment benefits of mammography screening can be realized.
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Affiliation(s)
- Debra L Monticciolo
- Vice Chair for Research, and Section Chief, Breast Imaging, Department of Radiology, Texas A&M University, Temple, Texas; Baylor Scott & White Healthcare-Central Texas, Temple, Texas.
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