Mammography Use Among Medicare Beneficiaries After Elimination of Cost Sharing

Social determinants of health and health inequities in breast cancer screening: a scoping review

Introduction

This scoping review aims to highlight key social determinants of health associated with breast cancer screening behavior in United States women aged ≥40  years old, identify public and private databases with SDOH data at city, state, and national levels, and share lessons learned from United States based observational studies in addressing SDOH in underserved women influencing breast cancer screening behaviors.

Methods

The Arksey and O'Malley York methodology was used as guidance for this review: (1) identifying research questions; (2) searching for relevant studies; (3) selecting studies relevant to the research questions; (4) charting the data; and (5) collating, summarizing, and reporting results.

Results

The 72 included studies were published between 2013 and 2023. Among the various SDOH identified, those related to socioeconomic status (n = 96) exhibited the highest frequency. The Health Care Access and Quality category was reported in the highest number of studies (n = 44; 61%), showing its statistical significance in relation to access to mammography. Insurance status was the most reported sub-categorical factor of Health Care Access and Quality.

Discussion

Results may inform future evidence-based interventions aiming to address the underlying factors contributing to low screening rates for breast cancer in the United States.

Mammography screening beliefs and barriers through the lens of Black women during the COVID-19 pandemic

BACKGROUND

Mammography is an effective screening tool that leads to decreased breast cancer mortality, yet minority women continue to experience barriers. The coronavirus disease 2019 (COVID-19) pandemic has been proven to have negatively affected minority communities, yet its effect on mammography screening habits in Black women is uncertain. The purpose of this study was to evaluate breast cancer mammography screening habits and barriers for Black women in two northeast communities amid the COVID-19 pandemic.

METHODS

The study participants were Black women aged 40 years or older who were recruited from community outreach initiatives. Study coordinators conducted telephone surveys to determine mammography screening behaviors, perceptions, and psychosocial factors.

RESULTS

Two hundred seventy-seven surveys were completed. Two hundred fifty-six patients who reported ever having a mammogram became the study population of interest. One hundred seventy-four of these patients (68%) reported having a mammogram within the past year (nondelayed), and 82 (32%) had a mammogram more than a year ago (delayed). Only thirty-one of the delayed participants (37.8%) had private insurance. There was a significant difference in the mean score for mammography screening perceived barriers for nondelayed participants (mean = 9.9, standard deviation [SD] = 3.6) versus delayed participants (mean = 11.2, SD = 4.3, p = .03). There was also a significant difference in the mean score when they were asked, "How likely is it that 'other health problems would keep you from having a mammogram'?" (p = .002).

CONCLUSIONS

Barriers to mammography screening for Black women during the COVID-19 era include insurance, competing health issues, and perceptions of screening. Community outreach efforts should concentrate on building trust and collaborating with organizations to improve screening despite the COVID-19 pandemic.

Coverage Parity And Racial And Ethnic Disparities In Mental Health And Substance Use Care Among Medicare Beneficiaries

Many older Americans do not receive needed care for mental health and substance use disorders (MHSUD), and there are substantial racial and ethnic disparities in receipt of this care across the lifespan. Medicare introduced cost-sharing parity for outpatient MHSUD care during the period 2010-14, reducing beneficiaries' out-of-pocket share of MHSUD spending from 50 percent to 20 percent. Among traditional Medicare beneficiaries ages sixty-five and older, we examined changes in MHSUD use and spending during the period 2008-18 for low-income beneficiaries with the cost-sharing reduction versus a control group of beneficiaries with free care throughout the study period among Black, Hispanic, Asian, and American Indian/Alaska Native versus White beneficiaries. Among older Medicare beneficiaries, overall use of MHSUD services increased during this period. For White beneficiaries, MHSUD cost-sharing parity was associated with an increased likelihood of having specialty MHSUD visits and medication use and a reduced likelihood of having unmonitored MHSUD medication use and MHSUD emergency department visits and hospitalizations. However, cost-sharing parity was associated with smaller or no gains in MHSUD services use for racial and ethnic minority beneficiaries compared with White beneficiaries, thus widening racial and ethnic disparities in MHSUD care.

Change in mammography screening attendance after removing the out-of-pocket fee: a population-based study in Sweden (2014-2018)

Purpose

To assess the change in mammography screening attendance in Sweden—overall and in sociodemographic groups at risk of low attendance—after removal of the out-of-pocket fee in 2016.

Methods

Individual-level data on all screening invitations and attendance between 2014 and 2018 were linked to sociodemographic data from Statistics Sweden. Odds ratios and 95% confidence intervals (CIs) for attendance by time period and sociodemographic factor were computed using mixed logistic regression to account for repeated measures within women. The study sample included 1.4 million women, aged 40–75, who had a mammography screening appointment in 2014–2015 and/or 2017–2018 in 14 of Sweden’s 21 health care regions.

Results

Overall screening attendance was 83.8% in 2014–2015 and 84.1% in 2017–2018 (+ 0.3 percentage points, 95% CI 0.2–0.4). The greatest increase in attendance was observed in non-Nordic women with the lowest income, where attendance rose from 62.9 to 65.8% (+ 2.9 points, 95% CI 2.3–3.6), and among women with four or more risk factors for low attendance, where attendance rose from 59.2 to 62.0% (+ 2.8 points, 95% CI 2.2–3.4).

Conclusion

Screening attendance did not undergo any important increase after implementing free screening, although attendance among some sociodemographic groups increased by almost three percentage points after the policy change.

Utilization Impact of Cost-Sharing Elimination for Preventive Care Services: A Rapid Review

Consumer cost-sharing has been shown to diminish utilization of preventive services. Recent efforts, including provisions within the Affordable Care Act, have sought to increase use of preventive care through elimination of cost-sharing for clinically indicated services. We conducted a rapid review of the literature to determine the impact of cost-share elimination on utilization of preventive services. Searches were conducted in PubMed, Scopus, and CINAHL Complete databases as well as in grey literature. A total of 35 articles were included in qualitative synthesis and findings were summarized for three clinical service categories: cancer screenings, contraceptives, and additional services. Impacts of cost-sharing elimination varied depending on clinical service, with a majority of findings showing increases in use. Studies that included socioeconomic status reported that those who were financially vulnerable incurred substantial increases in utilization. Future investigations on additional clinical services are warranted as is research to better elucidate populations who most benefit from cost-sharing elimination.

Reduced Mammography Screening for Breast Cancer among Women with Visual Impairment

PURPOSE

Timely mammography to screen for breast cancer in accordance with the United States Preventive Services Task Force (USPSTF) recommendations can reduce morbidity and mortality substantially. This study assessed whether the odds of undergoing screening mammography are similar for women with and without visual impairment (VI).

DESIGN

Retrospective, longitudinal cohort study.

PARTICIPANTS

Women aged 65 to 72 years enrolled in fee-for-service Medicare from January 1, 2008, through December 31, 2015.

METHODS

Patients with no vision loss (NVL), partial vision loss (PVL), and severe vision loss (SVL) were matched 1:1:1 based on age, race, time in Medicare, urbanicity of residence, and overall health. Women with pre-existing breast cancer were excluded. Multivariable conditional logistic regression modeling compared the odds of undergoing screening mammography within a 2-year follow-up period among the 3 groups.

MAIN OUTCOMES MEASURES

Proportion of participants undergoing mammography and adjusted odds ratios (ORs) of undergoing mammography within 2 years of follow-up.

RESULTS

A total of 1044 patients were matched (348 in each group). The mean ± standard deviation age at the index date was 69.0 ± 1.5 years for all 3 groups. The proportion of women undergoing 1 mammography screening or more within the 2-year follow-up was 69.0% (n = 240), 56.9% (n = 198), and 56.0% (n = 195) for the NVL, PVL, and SVL groups, respectively (P = 0.0005). The mean ± standard deviation number of mammography screenings undergone per patient during the 5-year period (3-year look-back plus 2-year follow-up) was 3.1 ± 2.0, 2.5 ± 2.0, and 2.3 ± 2.1 for the NVL, PVL, and SVL groups, respectively (P < 0.0001). Women with SVL had 42% decreased odds (OR, 0.58; 95% CI, 0.37-0.90; P = 0.01), and those with PVL had 44% decreased odds (OR, 0.56; CI, 0.36-0.87; P = 0.009) of undergoing mammography during follow-up compared with those with NVL.

CONCLUSIONS

Women with VI were significantly less likely to undergo mammography screening for breast cancer than women without VI. Clinicians should look for ways to help ensure that patients with VI undergo mammography and other preventive screenings as recommended by the USPSTF.

Current Guidelines and Gaps in Breast Cancer Screening

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.

The effect of the Affordable Care Act on patient out-of-pocket cost and use of preventive cancer screenings in Massachusetts

In an effort to increase use of preventive health care, The Patient Protection and Affordable Care Act (ACA) eliminated cost-sharing for preventive cancer screening services for the privately insured. The impact on patient spending and use of these screenings is still poorly understood. We used an interrupted time series analysis with the Massachusetts All-Payer Claims Database (2009-2012) to assess changes in trends in costs and use of breast, cervical and colorectal cancer screenings after the ACA policy. We find that the ACA was associated with a 0.024 (95% CI: -0.031, -0.017, p < 0.001) and 0.424 (95% CI: -0.481, -0.368, p < 0.001) percentage point decrease in the likelihood of a copayment each week for preventive breast and cervical cancer screenings respectively. The likelihood of copayment for colon cancer screening declined throughout the study period, with the rate of decline slowing following the ACA (trend in percent of screenings with copayment -0.130 before vs -0.071 after ACA, p = 0.014). Overall, we find only weak evidence that the ACA policy increased screenings. We find no significant effect on utilization for cervical cancer or colon cancer screening. For breast cancer screening, we find a small immediate increase in the utilization rate in the month after the policy change, with no change in trend after the ACA policy. Policy makers may need to consider other complementary policy options to increase screening rates.

Cervical and colorectal cancer screening prevalence before and after Affordable Care Act Medicaid expansion

Community health centers (CHCs), which serve socioeconomically disadvantaged patients, experienced an increase in insured visits after the 2014 Affordable Care Act (ACA) coverage options began. Yet, little is known about how cancer screening rates changed post-ACA. Therefore, this study assessed changes in the prevalence of cervical and colorectal cancer screening from pre- to post-ACA in expansion and non-expansion states among patients seen in CHCs. Electronic health record data on 624,601 non-pregnant patients aged 21-64 eligible for cervical or colorectal cancer screening between 1/1/2012 and 12/31/2015 from 203 CHCs were analyzed. We assessed changes in prevalence and screening likelihood among patients, by insurance type and race/ethnicity and compared Medicaid expansion and non-expansion states using difference-in-difference methodology. Female patients had 19% increased odds of receiving cervical cancer screening post- relative to pre-ACA in expansion states [adjusted odds ratio (aOR) = 1.19, 95% confidence interval (CI) = 1.09-1.31] and 23% increased odds in non-expansion states (aOR = 1.23, 95% CI = 1.05-1.46): the greatest increase was among uninsured patients in expansion states (aOR = 1.36, 95% CI = 1.16-1.59) and privately-insured patients in non-expansion states (aOR = 1.43, 95% CI = 1.11-1.84). Colorectal cancer screening prevalence increased from 11% to 18% pre- to post-ACA in expansion states and from 13% to 21% in non-expansion states. For most outcomes, the observed changes were not significantly different between expansion and non-expansion states. Despite increased prevalences of cervical and colorectal cancer screening in both expansion and non-expansion states across all race/ethnicity groups, rates remained suboptimal for this population of socioeconomically disadvantaged patients.

Effectiveness of Medicare cost-sharing elimination for Cancer screening on utilization

Background

The Patient Protection and Affordable Care Act (ACA) eliminated the cost-sharing requirement for several preventive cancer screenings. This study examined the cancer screening utilization of mammogram, Pap smear and colonoscopy in Medicare fee-for-service (FFS) under the ACA.

Methods

The primary data were the 2007–2013 Medicare Current Beneficiary Survey linked to FFS claims. The effect of the cost-sharing removal on the probability of receiving a preventive cancer screening test was estimated using a logistic regression, separately for each screening test, adjusting for the complex survey design. The model was also separately estimated for different socioeconomic and race/ethnic groups.

The study sample included beneficiaries with Part B coverage for the entire calendar year, excluding beneficiaries in Medicaid or Medicare Advantage plans. Beneficiaries with a claims-documented or self-reported history of targeted cancers, who were likely to have diagnostic tests or have surveillance screenings were excluded.

The screening measures were constructed separately following Medicare coverage and U.S. Preventive Services Task Force (USPSTF) recommendations. We measured the screening utilization outcome drawing from claims data, as well as using the self-reported survey data.

Results

After the cost-sharing removal policy, we found no statistically significant difference in a beneficiary’s probability of receiving a colonoscopy (transition period: OR = 1.08, 95% CI = 0.90–1.29; post-policy period: OR = 1.08, 95% CI = 0.83–1.42), a mammogram (transition period: OR = 1.03, 95% CI = 0.91–1.17; post-policy period: OR = 1.07, 95% CI = 0.88–1.30), or a biennial Pap smear (transition period: OR = 0.87, 95% CI = 0.69–1.09; post-policy period: OR = 0.72, 95% CI = 0.51–1.03) in claims-based measures following Medicare coverage. Similarly, we found null effects of the policy change on utilization of colonoscopy among enrollees 50–75 years old, biennial mammograms by women 50–74, and triennial Pap smear tests among women 21–65 in claims-based measures according to USPSTF. The findings from survey-based measures were consistent with the estimates from claims-based measures, except that the use of Pap smear declined since 2011. Further, the policy change did not increase utilization in patients with disadvantaged socioeconomic characteristics. Yet the disparate patterns in adjusted screening rates by socioeconomic status and race/ethnicity persisted over time.

Conclusions

Removing out-of-pocket costs for screenings did not provide enough incentives to increase the screening rates among Medicare beneficiaries.

Time to Follow-up After Colorectal Cancer Screening by Health Insurance Type

INTRODUCTION

The purpose of this study was to test the hypothesis that patients with Medicaid insurance or Medicaid-like coverage would have longer times to follow-up and be less likely to complete colonoscopy compared with patients with commercial insurance within the same healthcare systems.

METHODS

A total of 35,009 patients aged 50-64years with a positive fecal immunochemical test were evaluated in Northern and Southern California Kaiser Permanente systems and in a North Texas safety-net system between 2011 and 2012. Kaplan-Meier estimation was used between 2016 and 2017 to calculate the probability of having follow-up colonoscopy by coverage type. Among Kaiser Permanente patients, Cox regression was used to estimate hazard ratios and 95% CIs for the association between coverage type and receipt of follow-up, adjusting for sociodemographics and health status.

RESULTS

Even within the same integrated system with organized follow-up, patients with Medicaid were 24% less likely to complete follow-up as those with commercial insurance. Percentage receiving colonoscopy within 3 months after a positive fecal immunochemical test was 74.6% for commercial insurance, 63.10% for Medicaid only, and 37.5% for patients served by the integrated safety-net system.

CONCLUSIONS

This study found that patients with Medicaid were less likely than those with commercial insurance to complete follow-up colonoscopy after a positive fecal immunochemical test and had longer average times to follow-up. With the future of coverage mechanisms uncertain, it is important and timely to assess influences of health insurance coverage on likelihood of follow-up colonoscopy and identify potential disparities in screening completion.

Breast Screening Utilization and Cost Sharing Among Employed Insured Women After the Affordable Care Act

OBJECTIVE

To assess changes in screening mammography cost sharing and utilization before and after the Affordable Care Act (ACA) and the revised US Preventive Services Task Force (USPSTF) guidelines. To compare mammography cost sharing between women aged 40 to 49 and those 50 to 74.

METHODS

We used patient-level analytic files between 2004 and 2014 from Clinformatics Data Mart (OptumInsight, Eden Prairie, Minnesota). We included women 40 to 74 years without a history of breast cancer or mastectomy. We conducted an interrupted time series analyses assessing cost sharing and utilization trends before and after the ACA implementation and USPSTF revised guidelines.

RESULTS

We identified 1,763,959 commercially insured women aged 40 to 74 years. Between 2004 and 2014, the proportion of women with zero cost share for screening mammography increased from 81.9% in 2004 to 98.2% in 2014, reaching 93.1% with the 2010 ACA implementation. The adjusted median cost share remained $0 over time. Initially at 36.0% in 2004, screening utilization peaked at 42.2% in 2009 with the USPSTF guidelines change, dropping to 40.0% in 2014. Comparing women aged 40 to 49, 50 to 64, and 65 to 74, the proportion exposed to cost sharing declined over time in all groups.

CONCLUSIONS

A substantial majority of commercially insured women had first-dollar coverage for mammography before the ACA. After ACA, nearly all women had access to zero cost-share mammography. The lack of an increase in mammography use post-ACA can be partially attributed to a USPSTF guideline change, the high proportion of women without cost sharing before the ACA, and the relatively low levels of cost sharing before the policy implementation.

Prevalence of Out-Of-Pocket Payments for Mammography Screening Among Recently Screened Women

Background: Because cost may be a barrier to receiving mammography screening, cost sharing for "in-network" screening mammograms was eliminated in many insurance plans with implementation of the Affordable Care Act. We examined prevalence of out-of-pocket payments for screening mammography after elimination in many plans. Materials and Methods: Using 2015 National Health Interview Survey data, we examined whether women aged 50-74 years who had screening mammography within the previous year (n = 3,278) reported paying any cost for mammograms. Logistic regression models stratified by age (50-64 and 65-74 years) examined out-of-pocket payment by demographics and insurance (ages 50-64 years: private, Medicaid, other, and uninsured; ages 65-74 years: private ± Medicare, Medicare+Medicaid, Medicare Advantage, Medicare only, and other). Results: Of women aged 50-64 years, 23.5% reported payment, including 39.1% of uninsured women. Compared with that of privately insured women, payment was less likely for women with Medicaid (adjusted OR 0.17 [95% CI 0.07-0.41]) or other insurance (0.49 [0.25-0.96]) and more likely for uninsured women (1.99 [0.99-4.02]) (p < 0.001 across groups). For women aged 65-74 years, 11.9% reported payment, including 22.5% of Medicare-only beneficiaries. Compared with private ± Medicare beneficiaries, payment was less likely for Medicare+Medicaid beneficiaries (adjusted OR 0.21 [95% CI 0.06-0.73]) and more likely for Medicare-only beneficiaries (1.83 [1.01-3.32]) (p = 0.005 across groups). Conclusions: Although most women reported no payment for their most recent screening mammogram in 2015, some payment was reported by >20% of women aged 50-64 years or aged 65-74 years with Medicare only, and by almost 40% of uninsured women aged 50-64 years. Efforts are needed to understand why many women in some groups report paying out of pocket for mammograms and whether this impacts screening use.

Colorectal cancer screening in the United States: Trends from 2008 to 2015 and variation by health insurance coverage

Regular colorectal cancer (CRC) screening is recommended for reducing CRC incidence and mortality. This paper provides an updated analysis of CRC screening in the United States (US) and examines CRC screening by several features of health insurance coverage. Recommendation-consistent CRC screening was calculated for adults aged 50-75 in 2008, 2010, 2013 and 2015 using data from the National Health Interview Survey. CRC screening prevalence in 2015 was described overall and by sociodemographic subgroups. CRC screening by health insurance coverage was further examined using multivariable logistic regression, stratified by age (50-64 years and 65-75 years) and adjusted for age, race/ethnicity, sex, education, income, time in US, and comorbid conditions. Recommendation-consistent screening increased from 51.6% in 2008 to 58.3% in 2010 (p < 0.001). Use plateaued from 2010 to 2013 but increased to 61.3% in 2015 (p < 0.001). In 2015, adults aged 50-64 years with traditional employer-sponsored private insurance were more likely to be screened (62.2%) than those with traditional private direct purchase plans (50.9%) and the uninsured (24.8%) (p < 0.01, respectively). After multivariable adjustment, differences between traditional employer-sponsored private insurance and the uninsured remained statistically significant. Adults aged 65-75 with Medicare and private insurance were more likely to be screened (76.3%) than those with Medicare, no supplemental insurance (68.8%) or Medicare and Medicaid (65.2%) (p < 0.001). After multivariable adjustment, the differences between Medicare and private insurance and Medicare no supplemental insurance remained statistically significant. CRC screening rates have increased over time, but certain segments of the population, especially the uninsured, continue to screen below recommended levels.

The ACA and Cancer Screening and Diagnosis

The Patient Protection and Affordable Care Act (ACA) included multiple provisions expected to increase cancer screening and subsequently early diagnosis of cancer. Key provisions included new coverage options for low-income adults and young adults, as well as elimination of cost sharing for recommended preventive services across most health insurance plans. This article reviews relevant quantitative studies published since the ACA's passage to assess whether the goal of increasing access to preventive services has been met. Because of lags in data availability, most studies examined only a short period post-ACA. Findings on changes in screening in the general population were mixed, although impacts were greatest among those with lower education and income, as well as groups that previously faced the highest cost barriers to screening. Furthermore, multiple studies found evidence of increases in early-stage diagnoses for certain cancers. Thus, certain targeted populations appear to have better access to cancer screening after the ACA.

Elimination of Cost Sharing for Screening Mammography in Medicare Advantage Plans

BACKGROUND

The Affordable Care Act (ACA) required most insurers and the Medicare program to eliminate cost sharing for screening mammography.

METHODS

We conducted a difference-in-differences study of biennial screening mammography among 15,085 women 65 to 74 years of age in 24 Medicare Advantage plans that eliminated cost sharing to provide full coverage for screening mammography, as compared with 52,035 women in 48 matched control plans that had and maintained full coverage.

RESULTS

In plans that eliminated cost sharing, adjusted rates of biennial screening mammography increased from 59.9% (95% confidence interval [CI], 54.9 to 65.0) in the 2-year period before cost-sharing elimination to 65.4% (95% CI, 61.8 to 69.0) in the 2-year period thereafter. In control plans, the rates of biennial mammography were 73.1% (95% CI, 69.2 to 77.0) and 72.8% (95% CI, 69.7 to 76.0) during the same periods, yielding a difference in differences of 5.7 percentage points (95% CI, 3.0 to 8.4). The difference in differences was 9.8 percentage points (95% CI, 4.5 to 15.2) among women living in the areas with the highest quartile of educational attainment versus 4.3 percentage points (95% CI, 0.2 to 8.4) among women in the lowest quartile. As indicated by the difference-in-differences estimates, after the elimination of cost sharing, the rate of biennial mammography increased by 6.5 percentage points (95% CI, 3.7 to 9.4) for white women and 8.4 percentage points (95% CI, 2.5 to 14.4) for black women but was almost unchanged for Hispanic women (0.4 percentage points; 95% CI, -7.3 to 8.1).

CONCLUSIONS

The elimination of cost sharing for screening mammography under the ACA was associated with an increase in rates of use of this service among older women for whom screening is recommended. The effect was attenuated among women living in areas with lower educational attainment and was negligible among Hispanic women. (Funded by the National Institute on Aging.).