Medicare modernization and diffusion of endoscopy in FFS medicare

Should Measures of Health Care Availability Be Based on the Providers or the Procedures? A Case Study with Implications for Rural Colorectal Cancer Disparities

PURPOSE

Patients with colorectal cancer (CRC) living in rural areas have lower survival rates than those in urban areas, potentially because of lack of access to quality CRC screening and treatment. The purpose of this study was to compare traditional physician density (ie, colonoscopy provider availability per capita) against a new physician density measure using an example case of colonoscopy volume and quality. The latter is particularly relevant for rural providers, who may have fewer patients and are more frequently nongastroenterologists.

METHODS

We conducted a secondary data analysis of the 2014 Medicare Provider Utilization and Payment Database and the National Cancer Institute State Cancer Profile Database. Volume-weighted physician density scores at the state and county levels were created, accounting for (1) the physician's annual colonoscopy volume and (2) whether the physician performs ≥100 procedures per year. We compared volume-weighted versus traditional density, overall and by rurality, and examined their correlation with CRC screening, incidence, and mortality rates.

FINDINGS

The difference between volume-weighted and traditional density scores was particularly large in rural parts of the West and Midwest, and it was most similar in the Northeast. Although weak, correlations with CRC outcomes were stronger for volume-weighted density, and they did not differ by rurality.

CONCLUSIONS

Our new method is an improvement over traditional methods because it considers the variation of physician procedure volume, and it has a stronger correlation with population health outcomes. Weighted density scores portray a more realistic picture of physician supply, particularly in rural areas.

What Happened to Disparities in CRC Screening Among FFS Medicare Enrollees Following Medicare Modernization?

The Medicare Modernization Act of 2003, implemented in 2006, increased managed care options for seniors. It introduced insurance plans for prescription drug coverage for all Medicare beneficiaries, whether they were enrolled in FFS or managed care (Medicare Advantage) plans. The availability of drug coverage beginning in 2006 served to free up budgets for FFS Medicare enrollees that could be used to make copayments for colorectal cancer (CRC) screening using endoscopy (colonoscopy or sigmoidoscopy). In 2007, Medicare eliminated the copayments required by seniors for CRC screening by endoscopy. Later in 2008, CRC screening by colonoscopy became part of the gold standard for CRC screening. This legitimized its use and offered even further encouragement to seniors, who may have been reluctant to undergo the procedure because of the non-pecuniary risks associated with it. In addition, 37 CRC screening interventions occurred during this timeframe to enhance compliance with screening standards. Using multilevel analysis of individuals' endoscopy utilization, derived from 100% FFS Medicare claims, along with county-level market and contextual factors, we compare the periods before and after the MMA (2001-2005 to 2006-2009) to determine whether disparities in the utilization of endoscopic CRC screening occurred or changed over the decade. We examined Blacks, Asians, and Hispanics relative to Whites, and Females relative to Males (with race or ethnicity combined). We examined each state separately for evidence of disparities within states, to avoid confounding by geographic disparities. We expected that the net effect of the policy changes and the targeted interventions over the decade would be to increase CRC screening by endoscopy, reducing disparities. We saw improvements over time (reduced disparities relative to Whites) for Blacks and Hispanics residing in several states, and improvements over time for Females relative to Males in many states. For the vast majority of states, however, disparities persisted with Whites and Males exhibiting greater rates of utilization than other groups. States that undertook the interventions were more likely to have had improvements in disparities or positive disparities for women and minorities. While some gains were made over this time period, the gains were unevenly distributed across the USA and more work needs to be done to reduce remaining disparities.