Journal of General Internal Medicine

, Volume 27, Issue 9, pp 1112–1119 | Cite as

Two-year Trends in Cancer Screening Among Low Socioeconomic Status Women in an HMO-based High-deductible Health Plan

  • J. Frank Wharam
  • Amy Johnson Graves
  • Fang Zhang
  • Stephen B. Soumerai
  • Dennis Ross-Degnan
  • Bruce E. Landon
Original Research



Cancer screening is often fully covered under high-deductible health plans (HDHP), but low socioeconomic status (SES) women still might forego testing.


To determine the impact of switching to a HDHP on breast and cervical cancer screening among women of low SES.


Pre-post with comparison group.


Four thousand one hundred and eighty-eight health plan members enrolled for one year before and up to two years after an employer-mandated switch from a traditional HMO to an HMO-based HDHP, compared with 9418 propensity score matched controls who remained in HMOs by employer choice. Both groups had low outpatient copayments. High-deductible members had full coverage of mammography and Pap smears, but $500 to $2000 individual deductibles for most other services. HMO members had full coverage of cancer screening and low copayments for other services without any deductible. We stratified analyses by SES.


Transition to a HDHP.


Annual breast and cervical cancer screening rates; rates of annual preventive outpatient visits.


In follow-up years 1 and 2, low SES HDHP members experienced no statistically detectable changes in rates of breast cancer screening (ratio of change, 1.14, 95 % CI, [0.93,1.40] and 1.05, [0.80,1.37], respectively) or preventive visits (difference-in-differences, +1.9 %, [−11.9 %,+17.7 %] and +10.1 %, [−9.4 %,+33.7 %], respectively) relative to HMO counterparts. Similarly, among low SES HDHP members eligible for cervical cancer screening, no significant changes occurred in either screening rates (1.01, [0.86,1.20] and 1.08, [0.86,1.35]) or preventive visits (+0.2 %, [−11.4 %,+13.3 %] and −1.4 %, [−18.1,+18.6]). Patterns were statistically similar for high SES members.


During two follow-up years, transition to an HMO-based HDHP with coverage of primary care visits and cancer screening did not lead to differentially lower rates of breast and cervical cancer screening or preventive visits for low SES women. Generalizability is limited to commercially insured women transitioning to HDHPs with low cost-sharing for cancer screening and primary care visits, a common design.


high-deductible health plans cancer screening vulnerable populations women’s health 



The authors would like to acknowledge the helpful assistance with data collection of Irina Miroshnik, MS, of the Harvard Medical School and Harvard Pilgrim Health Care Department of Population Medicine. Dr. Wharam affirms that everyone who contributed significantly to the work is acknowledged here.

This study was funded by a grant from the Harvard Pilgrim Health Care Foundation.

Dr. Wharam presented interim results from this study on May 14, 2009 at the Society of General Internal Medicine national meeting in Miami, Florida

Conflict of Interest

The authors declare that they do not have a conflict of interest.


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Copyright information

© Society of General Internal Medicine 2012

Authors and Affiliations

  • J. Frank Wharam
    • 1
  • Amy Johnson Graves
    • 1
  • Fang Zhang
    • 1
  • Stephen B. Soumerai
    • 1
  • Dennis Ross-Degnan
    • 1
  • Bruce E. Landon
    • 2
  1. 1.Department of Population MedicineHarvard Medical School and Harvard Pilgrim Health Care InstituteBostonUSA
  2. 2.Department of Health Care PolicyHarvard Medical SchoolBostonUSA

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