ABSTRACT
BACKGROUND
Cancer screening is often fully covered under high-deductible health plans (HDHP), but low socioeconomic status (SES) women still might forego testing.
OBJECTIVE
To determine the impact of switching to a HDHP on breast and cervical cancer screening among women of low SES.
DESIGN
Pre-post with comparison group.
PARTICIPANTS
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.
INTERVENTION
Transition to a HDHP.
MAIN MEASURES
Annual breast and cervical cancer screening rates; rates of annual preventive outpatient visits.
KEY RESULTS
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.
CONCLUSION
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.
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References
Davis K. Will consumer-directed health care improve system performance? Issue Brief (Commonw Fund). 2004;(773):1–4.
Ginsburg PB. Controlling health care costs. New Engl J Med. 2004;351(16):1591–1593.
Shearer G. Commentary--Defined contribution health plans: attracting the healthy and well-off. Health Serv Res. 2004;39(4 Pt 2):1159–1166.
Lee TH, Zapert K. Do high-deductible health plans threaten quality of care? New Engl J Med. 2005;353(12):1202–1204.
Rubin RJ, Mendelson DN. Cost sharing in health insurance. N Engl J Med. 1995;333(11):733–734.
Kaiser. The Kaiser Family Foundation and Health Research and Educational Trust Employer health benefits 2011 annual survey. 2011; http://ehbs.kff.org/pdf/2011/8225.pdf. Accessed 21 March, 2012.
Reuters. Advocates see growth for health savings accounts. 2010; http://www.reuters.com/article/idUSTRE62M4AY20100323. Accessed 21 March 2012.
Newhouse JP, Manning WG, Morris CN, et al. Some interim results from a controlled trial of cost sharing in health insurance. N Engl J Med. Dec 17 1981;305(25):1501–1507.
Cherkin DC, Grothaus L, Wagner EH. The effect of office visit copayments on utilization in a health maintenance organization. Med Care. Nov 1989;27(11):1036–1045.
Lohr KN, Brook RH, Kamberg CJ, et al. Use of medical care in the Rand Health Insurance Experiment. Diagnosis- and service-specific analyses in a randomized controlled trial. Med Care. Sep 1986;24(9 Suppl):S1-87.
Solanki G, Schauffler HH. Cost-sharing and the utilization of clinical preventive services. Am J Prev Med. 1999;17(2):127–133.
Liang SY, Phillips KA, Tye S, Haas JS, Sakowski J. Does patient cost sharing matter? Its impact on recommended versus controversial cancer screening services. Am J Manag Care. 2004;10(2 Pt 1):99–107.
Friedman C, Ahmed F, Franks A, et al. Association between health insurance coverage of office visit and cancer screening among women. Med Care. 2002;40(11):1060–1067.
Blustein J. Medicare coverage, supplemental insurance, and the use of mammography by older women. New Engl J Med. 1995;332(17):1138–1143.
Wharam JF, Landon BE, Galbraith AA, Kleinman KP, Soumerai SB, Ross-Degnan D. Emergency department use and subsequent hospitalizations among members of a high-deductible health plan. Jama. 2007;297(10):1093–1102.
Trivedi AN, Rakowski W, Ayanian JZ. Effect of cost sharing on screening mammography in medicare health plans. N Engl J Med. Jan 24 2008;358(4):375–383.
Roddy PC, Wallen J, Meyers SM. Cost sharing and use of health services. The United Mine Workers of America Health Plan. Med Care. Sep 1986;24(9):873–876.
Rice T, Morrison KR. Patient cost sharing for medical services: a review of the literature and implications for health care reform. Med Care Rev. Fall 1994;51(3):235–287.
Gabel J, Claxton G, Gil I, et al. Health benefits in 2005: premium increases slow down, coverage continues to erode. Health Aff (Millwood). 2005;24(5):1273–1280.
Wharam JF, Galbraith AA, Kleinman KP, Soumerai SB, Ross-Degnan D, Landon BE. Cancer screening before and after switching to a high-deductible health plan. Ann Intern Med. May 6 2008;148(9):647–655.
Wharam JF, Graves AJ, Landon BE, Zhang F, Soumerai SB, Ross-Degnan D. Two-year Trends in Colorectal Cancer Screening After Switch to a High-deductible Health Plan. Med Care. May 13 2011.
Rowe JW, Brown-Stevenson T, Downey RL, Newhouse JP. The effect of consumer-directed health plans on the use of preventive and chronic illness services. Health Aff (Millwood). 2008;27(1):113–120.
Busch SH, Barry CL, Vegso SJ, Sindelar JL, Cullen MR. Effects of a cost-sharing exemption on use of preventive services at one large employer. Health Aff (Millwood). 2006;25(6):1529–1536.
Haviland A, McDevitt R, Sood N, Marquis MS. How Do Consumer-Directed Health Plans Affect Vulnerable Populations? Forum for Health Economics & Policy. 2011;14(2).
HEDIS. Breast cancer screening: percentage of women 50 to 69 years of age who had one or more mammograms during the measurement year or the year prior to the measurement year. 2006; http://www.qualitymeasures.ahrq.gov/summary/summary.aspx?doc_id=5756. Accessed 21 March, 2012.
HEDIS. Cervical cancer screening: percentage of women 18 to 64 years of age who received one or more Pap tests during the measurement year or the two years prior to the measurement year. 2006; http://www.qualitymeasures.ahrq.gov/summary/summary.aspx?doc_id=5757. Accessed 21 March, 2012.
HEDIS. Colorectal cancer screening: percentage of adults 50 to 80 years of age who had appropriate screening for colorectal cancer. 2006; http://www.qualitymeasures.ahrq.gov/summary/summary.aspx?doc_id=5755. Accessed 21 March, 2012.
Cook EF, Goldman L. Performance of tests of significance based on stratification by a multivariate confounder score or by a propensity score. J Clin Epidemiol. 1989;42(4):317–324.
D'Agostino RB, Jr. Propensity score methods for bias reduction in the comparison of a treatment to a non-randomized control group. Stat Med. Oct 15 1998;17(19):2265–2281.
Rubin DB. The design versus the analysis of observational studies for causal effects: parallels with the design of randomized trials. Stat Med. Jan 15 2007;26(1):20–36.
Coca-Perraillon M. Local and Global Optimal Propensity Score Matching. 2007; http://www2.sas.com/proceedings/forum2007/185-2007.pdf. Accessed 21 March, 2012.
The Johns Hopkins ACG Case-Mix System Reference Manual, Version 7.0. Baltimore, MD: The Johns Hopkins University; 2005.
Austin PC. Optimal caliper widths for propensity-score matching when estimating differences in means and differences in proportions in observational studies. Pharm Stat. Apr 27 2010.
Fenton JJ, Von Korff M, Lin EH, Ciechanowski P, Young BA. Quality of preventive care for diabetes: effects of visit frequency and competing demands. Ann Fam Med. Jan-Feb 2006;4(1):32–39.
Reid RJ, Roos NP, MacWilliam L, Frohlich N, Black C. Assessing population health care need using a claims-based ACG morbidity measure: a validation analysis in the Province of Manitoba. Health Serv Res. Oct 2002;37(5):1345–1364.
U.S. Bureau of the Census. Geographical areas reference manual, Washington, D.C., U.S. Bureau of the Census. 1994.
Krieger N, Chen JT, Waterman PD, Rehkopf DH, Subramanian SV. Race/ethnicity, gender, and monitoring socioeconomic gradients in health: a comparison of area-based socioeconomic measures--the public health disparities geocoding project. Am J Publ Health. 2003;93(10):1655–1671.
Vyas S, Kumaranayake L. Constructing socio-economic status indices: how to use principal components analysis. Health Pol Plann. Nov 2006;21(6):459–468.
Bonito AJ, Bann C, Eicheldinger C, Carpenter L. Creation of New Race-Ethnicity Codes and Socioeconomic Status (SES) Indicators for Medicare beneficiaries. 2008; http://www.ahrq.gov/qual/medicareindicators/medicareindicators.pdf. Accessed 21 March, 2012.
Koenker R, Bassett GW. Regression quantiles. Econometrica. 1978;46:33–50.
Liang KY, Zeger SL. Longitudinal data analysis using generalized linear models. Biometrika. 1986;73(1):13–22.
Zeger SL, Liang KY. Longitudinal data analysis for discrete and continuous outcomes. Biometrics. 1986;42(1):121–130.
Zoorob R, Anderson R, Cefalu C, Sidani M. Cancer screening guidelines. Am Fam Physician. Mar 15 2001;63(6):1101–1112.
http://www.sba.gov/sites/default/files/sbfaq.pdf. Accessed 21 March 2012.
Fronstin P. Employers may move By 2018 To Avoid Tax. 2010; http://healthcare.nationaljournal.com/2010/05/a-future-for-consumerdirected.php. Accessed 21 March, 2012.
The Boston Globe Staff. Study: High deductible health plans may proliferate. 2010; http://www.boston.com/business/ticker/2010/07/high_deductible.html. Accessed 21 March, 2012.
Acknowledgment
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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Dr. Wharam’s salary was supported by the Harvard Medical School and Harvard Pilgrim Health Care Institute Department of Population Medicine. This research was funded by a faculty grant from the Harvard Pilgrim Health Care Foundation.
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Wharam, J.F., Graves, A.J., Zhang, F. et al. Two-year Trends in Cancer Screening Among Low Socioeconomic Status Women in an HMO-based High-deductible Health Plan. J GEN INTERN MED 27, 1112–1119 (2012). https://doi.org/10.1007/s11606-012-2057-x
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DOI: https://doi.org/10.1007/s11606-012-2057-x