Estimating the impact of insurance expansion on colorectal cancer and related costs in North Carolina: A population-level simulation analysis

Lich, Kristen Hassmiller; OʼLeary, Meghan C.; Nambiar, Siddhartha; Townsley, Rachel M.; Mayorga, Marı́a E.; Hicklin, Karen; Frerichs, Leah; Shafer, Paul; Davis, Melinda M.; Wheeler, Stephanie B.

doi:10.1016/j.ypmed.2019.105847

Cited by 11 publications

(7 citation statements)

References 32 publications

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“…The NC-CRC simulation model has been previously used to simulate and compare intervention effects at the population level. [23][24][25][26] The NC-CRC model has 3 major components: 1) population demography, 2) disease natural history, and 3) individual screening and surveillance. The agents within the model are assigned demographics such as race, sex, and rurality according to a synthetic population representing the population of Oregon in 2010, described in further detail in the next section.…”

Section: Crc Simulation Modeling Methodsmentioning

confidence: 99%

“…The synthetic population was generated using micro-level census data and is meant to be a realistic representation of the Oregon population, taking into account important sociodemographic factors including insurance status, as previously described. 24,27 From the synthetic Oregon population, we selected synthetic agents representing privately insured individuals at age 50 y in 2010. We chose to simulate this segment of the synthetic population as we are interested in generating the full screening trajectories from age 50 to age 65 y.…”

Section: Crc Simulation Modeling Methodsmentioning

confidence: 99%

Section: Simulated Population Descriptionmentioning

confidence: 99%

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When History and Heterogeneity Matter: A Tutorial on the Impact of Markov Model Specifications in the Context of Colorectal Cancer Screening

et al. 2022

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Background Markov models are used in health research to simulate health care utilization and disease states over time. Health phenomena, however, are complex, and the memoryless assumption of Markov models may not appropriately represent reality. This tutorial provides guidance on the use of Markov models of different orders and stratification levels in health decision-analytic modeling. Colorectal cancer (CRC) screening is used as a case example to examine the impact of using different Markov modeling approaches on CRC outcomes. Methods This study used insurance claims data from commercially insured individuals in Oregon to estimate transition probabilities between CRC screening states (no screen, colonoscopy, fecal immunochemical test or fecal occult blood test). First-order, first-order stratified by sex and geography, and third-order Markov models were compared. Screening trajectories produced from the different Markov models were incorporated into a microsimulation model that simulated the natural history of CRC disease progression. Simulation outcomes (e.g., future screening choices, CRC incidence, deaths due to CRC) were compared across models. Results Simulated CRC screening trajectories and resulting CRC outcomes varied depending on the Markov modeling approach used. For example, when using the first-order, first-order stratified, and third-order Markov models, 30%, 31%, and 44% of individuals used colonoscopy as their only screening modality, respectively. Screening trajectories based on the third-order Markov model predicted that a higher percentage of individuals were up-to-date with CRC screening as compared with the other Markov models. Limitations The study was limited to insurance claims data spanning 5 y. It was not possible to validate which Markov model better predicts long-term screening behavior and outcomes. Conclusions Findings demonstrate the impact that different order and stratification assumptions can have in decision-analytic models. Highlights This tutorial uses colorectal cancer screening as a case example to provide guidance on the use of Markov models of different orders and stratification levels in health decision-analytic models. Colorectal cancer screening trajectories and projected health outcomes were sensitive to the use of alternate Markov model specifications. Although data limitations precluded the assessment of model accuracy beyond a 5-y period, within the 5-y period, the third-order Markov model was slightly more accurate in predicting the fifth colorectal cancer screening action than the first-order Markov model. Findings from this tutorial demonstrate the importance of examining the memoryless assumption of the first-order Markov model when simulating health care utilization over time.

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Section: Crc Simulation Modeling Methodsmentioning

confidence: 99%

Section: Crc Simulation Modeling Methodsmentioning

confidence: 99%

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When History and Heterogeneity Matter: A Tutorial on the Impact of Markov Model Specifications in the Context of Colorectal Cancer Screening

et al. 2022

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“…For benign and malignant colorectal diseases, these benefits span earlier diagnosis, access to appropriate treatment, and mitigation of financial toxicity. [62][63][64][65][66] The ACA-dependent provision increased the age for adults to stay on their parents' insurance plan to age 26 years; this is particularly beneficial for younger patients, such as those with IBD, who are at a higher risk of not having insurance. Ten states have still not expanded Medicaid however, affecting approximately two million people that fall into the Medicaid coverage gap, largely people of color in the South.…”

Section: Increasing Access To and Affordability Of Health Insurancementioning

confidence: 99%

Closing the Gap: Approaches to Improving Colorectal Surgery Care for the Uninsured and Underinsured

Isenberg,

Harbaugh

2024

Clin Colon Rectal Surg

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Health insurance plays a critical role in access to and delivery of health care in the United States. As the only industrialized nation without universal health coverage, Americans without adequate insurance (i.e., uninsured or underinsured individuals) face numerous obstacles to obtaining necessary health care. In this article, we review the mechanisms by which inadequate insurance leads to worse clinical outcomes in patients with common benign and malignant colorectal pathologies. We then discuss several evidence-based solutions for improving access to optimal colorectal care for these patients. These include increasing access to and affordability of health insurance, mitigating disparities between differently insured populations, strengthening the health care safety net, and tailoring outreach and clinical decision-making for the uninsured and underinsured. By exploring the nuance and impact of inadequate insurance coverage, we ultimately seek to highlight critical opportunities for future research and advocacy within the realm of insurance design and policy.

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“…11,15,16 While expanded Medicaid coverage through the Affordable Care Act has been associated with increased rates of CRC screening, this improvement has limiting factors, such as continued lower rates of access to primary and specialist providers for Medicaid compared to other insurance types. [17][18][19][20] Since insurance expansion alone is not sufficient to increase screening rates to meet national targets, 21,22 examining multilevel barriers to screening, including access, in rural areas more broadly can help inform efforts to increase screening rates and decrease inequities. 12,16,[23][24][25] The provision of colonoscopy in rural areas is likely to differ from that in urban settings, because of variation in who provides colonoscopy, geographic proximity to medical facilities, and patterns of referral to screening and treatment.…”

Section: Introductionmentioning

confidence: 99%

Provision of colonoscopy in rural settings: A qualitative assessment of provider context, barriers, facilitators, and capacity

Ramalingam,

Coury,

Barnes

et al. 2023

The Journal of Rural Health

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PurposeColonoscopy can prevent morbidity and mortality from colorectal cancer (CRC) and is the most commonly used screening method in the United States. Barriers to colonoscopy at multiple levels can contribute to disparities. Yet, in rural settings, little is known about who delivers colonoscopy and facilitators and barriers to colonoscopy access through screening completion.MethodsWe conducted a qualitative study with providers in rural Oregon who worked in endoscopy centers or primary care clinics. Semistructured interviews, conducted in July and August, 2021, focused on clinician experiences providing colonoscopy to rural Medicaid patients, including workflows, barriers, and access. We used thematic analysis, through immersion crystallization, to analyze interview transcripts and develop emergent themes.FindingsWe interviewed 19 providers. We found two categories of colonoscopy providers: primary care providers (PCPs) doing colonoscopy on their own patients (n = 9; 47%) and general surgeons providing colonoscopy to patients referred to their services (n = 10; 53%). Providers described barriers to colonoscopy at the provider, community, and patient levels and suggested patient supports could help overcome them. Providers found current colonoscopy capacity sufficient, but noted PCPs trained to perform colonoscopy would be key to continued accessibility. Finally, providers shared concerns about the shrinking number of PCP endoscopists, especially with anticipated increased screening demand related to the CRC screening guideline shift.ConclusionsThese themes reflect opportunities to address multilevel barriers to improve access, colonoscopy capacity, and patient education approaches. Our results highlight that PCPs are an essential part of the workforce that provides colonoscopy in rural areas.

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Estimating the impact of insurance expansion on colorectal cancer and related costs in North Carolina: A population-level simulation analysis

Cited by 11 publications

References 32 publications

When History and Heterogeneity Matter: A Tutorial on the Impact of Markov Model Specifications in the Context of Colorectal Cancer Screening

When History and Heterogeneity Matter: A Tutorial on the Impact of Markov Model Specifications in the Context of Colorectal Cancer Screening

Closing the Gap: Approaches to Improving Colorectal Surgery Care for the Uninsured and Underinsured

Provision of colonoscopy in rural settings: A qualitative assessment of provider context, barriers, facilitators, and capacity

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