Socioeconomic Differences in Use of Low‐Value Cancer Screenings and Distributional Effects in Medicare

Xu, Wendy; Jung, Jeah

doi:10.1111/1475-6773.12559

Cited by 9 publications

(13 citation statements)

References 33 publications

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“…While research has shown that the out-of-pocket expenses for preventive care lead to reduced use of services [3–5], we did not find the direct relation between the removal of the OOP cost and preventive cancer screening use in the Medicare population. The finding of a decline in Pap smear utilization observed in the survey was consistent with a general decreasing trend of Pap smear take-up rates in recent years in other national survey data [2], in accordance with a series of guideline updates to recommend less frequent Pap smear tests [32].…”

Section: Discussionsupporting

confidence: 89%

“…Similarly, Medicare pays for more frequent screenings: biennial Pap smears and annual mammograms are covered by Medicare without patient cost-sharing, while USPSTF only recommends a Pap smear every 3 years and biennial mammography. Moreover, the USPSTF guidelines are continuously updated even after the ACA implementation in 2010 [32]. For example, the Pap smear recommendation was updated in 2012, from biennial to triennial tests.…”

Section: New Contributionmentioning

confidence: 99%

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

Wickizer

Jung

2019

BMC Health Serv Res

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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.

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Section: Discussionsupporting

confidence: 89%

Section: New Contributionmentioning

confidence: 99%

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

Wickizer

Jung

2019

BMC Health Serv Res

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“…The process of systematically targeting and reducing health care overuse has been referred to as de-implementation. 7 In this article, we argue that deimplementation is critical for advancing equity for three reasons: 1) sometimes health care overuse adds harms on top of harms from underuse, something termed double jeopardy; 2) health care overuse is greater by Whites among insured populations, and this overuse is subsidized by minority members; 8 and 3) experiences of overuse differ by patient subgroups, which requires us, as researchers, to approach studying and communicating about overuse differently than how we approach underuse. We provide some ideas for how researchers can address these challenges.…”

Section: Equity Underuse and Overusementioning

confidence: 99%

“…Consequently, within insured populations, this means more socioeconomically disadvantaged patients subsidize overuse by more affluent patients. 8,10 For example, in an analysis of Medicare data, Xu and colleagues (2017) found that the highest income women received a net subsidy of $18.84 for low-value mammograms relative to poor women, and the size of this subsidy increased over time. Across a range of low-value screening tests, the result was that 10%-15% of the sample received a negative subsidy, and these patients were primarily the socioeconomically disadvantaged.…”

Section: Health Care Overuse As a Subsidymentioning

confidence: 99%

Promoting Health Equity through De-Implementation Research

et al. 2019

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Ensuring equitable access to quality health care historically has focused on gaps in care, where patients fail to receive the high-value care that will benefit them, something termed underuse. But providing high-quality health care sometimes requires reducing low-value care that delivers no benefit or where known harms outweigh expected benefits. These situations represent health care overuse. The process involved in reducing low-value care is known as de-implementation. In this article, we argue that de-implementation is critical for advancing equity for several reasons. First, medical overuse is associated with patient race, ethnicity, and socioeconomic status. In some cases, the result is even double jeopardy, where racial and ethnic minorities are at higher risk of both overuse and underuse. In these cases, more traditional efforts focused exclusively on underuse ignore half of the problem. Second, overuse of preventive care and screening is often greater for more socioeconomically advantaged patients. Within insured populations, this means more socioeconomically disadvantaged patients subsidize overuse. Finally, racial and ethnic minorities may have different experiences of overuse than Whites in the United States. This may make efforts to de-implement overuse particularly fraught. We therefore provide several actions for closing current research gaps, including: adding subgroup analyses in studies of medical overuse; specifying and measuring potential mechanisms related to equity (eg, double jeopardy vs thermostat models of overuse); and testing de-implementation strategies that may mitigate bias.Ethn Dis. 2019;29(Suppl 1):93-96; doi:10.18865/ed.29.S1.93.

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“…15 Previous US studies found that Medicare patients living in higher income census tracts had more overuse of imaging for prostate cancer, 29,30 and Medicare beneficiaries with higher income were more likely to use low-value cancer screenings and, in turn, received larger net subsidies from Medicare. 39 Beneficiaries living in areas of higher income were more likely to receive low-value imaging. 40 This may be a result of increased beneficiaries' demand and better access to low-value care.…”

Section: Discussionmentioning

confidence: 99%

External Validation of and Factors Associated with the Overuse Index: a Nationwide Population-Based Study from Taiwan

Tung

Chang

2020

J GEN INTERN MED

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T o counter the rapidly increasing healthcare spending around the world, 1 there is global interest in optimizing the delivery of health services, exemplified by increased use of high-value care or services and reduced use of low-value care or services. 2,3 Overuse/low-value care is defined as the provision of procedures and treatments that provide little or no benefit to beneficiaries while increasing the costs of healthcare. 2,[4][5][6][7][8][9] In the United States (US), estimates of spending on overuse vary widely. 7 Conservative estimates according to direct measurement of individual services range from 6 to 8% of total healthcare spending. 10 Studies of geographic variation (an indirect measure) put the proportion of Medicare spending on overuse closer to 29%. 11 Recent studies estimate that 14 to 25% of Medicare beneficiaries, 8% of privately insured adults, and 7% of adult military beneficiaries experience at least one overuse event per year. 6,8,9,12 Overuse occurs regardless of whether healthcare providers are paid by fee-for-service or salary in market-driven and highly regulated systems, 1,13 or in universal healthcare systems (e.g., United Kingdom (UK), Canada, and Taiwan). 7,14,15 However, it is difficult to use measures of individual lowvalue services to compare the overall overuse status across countries and regions. Thus, Segal et al. used claims data to develop the Overuse Index (OI), previously called the Johns Hopkins Overuse Index (JHOI), 6 which is the only composite index constructed and validated to measure regional variation in overall overuse. 6,8 The OI is a normalized measure, not an absolute measure. The OI was originally validated in the US Medicare population by demonstrating the relation of the OI with medical costs and no relation with total mortality, 6,16,17

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Socioeconomic Differences in Use of Low‐Value Cancer Screenings and Distributional Effects in Medicare

Abstract: FFS enrollees who are better off in terms of sociodemographic characteristics receive greater subsidies from taxpayers for using low-value cancer screenings.

Cited by 9 publications

References 33 publications

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

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

Promoting Health Equity through De-Implementation Research

External Validation of and Factors Associated with the Overuse Index: a Nationwide Population-Based Study from Taiwan

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