Greater use of copayment and deductibles may be reducing the number of women seeking mammography, a study of women enrolled in Medicare managed-care plans shows.
The researchers reviewed data from 174 plans and found that, on average, 77% of women in plans with full coverage had received their biennial screening, compared with 69% of women in plans with cost sharing for their visits.
In addition, the study reviewed seven plans that instituted a copayment or a deductible in 2003 and compared them with 14 plans that did not institute a copayment or deductible. The mammography rates in those plans that adopted cost sharing declined by 5%. In contrast, mammography rates increased 3% in 14 plans that did not institute cost sharing, reported Dr. Amal N. Trivedi of the department of community health at Brown University, Providence, R.I., and colleagues (N. Engl. J. Med. 2008;358:375-83).
The study used data from the Medicare Health Plan Employer Data and Information Set from 2001 to 2004, for 174 Medicare health plans and 366,475 women aged 65-69 years.
Three of the plans had cost sharing in 2001, 9 in 2002, 10 in 2003, and 21 in 2004. The three plans with cost sharing in 2001 covered less than 1% of the women in the plans at that time. The 21 plans in 2004 covered 11%. Copayments in the plans ranged from $12.50 to $35.
The investigators found that black women and women with less education and lower incomes were more likely to be in cost-sharing plans. But the effect of cost sharing at reducing the rate of mammography was greater among whites than among blacks. Among white patients, cost-sharing plans had an 8% lower mammography rate than did plans with no cost sharing. Among black patients, cost-sharing plans had a 4% lower mammography rate.
The adoption of cost sharing is increasing among health plans generally. Mammography rates appear to have declined since 2000, after increasing greatly throughout the 1990s, Dr. Trivedi wrote in the study, which was supported by a grant from the Agency for Healthcare Research and Quality.
One study that looked at mammography rates, conducted by researchers at the National Cancer Institute using a large, national database, reported that 70% of women had received a mammography within the past 2 years in 2000 (Cancer 2007;109:2405-9). By 2005, that figure had dropped to 66%.
In an accompanying editorial, Dr. Peter B. Bach said the study by Dr. Trivedi and colleagues showed a “large” impact relative to the “modest” copayments and deductibles imposed on the patients.
“Their findings are robust, with similar findings in unadjusted analyses and in multivariable analyses adjusted for potential demographic and regional confounders,” wrote Dr. Bach of the department of epidemiology and biostatistics, and the Health Outcomes Research Group, at Memorial Sloan-Kettering Cancer Center, New York (N. Engl. J. Med. 2008;358:411-3).
Noting that Dr. Trivedi and colleagues concluded that cost-sharing strategies apparently do more harm than good in mammography and should probably be waived for this important screening procedure, Dr. Bach said the study suggests a dilemma for insurers.
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