The effect of health insurance plan type on initial colorectal cancer screening in the United States since the inception of health care reform in Massachusetts
Berger, Loretta Kathleen
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The Accountable Care Act (ACA) will expand coverage to millions of Americans. Health insurance plans designed to contain costs and incentivize patients may pose risks that deter members from utilizing recommended services despite provisions such as zero-cost-sharing intended to encourage their use. We evaluated trends (from 2007 to 2011) in health insurance plan type and initial colorectal cancer (CRCA) screening per current guidelines. We hypothesized that consumer-directed and high-deductible health plans (CDHP/HDHP) would be associated with decreased and delayed CRCA screening, and a shift toward lower-cost screening options. Using Thomson MarketScan® data, we analyzed commercial claims for 989,038 American adults (prior colectomy or CRCA excluded) over a full three-year period (starting in January of the fiftieth birthday-year) to assess for CRCA screening (colonoscopy, sigmoidoscopy, or stool test). Using logistic regression, we found that CDHP/HDHP members showed increased likelihood of having had any CRCA screening compared to Preferred Provider Organization (PPO) members, in both Massachusetts (Odds Ratio [OR] 2.321, 95% Confidence Interval [CI] 1.788-3.014) and the Nation (OR 1.640, 95% CI 1.602-1.678). Of those screened, CDHP/HDHP patients were more likely to receive colonoscopy than other recommended alternatives compared to PPO (Massachusetts OR 1.289, 95% CI 1.007-1.651; U.S. OR 1.225, 95% CI 1.192-1.259). Using linear regression, we found that CDHP/HDHP patients were only slightly older at screening compared to PPO, and the difference, while statistically significant, was likely too small to be clinically meaningful. We conclude that contrary to our expectations, CDHP/HDHP members have not been deterred from seeking and obtaining appropriate and timely initial CRCA screening, and they have not chosen lower-cost options. These findings may reflect the newly insured effect, although one limitation of this study was the inability to adjust for selection into CDHP/HDHP. Further study should determine whether CDHP/HDHP members subsequently experience unexpected financial burdens related to CRCA screening that affect future utilization of recommended care. In the pursuit of lower costs through better outcomes, attention should be paid to designing simple and affordable plans with easily understandable features that encourage both patients and providers to follow recommended guidelines while considering the cost-effectiveness of available options.
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