1. Cost-Sharing and Screening Mammography Amal Trivedi, MD, MPH 2008 AcademyHealth Annual Research Meeting

3. Key Developments in Insurance Coverage for Mammography Medicare adds screening mammography to covered benefits Medicare adds screening mammography to covered benefits Beneficiaries still pay 20% coinsurance without supplemental coverage Beneficiaries still pay 20% coinsurance without supplemental coverage Persons with supplemental coverage 2.5 times more likely to get screened Persons with supplemental coverage 2.5 times more likely to get screened Breast and Cervical Cancer Screening Program Breast and Cervical Cancer Screening Program Provides free screening for uninsured, low-income women <65 Provides free screening for uninsured, low-income women <65

4. Why Have Mammography Rates Leveled or Declined since 2000? Conflicting messages about importance of screening Conflicting messages about importance of screening Reduced reimbursement for mammography Reduced reimbursement for mammography If generous coverage increased screening rates during 1990’s, greater cost-sharing may have reduced rates since 2000 If generous coverage increased screening rates during 1990’s, greater cost-sharing may have reduced rates since 2000

5. Objectives To determine the prevalence of mammography cost-sharing in Medicare health plans from 2001-4 To understand the impact of cost-sharing on the appropriate use of mammography To assess effects of mammography cost-sharing on vulnerable population groups

6. Sources of Data 2001-4 Medicare HEDIS data 2001-4 Medicare HEDIS data 2001-4 Medicare enrollment file 2001-4 Medicare enrollment file 2001-4 CMS health plan benefit data 2001-4 CMS health plan benefit data 2004 Interstudy Competitive Edge database 2004 Interstudy Competitive Edge database

7. Study Population Included women age 65-69 Included women age 65-69 Excluded women who died during the measurement year Excluded women who died during the measurement year Final study population: 366,475 women in 174 health plans Final study population: 366,475 women in 174 health plans

8. Trends in Mammography Cost-sharing Year # of plans (N=174) % of women in cost-sharing plans 200130.5 2002104.3 2003114.8 20042111.4 Median copayment $20 (Range $13-$35) 5 plans charged 20% coinsurance

9. Breast Cancer Screening Rates in Cost- Sharing and Full-coverage Plans

10. Adjusted Impact of Cost-sharing on Screening Mammography Effect of Cost- sharing 95% CI/p Unadjusted-8.3% Adjusted for SES, plan characteristics, and clustering by plan -7.2% -9.7%, -4.6% P<0.001 * Cost-sharing had the largest effect on mammography of any of the plan covariates in the model

11. Adjusted Effect of Cost-sharing by Income and Education P<0.001 for trends

12. Mammography Rates in plans that instituted cost- sharing compared to matched controls 20022004Change∆-∆ Adjusted ∆-∆ Added cost- sharing 74.8% Maintained full coverage 71.9%

13. Mammography Rates in 7 Plans that Instituted Cost- sharing in 2003 Compared to 14 Matched Control Plans 20022004Change Added cost- sharing 74.8%69.3%-5.5% Maintained full coverage 71.9%75.3%+3.4%

14. Mammography Rates in 7 Plans that Instituted Cost- sharing in 2003 Compared to 14 Matched Control Plans 20022004Change∆-∆Adj.∆-∆ Added cost- sharing 74.8%69.3%-5.5%-8.9% Maintained full coverage 71.9%75.3%+3.4%

15. Mammography Rates in 7 Plans that Instituted Cost- sharing in 2003 Compared to 14 Matched Control Plans 20022004Change∆-∆Adj.∆-∆ Added cost- sharing 74.8%69.3%-5.5%-8.9%-8.8% (-4.0, -13.6%) P=0.002 Maintained full coverage 71.9%75.3%+3.4%

16. Conclusions Copayments of >$10 or coinsurance of >10% associated with lower rates of breast cancer screening Copayments of >$10 or coinsurance of >10% associated with lower rates of breast cancer screening Cost-sharing disproportionately affects vulnerable populations Cost-sharing disproportionately affects vulnerable populations Prevalence of cost-sharing is dramatically increasing in Medicare managed care Prevalence of cost-sharing is dramatically increasing in Medicare managed care

17. Implications Cost-sharing should be tailored to the underlying value of the health service Cost-sharing should be tailored to the underlying value of the health service Eliminating copayments may increase adherence to mammography Eliminating copayments may increase adherence to mammography Important implications for Medicare FFS, where enrollees without supplemental coverage face 20% coinsurance Important implications for Medicare FFS, where enrollees without supplemental coverage face 20% coinsurance

18. Prostate Surface Antigen Testing Prostate surface antigen (PSA) testing is free under Medicare Part B Prostate surface antigen (PSA) testing is free under Medicare Part B No data that PSA testing improves outcomes No data that PSA testing improves outcomes Not recommended for universal screening Not recommended for universal screening Unclear why PSA testing is free, while mammography requires 20% coinsurance