Cost Sharing Cuts Compliance on Mammograms : Mammography rates in plans that adopted cost sharing dropped 5% vs. a 3% rise in plans that did not.


Greater use of copayment and deductibles may be reducing the number of women seeking mammography, a new study of women enrolled in Medicare managed-care plans shows.

The investigators 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 health care 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.

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.

Among the 174 plans, only 3 had cost sharing in 2001; 9 had it 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 study also 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 mammogram 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.

Deductibles and copayments are adopted by insurers to dissuade patients from using health care services extravagantly.

But in some cases, the strategy may backfire, resulting in higher costs and poorer health.

If, however, insurers choose to exempt some services from copayments or deductibles, they face the prospect of reconsidering all kinds of services and trusting that they can determine which ones are truly beneficial, he wrote.

It would be a very daunting task, he added.

The case of mammography is a particularly striking example, because mammography is a service that women tend to know is highly beneficial. Yet, the cost sharing kept 8% of consumers from seeking it out, Dr. Bach noted.

“This finding bodes poorly for the high-deductible movement, since one would expect that patients would make suboptimal decisions even more often in cases in which the health care service is more expensive, has received less publicity, has less rigorous quality control, or is more unpleasant or risky,” Dr. Bach concluded.


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