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ACA-Mandated Elimination of Cost Sharing for Preventive Screening Has Had Limited Early Impact
Shivan J. Mehta, MD, MBA; Daniel Polsky, PhD; Jingsan Zhu, MBA; James D. Lewis, MD, MSCE; Jonathan T. Kolstad, PhD; George Loewenstein, PhD; and Kevin G. Volpp, MD, PhD
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ACA-Mandated Elimination of Cost Sharing for Preventive Screening Has Had Limited Early Impact

Shivan J. Mehta, MD, MBA; Daniel Polsky, PhD; Jingsan Zhu, MBA; James D. Lewis, MD, MSCE; Jonathan T. Kolstad, PhD; George Loewenstein, PhD; and Kevin G. Volpp, MD, PhD
The ACA eliminated patient cost sharing for evidence-based preventive care, yet this policy has not resulted in substantial increases in colonoscopy and mammography utilization.
ABSTRACT
Objectives:
The Affordable Care Act eliminated patient cost sharing for evidence-based preventive care, yet the impact of this policy on colonoscopy and mammography rates is unclear. We examined the elimination of cost sharing among small business beneficiaries of Humana, a large national insurer.

Study Design: This was a retrospective interrupted time series analysis of whether the change in cost-sharing policy was associated with a change in screening utilization, using grandfathered plans as a comparison group.

Methods: We compared beneficiaries in small business nongrandfathered plans that were required to eliminate cost sharing (intervention) with those in grandfathered plans that did not have to change cost sharing (control). There were 63,246 men and women aged 50 to 64 years eligible for colorectal cancer screening, and 30,802 women aged 50 to 64 years eligible for breast cancer screening. The primary outcome variables were rates of colonoscopy and mammography per person-month, with secondary analysis of colonoscopy rates coded as preventive only.

Results: There was no significant change in the level or slope of colonoscopy and mammography utilization for intervention plans relative to the control plans. There was also no significant relevant change among those colonoscopies coded as preventive.

Conclusions: The results suggest that the implementation of the policy is not having its intended effects, as cost sharing rates for colonoscopy and mammography did not change substantially, and utilization of colonoscopy and mammography changed little, following this new policy approach.

Am J Manag Care. 2015;21(7):511-517
Take-Away Points

The Affordable Care Act eliminated patient cost sharing for evidence-based preventive care, yet the implementation of this policy in a large national insurer has not resulted in substantially higher utilization of colonoscopy and mammography.
  • Only those colonoscopies coded as preventive were eligible for the policy change, so many patients were still subject to cost sharing.
  • Many physicians and patients may have been unaware of cost sharing for this policy change prior to having the procedure done.
  • Additional measures are needed to increase screening rates, including waiving cost sharing for all eligible colonoscopies and making financial incentives more salient for patients.
The Affordable Care Act (ACA) of 2010 contains provisions for reducing financial barriers to receiving evidence-based preventive care. Specifically, it mandates that health insurance plans provide benefits for, and require no cost sharing for, services recommended with a rating of A or B by the US Preventive Services Task Force (USPSTF).1

Despite aggressive efforts to increase breast and colorectal cancer screening in the past decade, screening rates remain suboptimal.2 Across the United States, the rates of colorectal and breast cancer screening are 59% and 72%, respectively.3,4 The ACA policy attempts to increase these rates through first-dollar coverage of these screening tests.

Patient cost sharing has been shown in a variety of contexts to be an important driver of health service utilization,5 and higher cost sharing has been shown to reduce utilization of services, though it also has the potential downside of reducing both desirable and less desirable healthcare utilization.6-10 Concerns about the impact of higher cost sharing on cancer screening rates and preventive service utilization have been heightened by the proliferation of high-deductible insurance plans.11

Per ACA policy, all new private insurance plans were required to eliminate cost sharing for such services starting on September 23, 2010, with Medicare plans facing similar requirements starting January 1, 2011. Commercial plans were designated as grandfathered if they existed in March 2010 and did not make any coverage changes. In this study, we examined the impact of the elimination of cost sharing for preventive services on colon and breast cancer screening rates among beneficiaries of Humana, a large national private health insurance plan, using grandfathered plans as a control group. We hypothesized that there would not be a dramatic impact of the policy on preventive health utilization due to the lack of knowledge about cost sharing and additional patient barriers to screening.

METHODS

Data Source and Study Population

We analyzed de-identified data from Humana for all beneficiaries aged 50 to 64 years who were enrolled in small business plans at any time between October 2008 and May 2012. Member eligibility files included beneficiary coverage and benefit design files describing different characteristics of each plan, including grandfathered status.

Patient-level data obtained from the beneficiary file included age, gender, and plan type, along with census tract data for income, race, and education. Using Healthcare Effectiveness Data and Information Set (HEDIS) coding (eAppendix 1, available at www.ajmc.com),12 claims data were obtained for colorectal cancer screening (ie, colonoscopy, fecal occult blood testing, and flexible sigmoidoscopy) and breast cancer screening (ie, mammography). Colonoscopies were defined as “preventive” if associated with the designated diagnosis code (V16.0, V18.51, V76.41, V76.51; these codes are from a small subset of HEDIS codes as defined by Humana for compliance with the ACA policy).

Patients eligible for colorectal cancer screening included men and women aged 50 to 64 years, and those eligible for breast cancer screening included women aged 50 to 64 years, as per the USPSTF recommendations.13 Patients 65 years or older were not included, as they would be eligible for Medicare.

The primary outcome variables were rates of colonoscopy and mammography per person-month, and the secondary outcome was rate of colonoscopy coded as preventive per person-month. We did not exclusively measure procedures used only for cancer screening. Likewise, we did not measure the proportion of the population that was up-to-date with screening, as the turnover of the insurer’s population limited ability to look back and fully capture prior use of these screening tests. Rather, we looked at the overall utilization rates without a lookback period to examine differential rates in screening as a result of the policy. Colonoscopy is the primary modality for colorectal cancer screening in this country,3 and even when employed for the evaluation of symptoms, it serves as a diagnostic test for colorectal cancer. We also found predominant use of colonoscopy in our sample, with no increase in fecal occult blood tests over time and minimal flexible sigmoidoscopy use (data not shown).

Cost sharing refers to the out-of-pocket costs paid by the beneficiary, including copayment, deductible, and coinsurance for all the claims related to the procedure (physician and facility) billed on the same day. Given the nature of the policy reform, we examined the percentage of colonoscopies and mammograms with greater than zero cost sharing, but also looked at the mean cost sharing amount.

For the purposes of the analysis, time zero was the first renewal month for each plan after September 2010. Changes in benefit design for small business plans are typically made during the renewal month, which is plan-specific and is distributed throughout the year, so time zero ranged from October 2010 to September 2011 for the different plans (eAppendix 2). Small business plans were categorized as non-grandfathered or grandfathered, as denoted by the insurer, based on whether they were required by the policy to have no cost sharing for preventive procedures. Hereafter, we will refer to the non-grandfathered plans as the intervention group and the grandfathered plans as the control group.

We only included beneficiaries enrolled in plans that were in existence on March 2010, which was the time when grandfathered status was determined. To be included in the analysis, beneficiaries had to be continuously  enrolled for 2 years prior to the change in the policy (time zero) and for a minimum of 9 months afterward. This allowed us to analyze the impact of policy change on a consistent cohort over time. Members from 23,028 unique small business coverage plans from 48 states were enrolled. The 5 states with the most enrollees were Texas (20.6%), Illinois (15.9%), Kentucky (9.8%), Florida (8.5%), and Wisconsin (6.8%).

Statistical Methods

We assigned time zero to the renewal time during the policy change period to normalize the policy effect and assess overall trends for 24 months before and 9 months after time zero (ranging from month –24 to month 9). Thus, time zero and the months did not all occur at the same time for different plans. We first looked at the proportion of colonoscopy and mammography with greater than zero cost sharing and the degree to which this changed following implementation of the new policy. We then assessed trends in procedure utilization for the eligible cohort of beneficiaries who were continuously enrolled, demonstrating this graphically.

We used an aggregate-level “differenced” interrupted time series to examine whether the change in cost sharing policy was associated with a change in screening utilization for the small business population, since this was the group for which we could directly compare rates in plans that had benefit design changes (intervention group) and those that were grandfathered (control group). Using this design, we compared each intervention and control group with itself, before and after the policy change.14,15 This approach reduces potential biases from unmeasured variables and accounts for underlying changes in screening rates over time that are constant between both groups and might reflect general changes in clinical practice.16 The intervention and control groups had similar characteristics (Table 1), and individual designation to those groups was at the plan level. Education, race, and income data were obtained from the census tract data for the area of residence of the beneficiary. We assigned small business plans to the intervention or the control group based on designation by the insurer.

For this interrupted time series analysis, the outcome of interest was the aggregate difference between the rate of colonoscopy or mammography for the intervention and the control group. This was determined at each monthly time point by calculating the difference between the rates (per 1000 beneficiaries) of the intervention and the control group, which resulted in 33 data points. We utilized a generalized linear regression model, which included variables for month, post policy, and month post policy. A secondary analysis was performed looking only at colonoscopies coded as preventive. The “post policy” coefficient provides the level change (absolute difference) in percent screened between the study groups in the month immediately after the policy, and the coefficient of “month post policy” demonstrates any slope change after the policy. These 2 variables are the coefficients of interest, as they evaluate the changes in level and slope for colonoscopy and mammography rates, controlling for baseline trend. A positive coefficient represents a relative increase in the level or slope of monthly screening rate for members in the intervention plans compared with the control plans from pre- to post policy change.

All analyses were carried out using SAS software version 9.3 (SAS Institute, Cary, North Carolina). Approval for this study was obtained from the Institutional Review Board of the University of Pennsylvania. Humana was involved in the design and conduct of the study, in the collection and interpretation of the data, and in the review of the manuscript.

RESULTS

Demographics


For colonoscopy and mammography, the intervention and control groups had similar demographic characteristics including age, gender, education, race, and income (Table 1). There were 25,926 members in the intervention group and 37,320 members in the control group for colonoscopy; both groups were 49% female. In the colonoscopy intervention and control groups, respectively, mean ages were 55.2 years and 55.3 years; percentages with greater than high school education were 73% and 74%; percentages living in areas with greater than 80% white population were 71% and 72%; and median incomes for census tract were $68,700 and $70,200. There were 12,603 members in the intervention group and 18,199 members in the control group for mammography. In the mammography intervention and control groups, respectively, mean ages were 55.2 and 55.3 years; the percentage with greater than high school education were 73% and 74%; the percentage living in areas with greater than 80% white population was 70% and 72%; and median incomes for census tract were $68,100 and $69,600.

Cost Sharing Changes

 
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