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The American Journal of Managed Care February 2020
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Co-payment Policies and Breast and Cervical Cancer Screening in Medicaid
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Co-payment Policies and Breast and Cervical Cancer Screening in Medicaid

Lindsay M. Sabik, PhD; Anushree M. Vichare, PhD; Bassam Dahman, PhD; and Cathy J. Bradley, PhD
Co-payments for preventive services can discourage breast and cervical cancer screening among Medicaid enrollees, particularly breast cancer screening, which is more costly and time-consuming.
RESULTS

Table 1 describes co-payment policies for our sample states. Twelve states had no co-payments in any of the years studied. Of the 26 states that required co-payments, 2 (Minnesota, Nebraska) waived preventive co-payments over the entire study period. Cost-sharing policies changed over the study period for 5 states. Delaware, Kentucky, Michigan, and South Carolina had no co-payments required for any services in 2003 but in 2008 and 2010 required co-payments for all visits, including those for preventive services. Additionally, co-payments for preventive visits were waived in Missouri in 2003, but these waivers were discontinued in 2008 and 2010.

Table 2 reports results for mammogram receipt; 19% of women enrolled for 12 months and 11% enrolled for any number of months during the calendar year had a Medicaid claim for screening mammography. The low observed screening rates are similar to those observed in other research using MAX data to examine cancer screening.18 In panel A, we report results from models of mammography receipt among women aged 50 to 64 years comparing screening rates among women with co-payments for preventive services visits with rates among women without a co-payment for preventive services (either because the co-payment is waived for preventive care or because the state does not require a co-payment for any visit). Women with co-payments for preventive services are less likely to receive a screening mammogram than those without a co-payment for preventive care (adjusted odds ratio [aOR], 0.81; 95% CI, 0.71-0.94 for 12-month enrollment sample). Results are similar when the sample includes women with any number of months of enrollment during the year.

Panel B reports results from models comparing all 3 co-payment policies. Women for whom co-payments applied to preventive visits had a lower likelihood of receiving a mammogram than women without co-payments for any visits (aOR, 0.84; 95% CI, 0.72-0.97). In the 12-month enrollment sample, receipt of a mammogram among women with co-payments for preventive services did not differ significantly from that among women with co-payments for other outpatient visits but for whom co-payments were waived for preventive services (aOR, 0.70; 95% CI, 0.48-1.01); the corresponding estimate for the sample with any length of enrollment suggests that women with co-payments for preventive services were less likely to receive a mammogram than women without co-payments for most visits but no co-payment for preventive services (aOR, 0.71; 95% CI, 0.54-0.94). Among the sample with 12 months of continuous Medicaid enrollment, the group with co-payments for most visits but not preventive services had the highest predicted probability (24%) of receiving a screening mammogram, whereas those who had co-payments for all visits had the lowest predicted probability (18%) of receiving a mammogram (eAppendix Figure).

Table 3 presents model estimates for cervical cancer screening; 30% of women enrolled for a full 12 months and 22% enrolled for any number of months during the calendar year had a Medicaid claim for a Pap test. Women with co-payments for preventive services were slightly less likely to receive a Pap test during the year (aOR, 0.96; 95% CI, 0.94-0.98 for 12-month enrollment sample) (panel A). Panel B compares women under the 3 co-payment policies. Women with co-payments for preventive services were slightly more likely to receive cervical cancer screening compared with women who had no co-payments for any type of visit (aOR, 1.05; 95% CI, 1.03-1.07). In contrast, women with co-payments for preventive services were less likely to receive a Pap test than women with co-payments for most visits but not preventive visits (aOR, 0.70; 95% CI, 0.68-0.73). Based on these results, we estimate that among the sample with 12 months of continuous Medicaid enrollment, those with co-payments waived for preventive visits had the highest predicted probability (29%) of receiving a Pap test, whereas those without co-payments for any visits and with co-payments for preventive services had similar rates of Pap tests (eAppendix Figure).

Summary statistics, full regression results, and sensitivity analyses are presented in the eAppendix. eAppendix Table 2 reports descriptive statistics for the full sample and stratified by whether state Medicaid policy requires co-payments for any visits. Characteristics of the mammogram- and Pap test–eligible samples were similar, except that most Pap test–eligible cases were younger than 40 years (82%). Full regression results for the mammography sample are presented in eAppendix Tables 3 and 4. Conditional on all other covariates, women enrolled in earlier years were more likely to receive screening than those enrolled in 2010. Across all models, receipt of mammography is positively associated with FQHC, RHC, and specialist density in the enrollee’s county but negatively associated with PCP density in the county. Receipt of Pap tests is also positively associated with FQHC and RHC density in the enrollee’s county and negatively associated with PCP density in the county conditional on other controls. In contrast with mammography, specialist density is not consistently associated with cervical cancer screening across models.

We also tested whether our results changed when including an indicator for the percentage of enrollees in comprehensive managed care in each state year using a range of thresholds to define this variable. Results remained virtually the same (eAppendix Tables 5 and 6).


 
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