Impact of the 2008-2009 economic recession on screening colonoscopy utilization among the insured

Quantified trends in provider reimbursement and utilization volume in colorectal cancer screenings: analysis of Medicare claims from 2000 to 2019

AIM

Colorectal cancer (CRC) screening rates in the United States remain persistently below guideline targets, partly due to suboptimal patient utilization and provider reimbursement. To guide long-term national utilization estimates and set reasonable screening adherence targets, this study aimed to quantify trends in utilization of and reimbursement for CRC screenings using Medicare claims.

METHOD

Inflation-adjusted reimbursements and utilization volume associated with each CRC screening code were abstracted from Medicare claims between 2000 and 2019. Screenings, screenings/100 000 enrolees and reimbursement/screening were analysed with linear regression and compared with the equality of slopes tests. Average reimbursement per screening was compared using analysis of variance with Dunnett's T3 multiple comparisons test.

RESULTS

The growth rate of multitarget stool DNA tests (mt-sDNA)/100 000 was the highest at 170.4 screenings/year (R2 = 0.99, p ≤ 0.001), while that of faecal occult blood tests/100 000 was the lowest at -446.4 screenings/year (R2 = 0.90, p ≤ 0.001) (p ≤ 0.001). Provider reimbursements averaged $546.95 (95% CI $520.12-$573.78) per mt-sDNA screening, significantly higher than reimbursements for all invasive screenings. Only FOBTs significantly increased in reimbursement per screening at $0.62/year (R2 = 0.91, p ≤ 0.001).

CONCLUSION

We derived forecastable trend numbers for utilization and provider reimbursement. Faecal immunochemical tests/100 000 and mt-sDNA screenings/100 000 increased most rapidly during the entire study period. The number of nearly all invasive screenings/100 000 decreased rapidly; the number of colonoscopies/100 000 increased slightly, probably due to superior diagnostic strength. These trends indicate the that replacement of other invasive modalities with accessible noninvasive screenings will account for much of future screening behaviour and thus reductions in CRC incidence and mortality, especially given providers' reimbursement incentive to screen average-risk patients with stool-based tests.

When the economy falters, hearts suffer: Economic recessions as a social determinant of health in cardiovascular emergencies

INTRODUCTION

While the relationships between cardiovascular disease (CVD), stress, and financial strain are well studied, the association between recessionary periods and macroeconomic conditions on incidence of disease-specific CVD emergency department (ED) visits is not well established.

OBJECTIVES

This retrospective observational study aimed to assess the relationship between macroeconomic trends and CVD ED visits.

METHODS

This study uses data from the National Hospital Ambulatory Care Survey (NHAMCS), Federal Reserve Economic Database (FRED), National Bureau of Economic Research (NBER), and CVD groupings from National Vital Statistics (NVS) and Center for Medicare and Medicaid Services (CMS) from 1999 to 2020 to analyze ED visits in relation to macroeconomic indicators and NBER defined recessions and expansions.

RESULTS

CVD ED visits grew by 79.7% from 1999 to 2020, significantly more than total ED visits (27.8%, p < 0.001). A national estimate of 213.2 million CVD ED visits, with 22.9 million visits in economic recessions were analyzed. A secondary group including a 6-month period before and after each recession (defined as a "broadened recession") was also analyzed to account for potential leading and lagging effects of the recession, with a total of 50.0 million visits. A significantly higher proportion of CVD ED visits related to heart failure (HF) and other acute ischemic heart diseases (IHD) was observed during recessionary time periods both directly and with a 6-month lead and lag (p < 0.05). The proportion of aortic aneurysm and dissection (AAA) and atherosclerosis (ASVD) ED visits was significantly higher (p = 0.024) in the recession period with a 6-month lead and lag. When controlled for common demographic factors, economic approximations of recession such as the CPI, federal funds rate, and real disposable income were significantly associated with increased CVD ED visits.

CONCLUSION

Macroeconomic trends have a significant relationship with the overall mix of CVD ED visits and represent an understudied social determinant of health.

Unemployment and cancer screening: Baseline estimates to inform health care delivery in the context of COVID-19 economic distress

Background

During the coronavirus disease 2019 pandemic, US unemployment rates rose to historic highs, and they remain nearly double those of prepandemic levels. Employers are the most common source of health insurance among nonelderly adults. Thus, job loss may lead to a loss of health insurance and reduce access to cancer screening. This study examined associations between unemployment, health insurance, and cancer screening to inform the pandemic's potential impacts on early cancer detection.

Methods

Up‐to‐date and past‐year breast, cervical, colorectal, and prostate cancer screening prevalences were computed for nonelderly respondents (aged <65 years) with 2000‐2018 National Health Interview Survey data. Multivariable logistic regression models with marginal probabilities were used to estimate unemployed‐versus‐employed unadjusted and adjusted prevalence ratios.

Results

Unemployed adults (2000‐2018) were 4 times more likely to lack insurance than employed adults (41.4% vs 10.0%; P < .001). Unemployed adults had a significantly lower up‐to‐date prevalence of screening for cervical cancer (78.5% vs 86.2%; P < .001), breast cancer (67.8% vs 77.5%; P < .001), colorectal cancer (41.9 vs 48.5%; P < .001), and prostate cancer (25.4% vs 36.4%; P < .001). These differences were eliminated after accounting for health insurance coverage.

Conclusions

Unemployment was adversely associated with up‐to‐date cancer screening, and this was fully explained by a lack of health insurance. Ensuring the continuation of health insurance coverage after job loss may mitigate the pandemic's economic distress and future economic downturns' impact on cancer screening.

Unemployment is adversely associated with up‐to‐date cancer screening, and this is fully explained by a lack of health insurance.

Return to Work: Managing Employee Population Health During the COVID-19 Pandemic

Coronavirus disease-2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), has abruptly transformed the outlook of employer health benefits plans for 2020 and 2021. Containing the spread of the virus and facilitating care of those infected have quickly emerged as immediate priorities. Employers have adjusted health benefits coverage to make COVID-19 testing and treatment accessible and remove barriers to care in order to facilitate the containment of the disease. Employers also are introducing strategies focused on testing, surveillance, workplace modifications, and hygiene to keep workforces healthy and workplaces safe. This paper is intended to provide evidence-based perspectives for self-insured employers for managing population health during the COVID-19 pandemic. Such considerations include (1) return to work practices focused on mitigating the spread of COVID-19 through safety practices, testing and surveillance; and (2) anticipating the impact of COVID-19 on health benefits and costs (including adaptations in delivery of care, social and behavioral health needs, and managing interrupted care for chronic conditions).

Are temporal trends in colonoscopy among young adults concordant with colorectal cancer incidence?

Objective

In the United States, colorectal cancer incidence has increased in adults under age 55. Although debate remains about whether this rise is a result of increased detection because of more colonoscopy utilization, population-based trends in colonoscopy among this age group are unknown. We examined changes in colonoscopy rates, as well as colorectal cancer incidence, among adults aged 40–54, using nationally representative data.

Methods

Recent (past year) colonoscopy rates were computed among 53,175 respondents aged 40–54 in National Health Interview Survey data from 2000 through 2015 by five-year age group. Colorectal cancer incidence rates and incidence rate ratios were estimated from 18 population-based Surveillance Epidemiology and End Result registries during the same period.

Results

Among respondents aged 40–44, past-year colonoscopy rates were stable during 2000–2015, and ranged from 2.3% to 3.5% ( p-value for trend = 0.771). In contrast, colonoscopy rates increased from 2.5% in 2000 to 5.2% in 2015 among ages 45–49, and from 5.0% to 14.1% in ages 50–54 (test for trend p-values < 0.001). During 2000–2015, colorectal cancer incidence rates increased by 28% in people aged 40–44 (incidence rate ratio = 1.28, 95% CI 1.20, 2.37), 15% in those aged 45–49 (incidence rate ratio = 1.15, 95%CI 1.10, 1.21), and 17% in those aged 50–54 (incidence rate ratio = 1.17, 95%CI 1.13, 1.21), respectively.

Conclusion

Increases in colonoscopy rates were confined to ages 45–54, whereas colorectal cancer incidence rates rose in those aged 40–44, 45–49, and 50–54. Colonoscopy trends do not fully align with colorectal cancer incidence patterns.

Medicare Cancer Screening in the Context of Clinical Guidelines: 2000 to 2012

OBJECTIVES

Cancer screening is a ubiquitous and controversial public health issue, particularly in the elderly population. Despite extensive evidence-based guidelines for screening, it is unclear how cancer screening has changed in the Medicare population over time. We characterize trends in cancer screening for the most common cancer types in the Medicare fee-for-service (FFS) program in the context of conflicting guidelines from 2000 to 2012.

MATERIALS AND METHODS

We performed a descriptive analysis of retrospective claims data from the Medicare FFS program based on billing codes. Our data include all claims for Medicare part B beneficiaries who received breast, colorectal (CRC), or prostate cancer screening from 2000 to 2012 based on billing codes. We utilize a Monte Carlo permutation method to detect changes in screening trends.

RESULTS

In total, 231,416,732 screening tests were analyzed from 2000 to 2012, representing an average of 436.8 tests per 1000 beneficiaries per year. Mammography rates declined 7.4%, with digital mammography extensively replacing film. CRC cancer screening rates declined overall. As a percentage of all CRC screening tests, colonoscopy grew from 32% to 71%. Prostate screening rates increased 16% from 2000 to 2007, and then declined to 7% less than its 2000 rate by 2012.

DISCUSSION

Both the aggressiveness of screening guidelines and screening rates for the Medicare FFS population peaked and then declined from 2000 to 2012. However, guideline publications did not consistently precede utilization trend shifts. Technology adoption, practical and financial concerns, and patient preferences may have also contributed to the observed trends. Further research should be performed on the impact of multiple, conflicting guidelines in cancer screening.

Burden and Cost of Gastrointestinal, Liver, and Pancreatic Diseases in the United States: Update 2018

BACKGROUND & AIMS

Estimates of disease burden can inform national health priorities for research, clinical care, and policy. We aimed to estimate health care use and spending among gastrointestinal (GI) (including luminal, liver, and pancreatic) diseases in the United States.

METHODS

We estimated health care use and spending based on the most currently available administrative claims from commercial and Medicare Supplemental plans, data from the GI Quality Improvement Consortium Registry, and national databases.

RESULTS

In 2015, annual health care expenditures for gastrointestinal diseases totaled $135.9 billion. Hepatitis ($23.3 billion), esophageal disorders ($18.1 billion), biliary tract disease ($10.3 billion), abdominal pain ($10.2 billion), and inflammatory bowel disease ($7.2 billion) were the most expensive. Yearly, there were more than 54.4 million ambulatory visits with a primary diagnosis for a GI disease, 3.0 million hospital admissions, and 540,500 all-cause 30-day readmissions. There were 266,600 new cases of GI cancers diagnosed and 144,300 cancer deaths. Each year, there were 97,700 deaths from non-malignant GI diseases. An estimated 11.0 million colonoscopies, 6.1 million upper endoscopies, 313,000 flexible sigmoidoscopies, 178,400 upper endoscopic ultrasound examinations, and 169,500 endoscopic retrograde cholangiopancreatography procedures were performed annually. Among average-risk persons aged 50-75 years who underwent colonoscopy, 34.6% had 1 or more adenomatous polyps, 4.7% had 1 or more advanced adenomatous polyps, and 5.7% had 1 or more serrated polyps removed.

CONCLUSIONS

GI diseases contribute substantially to health care use in the United States. Total expenditures for GI diseases are $135.9 billion annually-greater than for other common diseases. Expenditures are likely to continue increasing.

Increasing Inequality in Physical Activity Among Minnesota Secondary Schools, 2001-2010

BACKGROUND

Two Healthy People 2020 goals are to increase physical activity (PA) and to reduce disparities in PA. We explored whether PA at the school level changed over time in Minnesota schools and whether differences existed by demographic and socioeconomic factors.

METHODS

We examine self-reported PA (n = 276,089 students; N = 276 schools) for 2001-2010 from the Minnesota Student Survey linked to school demographic data from the National Center for Education Statistics and the Rural-Urban Commuting Area Codes. We conducted analyses at the school level using multivariable linear regression with cluster-robust recommendation errors.

RESULTS

Overall, students who met PA recommendations increased from 59.8% in 2001 to 66.3% in 2010 (P < .001). Large gains in PA occurred at schools with fewer racial/ethnic minority students (0%-60.1% in 2001 to 67.5% in 2010, P < .001), whereas gains in PA were comparatively small at schools with a high proportion of racial/ethnic minority students in 2001 (30%-59.2% in 2001 to 62.7% in 2010).

CONCLUSIONS

We found increasing inequalities in school-level PA by racial/ethnic characteristics of their schools and communities among secondary school students. Future research should monitor patterns of PA over time and explore mechanisms for patterns of inequality.

Increasing Rates of Surgery for Patients With Nonmalignant Colorectal Polyps in the United States

BACKGROUND & AIMS

Despite the availability of endoscopic therapy, many patients in the United States undergo surgical resection for nonmalignant colorectal polyps. We aimed to quantify and examine trends in the use of surgery for nonmalignant colorectal polyps in a nationally representative sample.

METHODS

We analyzed data from the Healthcare Cost and Utilization Project National Inpatient Sample for 2000 through 2014. We included all adult patients who underwent elective colectomy or proctectomy and had a diagnosis of either nonmalignant colorectal polyp or colorectal cancer. We compared trends in surgery for nonmalignant colorectal polyps with surgery for colorectal cancer and calculated age, sex, race, region, and teaching status/bed-size-specific incidence rates of surgery for nonmalignant colorectal polyps.

RESULTS

From 2000 through 2014, there were 1,230,458 surgeries for nonmalignant colorectal polyps and colorectal cancer in the United States. Among those surgeries, 25% were performed for nonmalignant colorectal polyps. The incidence of surgery for nonmalignant colorectal polyps has increased significantly, from 5.9 in 2000 to 9.4 in 2014 per 100,000 adults (incidence rate difference, 3.56; 95% confidence interval 3.40-3.72), while the incidence of surgery for colorectal cancer has significantly decreased, from 31.5 to 24.7 surgeries per 100,000 adults (incidence rate difference, -6.80; 95% confidence interval -7.11 to -6.49). The incidence of surgery for nonmalignant colorectal polyps has been increasing among individuals age 20 to 79, in men and women and including all races and ethnicities.

CONCLUSIONS

In an analysis of a large, nationally representative sample, we found that surgery for nonmalignant colorectal polyps is common and has significantly increased over the past 14 years.

Trends in cancer mortality in Spain: the influence of the financial crisis

OBJECTIVE

To determine if the onset of the economic crisis in Spain affected cancer mortality and mortality trends.

METHOD

We conducted a longitudinal ecological study based on all cancer-related deaths and on specific types of cancer (lung, colon, breast and prostate) in Spain between 2000 and 2013. We computed age-standardised mortality rates in men and women, and fit mixed Poisson models to analyse the effect of the crisis on cancer mortality and trends therein.

RESULTS

After the onset of the economic crisis, cancer mortality continued to decline, but with a significant slowing of the yearly rate of decline (men: RR = 0.987, 95%CI = 0.985-0.990, before the crisis, and RR = 0.993, 95%CI = 0.991-0.996, afterwards; women: RR = 0.990, 95%CI = 0.988-0.993, before, and RR = 1.002, 95%CI = 0.998-1.006, afterwards). In men, lung cancer mortality was reduced, continuing the trend observed in the pre-crisis period; the trend in colon cancer mortality did not change significantly and continued to increase; and the yearly decline in prostate cancer mortality slowed significantly. In women, lung cancer mortality continued to increase each year, as before the crisis; colon cancer continued to decease; and the previous yearly downward trend in breast cancer mortality slowed down following the onset of the crisis.

CONCLUSIONS

Since the onset of the economic crisis in Spain the rate of decline in cancer mortality has slowed significantly, and this situation could be exacerbated by the current austerity measures in healthcare.

Increased Post-procedural Non-gastrointestinal Adverse Events After Outpatient Colonoscopy in High-risk Patients

BACKGROUND & AIMS

The incidence and predictors of non-gastrointestinal (GI) adverse events (AEs) after colonoscopy are not well-understood. We studied the effects of antithrombotic agents, cardiopulmonary comorbidities, and age on risk of non-GI AEs after colonoscopy.

METHODS

We performed a retrospective longitudinal analysis to assess the diagnosis, procedure, and prescription drug codes in a United States commercial claims database (March 2010-March 2012). Data from patients at increased risk (n = 82,025; defined as patients with pulmonary comorbidities or cardiovascular disease requiring antithrombotic medications) were compared with data from 398,663 average-risk patients. In a 1:1 matched analysis, 51,932 patients at increased risk, examined by colonoscopy, were compared with 51,932 matched (on the basis of age, sex, and comorbidities) patients at increased risk who did not undergo colonoscopy. We tracked cardiac, pulmonary, and neurovascular events 1-30 days after colonoscopy.

RESULTS

Thirty days after outpatient colonoscopy, non-GI AEs were significantly higher in patients taking antithrombotic medications (7.3%; odds ratio [OR], 10.75; 95% confidence interval, 10.13-11.42) or those with pulmonary comorbidities (1.8%; OR, 2.44; 95% confidence interval, 2.27-2.62) vs average-risk patients (0.7%) and in patients 60-69 years old (OR, 2.21; 95% confidence interval, 2.01-2.42) or 70 years or older (OR, 6.45; 95% confidence interval, 5.89-7.06), compared with patients younger than 50 years. The 30-day incidence of non-GI AEs in patients at increased risk who underwent colonoscopy was also significantly higher than in matched patients at increased risk who did not undergo colonoscopy in the anticoagulant group (OR, 2.31; 95% confidence interval, 2.01-2.65) and in the chronic obstructive pulmonary disease group (OR, 1.33; 95% confidence interval, 1.13-1.56).

CONCLUSIONS

Increased number of comorbidities and older age (older than 60 years) are associated with increased risk of non-GI AEs after colonoscopy. These findings indicate the importance of determining comorbid risk and evaluating antithrombotic management before colonoscopy.

Comparing Rural and Urban Cervical and Breast Cancer Screening Rates in a Privately Insured Population

Low preventive screening varies by region and contributes to poor outcomes for breast and cervical cancer. Previous comparative urban and rural research on preventive screening has focused on government programs. This study quantified and compared rural and urban preventive cancer screening rates for women who were privately insured. National Quality Forum measures were used to calculate rates for women within rural and urban parts of the same Hospital Referral Region (HRR) using claims data. Mammography screening rates for women age 24 to 69 years were 77.1% in 2011 and 76.1% in 2008. Compared to urban women, mammography screening rates for women visiting rural physicians were lower in 42%, higher in 2% and identical in 56% of HRRs. Cervical cancer screening rates for women age 21 to 64 years were 82.9% in 2011 and 83.5% in 2008. Cervical cancer screening rates among women who saw rural physicians were lower in 55%, higher in 4%, and identical in 42% of HRRs. HRRs where rural areas underperformed urban areas increased between 2008 and 2011 for both screenings. Moderate but notable differences in women's preventive screening rates between rural and urban physicians highlight the need for practical solutions that increase use of screening services and reduce barriers to services in rural areas.

Trends in breast and colorectal cancer screening among U.S. adults by race, healthcare coverage, and SES before, during, and after the great recession

The aim of this study is examine trends in breast and colorectal cancer screening in the U.S. by race, healthcare coverage, and socio-economic status (SES) before the Great Recession (2003-2005), during the recession (2007-2009), and post-recession/Affordable Care Act (ACA) period (2010 - 2012). Data on a representative sample of U.S. adults was obtained from the Behavioral Risk Factor Surveillance System (BRFSS). Breast and colorectal cancer screening were defined in line with U.S. Preventative Services Task Force guidelines, and survey weighted statistical methods were utilized to analyze trends in cancer screening among 1,858,572 BRFSS participants. Overall, 83% of women received mammograms in the past 2 years, while 95% of adults received colorectal cancer screening in the past 10 years. Compared with the pre-recession period, the odds of colorectal screening within 5 years were slightly higher during the recession (OR: 1.05, 95% CI: 1.03-1.08) but significantly lower in the post-recession/ACA period (OR: 0.73, 95% CI: 0.72-0.75). Odds of mammography screening were lower during (OR: 0.94,95% CI: 0.91-0.96) and post-recession/ACA period (OR: 0.80, 95% CI: 0.78-0.82). Breast cancer screening rates declined in the recession and post-recession, while colorectal cancer screening rates increased during the recession and decreased post-recession. Low SES adults and those without healthcare coverage were the least likely to receive screening.

Recent declines in cancer incidence: related to the Great Recession?

PURPOSE

In recent years, cancer case counts in the U.S. underwent a large, rapid decline-an unexpected change given population growth for older persons at highest cancer risk. As these declines coincided with the Great Recession, we examined whether they were related to economic conditions.

METHODS

Using California Cancer Registry data from California's 30 most populous counties, we analyzed trends in cancer incidence during pre-recession (1996-2007) and recession/recovery (2008-2012) periods for all cancers combined and the ten most common sites. We evaluated the recession's association with rates using a multifactorial index that measured recession impact, and modeled associations between case counts and county-level unemployment rates using Poisson regression.

RESULTS

Yearly cancer incidence rate declines were greater during the recession/recovery (3.3% among males, 1.4% among females) than before (0.7 and 0.5%, respectively), particularly for prostate, lung, and colorectal cancers. Lower case counts, especially for prostate and liver cancer among males and breast cancer, melanoma, and ovarian cancer among females, were associated with higher unemployment rates, irrespective of time period, but independent of secular effects. The associations for melanoma translated up to a 3.6% decrease in cases with each 1% increase in unemployment. Incidence declines were not greater in counties with higher recession impact index.

CONCLUSIONS

Although recent declines in incidence of certain cancers are not differentially impacted by economic conditions related to the Great Recession relative to pre-recession conditions, the large recent absolute declines in the case counts of some cancer may be attributable to the large declines in unemployment in the recessionary period. This may occur through decreased engagement in preventive health behaviors, particularly for clinically less urgent cancers. Continued monitoring of trends is important to detect any rises in incidence rates as deferred diagnoses come to clinical attention.

Colorectal cancer screening: Estimated future colonoscopy need and current volume and capacity

BACKGROUND

In 2014, a national campaign was launched to increase colorectal cancer (CRC) screening rates in the United States to 80% by 2018; it is unknown whether there is sufficient colonoscopy capacity to reach this goal. This study estimated the number of colonoscopies needed to screen 80% of the eligible population with fecal immunochemical testing (FIT) or colonoscopy and determined whether there was sufficient colonoscopy capacity to meet the need.

METHODS

The Microsimulation Screening Analysis-Colon model was used to simulate CRC screening test use in the United States (2014-2040); the implementation of a national screening program in 2014 with FIT or colonoscopy with 80% participation was assumed. The 2012 Survey of Endoscopic Capacity (SECAP) estimated the number of colonoscopies that were performed and the number that could be performed.

RESULTS

If a national screening program started in 2014, by 2024, approximately 47 million FIT procedures and 5.1 million colonoscopies would be needed annually to screen the eligible population with a program using FIT as the primary screening test; approximately 11 to 13 million colonoscopies would be needed annually to screen the eligible population with a colonoscopy-only screening program. According to the SECAP survey, an estimated 15 million colonoscopies were performed in 2012, and an additional 10.5 million colonoscopies could be performed.

CONCLUSIONS

The estimated colonoscopy capacity is sufficient to screen 80% of the eligible US population with FIT, colonoscopy, or a mix of tests. Future analyses should take into account the geographic distribution of colonoscopy capacity. Cancer 2016;122:2479-86. © 2016 American Cancer Society.

The Effects of Job Insecurity on Health Care Utilization: Findings from a Panel of U.S. Workers

OBJECTIVE

To examine the impacts of job insecurity during the recession of 2007-2009 on health care utilization among a panel of U.S. employees.

DATA SOURCES/STUDY SETTING

Linked administrative and claims datasets on a panel of continuously employed, continuously insured individuals at a large multisite manufacturing firm that experienced widespread layoffs (N = 9,486).

STUDY DESIGN

We employed segmented regressions to examine temporal discontinuities in utilization during 2006-2012. To assess the effects of job insecurity, we compared individuals at high- and low-layoff plants. Because the dataset includes multiple observations for each individual, we included individual-level fixed effects.

PRINCIPAL FINDINGS

We found discontinuous increases in outpatient (3.5 visits/month/10,000 individuals, p = .002) and emergency (0.4 visits/month/10,000 individuals, p = .05) utilization in the panel of all employees. Compared with individuals at low-layoff plants, individuals at high-layoff plants decreased outpatient utilization (-4.0 visits/month/10,000 individuals, p = .008), suggesting foregone preventive care, with a marginally significant increase in emergency utilization (0.4 visits/month/10,000 individuals, p = .08).

CONCLUSIONS

These results suggest changes in health care utilization and potentially adverse impacts on employee health in response to job insecurity during the latest recession. This study contributes to our understanding of the impacts of economic crises on the health of the U.S. working population.

Changes in Receipt of Cancer Screening in Medicare Beneficiaries Following the Affordable Care Act

BACKGROUND

The Affordable Care Act (ACA) removed copayments for screening mammography and colonoscopy in Medicare beneficiaries, but its clinical impact is unknown.

METHODS

Using a 5% random sample of Medicare claims from 2009 through 2012 in individuals age 70 years or older who were due for screening, we examined claims for screening mammography and screening or surveillance colonoscopy for two years prior to ACA (2009-2010) and two years post-ACA (2011-2012). Receipt of the procedures at the patient level was compared across years using generalized estimating equations. Statistical tests were two-sided.

RESULTS

Compared with 2009, we found an increase in mammography uptake during the ACA coverage period, with multivariable odds ratios (MOR) of 1.22 (95% confidence interval [CI] = 1.20 to 1.25, P < .001) for 2011 and 1.17 (95% CI = 1.15 to 1.20, P < .001) for 2012 and less change in 2010 (OR = 1.03, 95% CI = 1.01 to 1.05, P = .01). In contrast to mammography, uptake of screening or surveillance colonoscopy decreased in 2012 (MOR = 0.95, 95% CI = 0.92 to 0.98, P = .002) compared with 2009, with no change in 2010 (MOR = 1.01, 95% CI = 0.99 to 1.04, P = .47) or 2011 (MOR = 1.01, 95% CI = 0.99 to 1.04, P = .34). Other factors associated with procedure receipt included younger age and prior preventive health visits. In an analysis restricted to patients age 70 to 74 years, colonoscopy use increased slightly in 2011 but was unchanged in 2012, and the findings by year for mammography were consistent with the main analysis.

CONCLUSIONS

Following ACA implementation with concomitant reduction in out-of-pocket expenditures, there was a statistically significant increment in mammography uptake but not colonoscopy. This suggests that affordability is a necessary but not sufficient facilitator of preventive services.

The Relationship between Local Economic Conditions and Acute Myocardial Infarction Hospital Utilization by Adults and Seniors in the United States, 1995-2011

OBJECTIVE

To assess the association between aggregate unemployment and hospital discharges for acute myocardial infarction (AMI) among adults and seniors, 1995-2011.

DATA SOURCES/STUDY SETTING

Community hospital discharge data from states collected for the Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (SID) and economic data from the Bureau of Labor Statistics, 1995-2011.

STUDY DESIGN

Quarterly time series study of unemployment and aggregate hospital discharges in local areas using fixed effects to control for differences between local areas.

DATA COLLECTION/EXTRACTION METHODS

Secondary data on inpatient stays and unemployment rates aggregated to micropolitan and metropolitan areas.

PRINCIPAL FINDINGS

For both adults and seniors, a 1 percentage point increase in the contemporaneous unemployment rate was associated with a statistically significant 0.80 percent (adults) to 0.96 percent (seniors) decline in AMI hospitalization during the first half of the study but was unrelated to the economic cycle in the second half of the study period.

CONCLUSIONS

The study found evidence that the aggregate relationship between health and the economy may be shifting for cardiovascular events, paralleling recent research that has shown a similar shift for some types of mortality (Ruhm 2013), self-reported health, and inpatient use among seniors (McInerney and Mellor 2012).

ACA-mandated elimination of cost sharing for preventive screening has had limited early impact

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.

Trends in the Cost and Use of Targeted Cancer Therapies for the Privately Insured Nonelderly: 2001 to 2011

PURPOSE

This study sought to define and identify drivers of trends in cost and use of targeted therapeutics among privately insured nonelderly patients with cancer receiving chemotherapy between 2001 and 2011.

METHODS

We classified oncology drugs as targeted oral anticancer medications, targeted intravenous anticancer medications, and all others. Using the LifeLink Health Plan Claims Database, we studied and disaggregated trends in use and in insurance and out-of-pocket payments per patient per month and during the first year of chemotherapy.

RESULTS

We found a large increase in the use of targeted intravenous anticancer medications and a gradual increase in targeted oral anticancer medications; targeted therapies accounted for 63% of all chemotherapy expenditures in 2011. Insurance payments per patient per month and in the first year of chemotherapy for targeted oral anticancer medications more than doubled in 10 years, surpassing payments for targeted intravenous anticancer medications, which remained fairly constant throughout. Substitution toward targeted therapies and growth in drug prices both at launch and postlaunch contributed to payer spending growth. Out-of-pocket spending for targeted oral anticancer medications was ≤ half of the amount for targeted intravenous anticancer medications.

CONCLUSION

Targeted therapies now dominate anticancer drug spending. More aggressive management of pharmacy benefits for targeted oral anticancer medications and payment reform for injectable drugs hold promise. Restraining the rapid rise in spending will require more than current oral drug parity laws, such as value-based insurance that makes the benefits and costs transparent and involves the patient directly in the choice of treatment.

Predicting Colonoscopy Completion Among African American and Latino/a Participants in a Patient Navigation Program

Patient navigation (PN) effectively increases screening colonoscopy (SC) rates, a key to reducing deaths from colorectal cancer (CRC). Ethnic minority populations have disproportionately low SC rates and high CRC mortality rates and, therefore, especially stand to benefit from PN. Adapting the Health Belief Model as an explanatory model, the current analysis examined predictors of SC rates in two randomized studies that used PN to increase SC among 411 African American and 461 Latino/a patients at a large urban medical center. Speaking Spanish but not English (odds ratio (OR), 2.192; p < 0.005), having a higher income (OR, 1.218; p < 0.005), and scoring higher on the Pros of Colonoscopy scale (OR, 1.535; p = 0.023) independently predicted colonoscopy completion. Health education and PN programs that increase awareness of the benefits of getting a colonoscopy may encourage colonoscopy completion. In the context of language-appropriate PN programs for African American and Latino/a individuals, those with lower incomes and English speakers may require additional education and counseling to support their decision-making around colonoscopy.

Association between the unemployment rate and inpatient cost per discharge by payer in the United States, 2005-2010

Background

Several reports have linked the 2007–2009 Great Recession in the United States with a slowdown in health care spending and decreased utilization. However, little is known regarding how the recent economic downturn affected hospital costs per inpatient stay for different segments of the population. The purpose of this study was to examine the association between changes in the unemployment rate and inpatient cost per discharge for Medicare and commercial discharges.

Methods

We used retrospective data at the Core Based Statistical Area (CBSA)-level from 46 states that contributed to the Healthcare Cost and Utilization Project State Inpatient Databases from 2005 to 2010. Unemployment data was derived from the American Community Survey. An instrumental variable two-stage least squares approach with fixed- or random-effects was used to examine the association between unemployment rate and inpatient cost per discharge by payer because of potential endogeneity.

Results

The marginal effect of unemployment was associated with an increase in inpatient cost per discharge for both payers. A one percentage point increase in the unemployment rate was associated with a $37 increase for commercial discharges and a $49 increase for Medicare discharges.

Conclusions

We find evidence that the inpatient cost per discharge is countercyclical across different segments of the population. The underlying mechanisms by which unemployment affects hospital resource use however, might differ between payer groups.

Using quantile regression to examine health care expenditures during the Great Recession

OBJECTIVE

To examine the association between the Great Recession of 2007-2009 and health care expenditures along the health care spending distribution, with a focus on racial/ethnic disparities.

DATA SOURCES/STUDY SETTING

Secondary data analyses of the Medical Expenditure Panel Survey (2005-2006 and 2008-2009).

STUDY DESIGN

Quantile multivariate regressions are employed to measure the different associations between the economic recession of 2007-2009 and health care spending. Race/ethnicity and interaction terms between race/ethnicity and a recession indicator are controlled to examine whether minorities encountered disproportionately lower health spending during the economic recession.

PRINCIPAL FINDINGS

The Great Recession was significantly associated with reductions in health care expenditures at the 10th-50th percentiles of the distribution, but not at the 75th-90th percentiles. Racial and ethnic disparities were more substantial at the lower end of the health expenditure distribution; however, on average the reduction in expenditures was similar for all race/ethnic groups. The Great Recession was also positively associated with spending on emergency department visits.

CONCLUSION

This study shows that the relationship between the Great Recession and health care spending varied along the health expenditure distribution. More variability was observed in the lower end of the health spending distribution compared to the higher end.

Breast and cervical screening by race/ethnicity: comparative analyses before and during the Great Recession

BACKGROUND

Traditionally, economic recessions have resulted in decreased utilization of preventive health services.

PURPOSE

To explore racial and ethnic differences in breast and cervical cancer screening rates before and during the Great Recession.

METHODS

The Medical Expenditure Panel was the source for identifying 10,894 women, ages 50-74 for breast screening and 19,957 women, ages 21-65 for cervical screening. Survey years included 2004-2005 and 2009-2010. Dependent variables were as follows: 1) receipt of mammogram within the past 2 years; and 2) receipt of a Pap smear within the past 3 years. The interaction of the recession and the likelihood of screening between whites and minorities was analyzed. Multivariate regressions were applied to estimate the likelihood of screening for the two time periods while controlling for a recession variable.

RESULTS

Nationally, breast and cervical cancer screening rates dropped during the recession period; white women contributed most to the decline. However, there were significant improvements in timely screening for both cancers among Hispanics during the recession period. After controlling for the recession, African American women were more likely to have timely screenings compared to white women. Screening rates during the recession were lowest in the South, Midwest and West.

CONCLUSION

There was a national reduction in the percentages of women who obtained timely breast and cervical screenings during the Great Recession. Outreach efforts are needed to ensure that women who were not screened during the recession are screened. Widespread education about the Affordable Care Act may be helpful.

Impact of the 2009 US Preventive Services Task Force guidelines on screening mammography rates on women in their 40s

BACKGROUND

The 2009 US Preventive Services Task Force breast cancer screening update recommended against routine screening mammography for women aged 40-49; confusion and release of conflicting guidelines followed. We examined the impact of the USPSTF update on population-level screening mammography rates in women ages 40-49.

METHODS AND FINDINGS

We conducted a retrospective, interrupted time-series analysis using a nationally representative, privately-insured population from 1/1/2006-12/31/2011. Women ages 40-64 enrolled for ≥ 1 month were included. The primary outcome was receipt of screening mammography, identified using administrative claims-based algorithms. Time-series regression models were estimated to determine the effect of the guideline change on screening mammography rates. 5.5 million women ages 40-64 were included. A 1.8 per 1,000 women (p = 0.003) decrease in monthly screening mammography rates for 40-49 year-old women was observed two months following the guideline change; no initial effect was seen for 50-64 year-old women. However, two years following the guideline change, a slight increase in screening mammography rates above expected was observed in both age groups.

CONCLUSIONS

We detected a modest initial drop in screening mammography rates in women ages 40-49 immediately after the 2009 USPSTF guideline followed by an increase in screening rates. Unfavorable public reactions and release of conflicting statements may have tempered the initial impact. Renewal of the screening debate may have brought mammography to the forefront of women's minds, contributing to the observed increase in mammography rates two years after the guideline change. This pattern is unlikely to reflect informed choice and underscores the need for improved translation of evidence-based care and guidelines into practice.

Race/Ethnicity, educational attainment, and foregone health care in the United States in the 2007-2009 recession

OBJECTIVES

This study assessed possible associations between recessions and changes in the magnitude of social disparities in foregone health care, building on previous studies that have linked recessions to lowered health care use.

METHODS

Data from the 2006 to 2010 waves of the National Health Interview Study were used to examine levels of foregone medical, dental and mental health care and prescribed medications. Differences by race/ethnicity and education were compared before the Great Recession of 2007 to 2009, during the early recession, and later in the recession and in its immediate wake.

RESULTS

Foregone care rose for working-aged adults overall in the 2 recessionary periods compared with the pre-recession. For multiple types of pre-recession care, foregoing care was more common for African Americans and Hispanics and less common for Asian Americans than for Whites. Less-educated individuals were more likely to forego all types of care pre-recession. Most disparities in foregone care were stable during the recession, though the African American-White gap in foregone medical care increased, as did the Hispanic-White gap and education gap in foregone dental care.

CONCLUSIONS

Our findings support the fundamental cause hypothesis, as even during a recession in which more advantaged groups may have had unusually high risk of losing financial assets and employer-provided health insurance, they maintained their relative advantage in access to health care. Attention to the macroeconomic context of social disparities in health care use is warranted.

An evaluation of colonoscopy surveillance guidelines: are we actually adhering to the guidelines?

BACKGROUND

National guidelines put forth by the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Gastroenterology provide recommendations regarding colorectal cancer screening and follow-up surveillance. Practice patterns may differ from these guidelines. This study analyzes the concordance between a tertiary equal access system and national guidelines for colorectal cancer and polyp surveillance.

METHODS

We performed a retrospective database review of all patients at a single institution undergoing screening colonoscopy from 2010 to 2011. Patient demographics, indication for colonoscopy, pathologic findings, and follow-up recommendations documented by the provider were analyzed. Multivariate analysis was performed in an attempt to identify predictors of discordant recommendations.

RESULTS

One thousand four hundred twenty patients were identified (mean age, 54.3 ± 7.7 years, 48.6% women). The gastroenterology service performed the majority of colonoscopies (87.2%) compared with the surgery service (11.6%). The major indications were routine screening (84.4%) and a strong family history of colorectal cancer (12.2%). The adenoma detection rate for the entire cohort was 27.4%. Other pathologic conditions identified included hyperplastic polyps (16%), lymphoid aggregates (3.5%), and invasive adenocarcinoma (0.1%). Overall, follow-up recommendations correlated with established guidelines in 97% of cases. By multivariate analysis, only the final pathologic finding of lymphoid aggregates was associated with discordant recommendations (odds ratio [OR], 4.62; 95% confidence interval [CI], 1.64 to 12.99; P = .004). When comparing discordant recommendations between specialties, there was a statistically significant difference between gastroenterology (1.6%) and surgery (7.6%) (P < .0001) providers; surgeons trended toward recommending earlier follow-up examinations (P = .37).

CONCLUSIONS

Overall, surveillance recommendations correlated well with current national guidelines. Concordance rates were higher with gastroenterologists in this cohort. Alterations based on final pathologic examination and individual cases remain clinically important.

Association between unemployment rates and prescription drug utilization in the United States, 2007-2010

BACKGROUND

While extensive evidence suggests that the economic recession has had far reaching effects on many economic sectors, little is known regarding its impact on prescription drug utilization. The purpose of this study is to describe the association between state-level unemployment rates and retail sales of seven therapeutic classes (statins, antidepressants, antipsychotics, angiotensin-converting enzyme [ACE] inhibitors, opiates, phosphodiesterase [PDE] inhibitors and oral contraceptives) in the United States.

METHODS

Using a retrospective mixed ecological design, we examined retail prescription sales using IMS Health Xponent™ from September 2007 through July 2010, and we used the Bureau of Labor Statistics to derive population-based rates and mixed-effects modeling with state-level controls to examine the association between unemployment and utilization. Our main outcome measure was state-level utilization per 100,000 people for each class.

RESULTS

Monthly unemployment levels and rates of use of each class varied substantially across the states. There were no statistically significant associations between use of ACE inhibitors or SSRIs/SNRIs and average unemployment in analyses across states, while for opioids and PDE inhibitors there were small statistically significant direct associations, and for the remaining classes inverse associations. Analyses using each state as its own control collectively exhibited statistically significant positive associations between increases in unemployment and prescription drug utilization for five of seven areas examined. This relationship was greatest for statins (on average, a 4% increase in utilization per 1% increased unemployment) and PDE inhibitors (3% increase in utilization per 1% increased unemployment), and lower for oral contraceptives and atypical antipsychotics.

CONCLUSION

We found no evidence of an association between increasing unemployment and decreasing prescription utilization, suggesting that any effects of the recent economic recession have been mitigated by other market forces.

Neighborhood socioeconomic status and use of colonoscopy in an insured population--a retrospective cohort study

BACKGROUND

Low-socioeconomic status (SES) is associated with a higher colorectal cancer (CRC) incidence and mortality. Screening with colonoscopy, the most commonly used test in the US, has been shown to reduce the risk of death from CRC. This study examined if, among insured persons receiving care in integrated healthcare delivery systems, differences exist in colonoscopy use according to neighborhood SES.

METHODS

We assembled a retrospective cohort of 100,566 men and women, 50-74 years old, who had been enrolled in one of three US health plans for ≥1 year on January 1, 2000. Subjects were followed until the date of first colonoscopy, date of disenrollment from the health plan, or December 31, 2007, whichever occurred first. We obtained data on colonoscopy use from administrative records. We defined screening colonoscopy as an examination that was not preceded by gastrointestinal conditions in the prior 6-month period. Neighborhood SES was measured using the percentage of households in each subject's census-tract with an income below 1999 federal poverty levels based on 2000 US census data. Analyses, adjusted for demographics and comorbidity index, were performed using Weibull regression models.

RESULTS

The average age of the cohort was 60 years and 52.7% were female. During 449,738 person-years of follow-up, fewer subjects in the lowest SES quartile (Q1) compared to the highest quartile (Q4) had any colonoscopy (26.7% vs. 37.1%) or a screening colonoscopy (7.6% vs. 13.3%). In regression analyses, compared to Q4, subjects in Q1 were 16% (adjusted HR = 0.84, 95% CI: 0.80-0.88) less likely to undergo any colonoscopy and 30%(adjusted HR = 0.70, CI: 0.65-0.75) less likely to undergo a screening colonoscopy.

CONCLUSION

People in lower-SES neighborhoods are less likely to undergo a colonoscopy, even among insured subjects receiving care in integrated healthcare systems. Removing health insurance barriers alone is unlikely to eliminate disparities in colonoscopy use.