Evaluation of Preventive Service Usage Related to the Patient Protection and Affordable Care Act

Abstract

Background: The Patient Protection and Affordable Care Act (ACA) mandated that insurers provide coverage of certain preventive care services recommended by the United States Preventive Services Task Force (USPSTF) without patient cost sharing. The covered preventive services include breast, colon and cervical cancer screenings. The ACA made these preventive services available for much of the U.S. population including the previously uninsured. Reviewing use of preventive services is a logical step in determining the effectiveness of the ACA in improving the health status of individuals in the United States. Further research is needed to determine the factors that lead to increased likelihood of utilizing preventive care, the ACA’s impact on preventive care utilization and the cost effectiveness of receiving preventive care. Objective: This project employs a retrospective longitudinal quasi-experimental design to answering three research questions. 1. Has the utilization of screenings for cancer of the colon, cervix or breast, for those of appropriate age for the services and who maintained continuous medical insurance coverage before and after the implementation of the ACA (September 23, 2010), changed as measured by screening rates following implementation? 2. Are individual-level and area-level socio-demographic characteristics, as defined in Andersen’s Behavior Model of Health Services Use, associated with receipt of mammography, colon and cervical cancer screening among age appropriate individuals with commercial insurance? 3. Is breast cancer screening most cost effective than not screening for women over the age of 40? Methods: The first study leveraged commercial medical claims to create a multivariate logistic regression model to match individuals (1:1) in treatment and comparison groups via propensity scoring. Monthly procedure prevalence rates over the study period (2007-2014) were calculated as well as prevalence rates for the proportion of procedures with greater than 0 cost sharing. A ‘differenced’ interrupted time series regression analysis was conducted with the primary outcome variable the rate of preventive service utilization per person per month. The second study used a repeated cross-sectional design. A multivariate binomial logistic regression analysis was conducted to determine whether pre-disposing, enabling and contextual characteristics defined by Andersen’s Behavioral Model of Health Services Use are associated with receipt of cancer screenings in a commercially insured group of age appropriate individuals with continuous medical coverage. Individuals who did not receive a preventive cancer screening were used as a comparison group. The third study utilized a Markov cost-utility model to evaluate costs, outcomes and cost effectiveness of screening mammography. The target population was women of the United States. Model inputs were based on data taken from the Surveillance, Epidemiology and End Results data, and several studies found through a literature review. Results: Study 1: The mammography, colonoscopy, and cervical screening cohorts contained 16,156, 29,946, and 26,188 individuals respectively, equally split between treatment and comparison groups. The results from this study demonstrate the overall trend in utilization of preventive mammography and cervical cancer screening slightly decreased as a result of the Affordable Care Act cost sharing benefit policy change. There was a non-significant decrease for colonoscopy utilization as a result of the ACA policy change. Study 2: Disparities in utilization were observed for each cancer screening. Variables identified as significant predictors of receiving a cancer screening included residence in a high-income zip code, having a regular primary care physician after the affordable care act cost sharing benefit changes were implemented, having insurance coverage that includes pharmacy benefits, and residing in the southern region of the United States. Study 3: The Cost Effectiveness plane shows that no mammography screening is completely dominated by mammography screening. This means that the costs of not screening are more than screening and the effectiveness of not screening is less than the effectiveness of mammography screening in detecting cancer.

Conclusion: Regular screening for breast, cervical and colon cancer can reduce the prevalence of the disease and have significant positive health impacts for the patient. While the ACA is not having the desired effect of increasing the uptake of cancer services in a commercially insured population, new policies that consider the impact of socio-economic disparities in the decision to seek care may be more successful. While cancer screenings may be cost effective, the decision to seek care is a personal one, that in recent times have been highly politicized. Further research is required to fully understand the complete cost benefit impact of cancer screenings. Policy makers can use this information to craft policies to benefit the health of their constituents and promote the transition to accountable care in their communities.