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Cancer Screening before and after Switching to a High-Deductible Health Plan
- J. Frank Wharam, MB, BCh, BAO, MPH;
- Alison A. Galbraith, MD, MPH;
- Ken P. Kleinman, ScD;
- Stephen B. Soumerai, ScD;
- Dennis Ross-Degnan, ScD; and
- Bruce E. Landon, MD, MBA
- From Harvard Medical School, Harvard Pilgrim Health Care, and Beth Israel Deaconess Medical Center, Boston, Massachusetts.
Abstract
Background: Health plans with high deductibles could lead patients to avoid preventive care, such as cancer screening.
Objective: To determine the effect of membership in a high-deductible health plan on cervical, breast, and colorectal cancer screening.
Design: Before–after comparison between groups.
Setting: A high-deductible health plan and an HMO in Massachusetts. The high-deductible health plan fully covered mammography, Papanicolaou tests, and fecal occult blood testing (FOBT) but not colonoscopy, flexible sigmoidoscopy, or double-contrast barium enema (DCBE).
Participants: 3169 high-deductible health plan members and 27 022 HMO members (who served as controls).
Measurements: Change in the proportions of patients undergoing breast, cervical, and colorectal cancer screening.
Results: Cancer screening in the high-deductible health plan group was unchanged from baseline to follow-up (adjusted ratios of change, 1.04 [95% CI, 0.91 to 1.19] for breast cancer, 1.04 [CI, 0.92 to 1.17] for cervical cancer, and 1.02 [CI, 0.89 to 1.16] for colorectal cancer). High-deductible health plan members had colonoscopy, flexible sigmoidoscopy, and DCBE less often (ratio of change, 0.73 [CI, 0.56 to 0.95]) and FOBT more often (ratio of change, 1.16 [CI, 1.01 to 1.33]) than HMO members.
Limitations: Population screening frequency was probably underestimated because the study could not assess screening before the baseline year. The study may have included people ineligible for screening because of previous colectomy, mastectomy, or hysterectomy. The findings are limited to a population with relatively high socioeconomic status, which is typical of employed, commercially insured populations.
Conclusion: Members of a high-deductible health plan did not seem to change their use of breast, cervical, and colorectal cancer screening when tests were fully covered. However, members may have substituted a fully covered screening test (FOBT) for tests subject to the deductible (colonoscopy, flexible sigmoidoscopy, and DCBE).
Article and Author Information
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Acknowledgment: The authors thank Fang Zhang, PhD, and Irina Miroshnik, MS, both from Harvard Medical School and Harvard Pilgrim Health Care Department of Ambulatory Care and Prevention, for their assistance in statistical analysis and interpretation in data collection, respectively. They also thank David Cochran, MD, Harvard Pilgrim Health Care's Senior Vice President of Strategic Development, for explanations about health plan data and technical support.
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Grant Support: By a faculty grant funded by the Harvard Pilgrim Health Care Foundation.
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Potential Financial Conflicts of Interest: Employment: J.F. Wharam (Harvard Pilgrim Health Care, Department of Ambulatory Care and Prevention), A.A. Galbraith (Department of Ambulatory Care and Prevention), K.P. Kleinman (Department of Ambulatory Care and Prevention), S.B. Soumerai (Department of Ambulatory Care and Prevention), D. Ross-Degnan (Department of Ambulatory Care and Prevention). Grants received: J.F. Wharam (Harvard Pilgrim Health Care), A.A. Galbraith (Harvard Pilgrim Health Care). Grants pending: J.F. Wharam (Harvard Pilgrim Health Care). The Department of Ambulatory Care and Prevention is jointly funded by Harvard Medical School and Harvard Pilgrim Health Care.
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Reproducible Research Statement: Study protocol: Available from Dr. Wharam (e-mail, jwharam{at}partners.org). Statistical code and data set: Not available.
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Requests for Single Reprints: J. Frank Wharam, MB, BCh, BAO, MPH, Department of Ambulatory Care and Prevention, Harvard Medical School and Harvard Pilgrim Health Care, 133 Brookline Avenue, 6th Floor, Boston, MA 02215; e-mail, jwharam{at}partners.org.
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Current Author Addresses: Drs. Wharam, Soumerai, and Ross-Degnan: Department of Ambulatory Care and Prevention, Harvard Medical School and Harvard Pilgrim Health Care, 133 Brookline Avenue, 6th Floor, Boston, MA 02215.
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Drs. Galbraith and Kleinman: Department of Ambulatory Care and Prevention, Harvard Medical School and Harvard Pilgrim Health Care, 133 Brookline Avenue, 3rd Floor, Boston, MA 02215.
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Dr. Landon: Department of Healthcare Policy, Harvard Medical School, 180 Longwood Avenue, Boston, MA 02115.
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Author Contributions: Conception and design: J.F. Wharam, A.A. Galbraith, K.P. Kleinman, D. Ross-Degnan, B.E. Landon.
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Analysis and interpretation of the data: J.F. Wharam, A.A. Galbraith, K.P. Kleinman, S.B. Soumerai, D. Ross-Degnan, B.E. Landon.
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Drafting of the article: J.F. Wharam.
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Critical revision of the article for important intellectual content: J.F. Wharam, A.A. Galbraith, K.P. Kleinman, S.B. Soumerai, D. Ross-Degnan, B.E. Landon.
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Final approval of the article: J.F. Wharam, A.A. Galbraith, K.P. Kleinman, S.B. Soumerai, D. Ross-Degnan, B.E. Landon.
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Statistical expertise: J.F. Wharam, K.P. Kleinman.
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Obtaining of funding: J.F. Wharam.
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Administrative, technical, or logistic support: J.F. Wharam, S.B. Soumerai.
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Collection and assembly of data: J.F. Wharam, A.A. Galbraith.
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