Wharam J Frank, Galbraith Alison A, Kleinman Ken P, Soumerai Stephen B, Ross-Degnan Dennis, Landon Bruce E
Department of Ambulatory Care and Prevention, Harvard Medical School, Harvard Pilgrim Health Care, and Beth Israel Deaconess Medical Center, Boston, Massachusetts 02215, USA.
Ann Intern Med. 2008 May 6;148(9):647-55. doi: 10.7326/0003-4819-148-9-200805060-00004.
Health plans with high deductibles could lead patients to avoid preventive care, such as cancer screening.
To determine the effect of membership in a high-deductible health plan on cervical, breast, and colorectal cancer screening.
Before-after comparison between groups.
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).
3169 high-deductible health plan members and 27,022 HMO members (who served as controls).
Change in the proportions of patients undergoing breast, cervical, and colorectal cancer screening.
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.
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.
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).
高免赔额的健康保险计划可能会导致患者避免接受预防性护理，如癌症筛查。
确定加入高免赔额健康保险计划对宫颈癌、乳腺癌和结直肠癌筛查的影响。
组间前后比较。
马萨诸塞州的一个高免赔额健康保险计划和一个健康维护组织（HMO）。高免赔额健康保险计划全额覆盖乳房X线摄影、巴氏试验和粪便潜血试验（FOBT），但不覆盖结肠镜检查、乙状结肠镜检查或双对比钡灌肠（DCBE）。
3169名高免赔额健康保险计划成员和27022名HMO成员（作为对照）。
接受乳腺癌、宫颈癌和结直肠癌筛查的患者比例的变化。
高免赔额健康保险计划组从基线到随访期间癌症筛查情况未变（乳腺癌调整后的变化率为1.04[95%CI，0.91至1.19]，宫颈癌为1.04[CI，0.92至1.17]），结直肠癌为1.02[CI，0.89至1.16]）。高免赔额健康保险计划成员进行结肠镜检查、乙状结肠镜检查和DCBE的频率低于HMO成员（变化率为0.73[CI,0.56至0.95]），而进行FOBT的频率高于HMO成员（变化率为1.16[CI，1.01至1.33]）。
由于该研究无法评估基线年份之前的筛查情况，人群筛查频率可能被低估。该研究可能纳入了因先前接受结肠切除术、乳房切除术或子宫切除术而不符合筛查条件的人。研究结果仅限于社会经济地位相对较高的人群，这在有工作且参加商业保险的人群中很典型。
当检查完全覆盖时，高免赔额健康保险计划的成员似乎没有改变他们对乳腺癌、宫颈癌和结直肠癌筛查的使用情况。然而，成员们可能用一项完全覆盖的筛查试验（FOBT）替代了需自付免赔额的试验（结肠镜检查、乙状结肠镜检查和DCBE）。
