Trivedi Amal N, Leyva Bryan, Lee Yoojin, Panagiotou Orestis A, Dahabreh Issa J
From the Departments of Health Services, Policy and Practice (A.N.T., B.L., Y.L., O.A.P., I.J.D.), and Epidemiology (I.J.D.), Brown University School of Public Health, and the Providence Veterans Affairs Medical Center (A.N.T.) - both in Providence, RI.
N Engl J Med. 2018 Jan 18;378(3):262-269. doi: 10.1056/NEJMsa1706808.
The Affordable Care Act (ACA) required most insurers and the Medicare program to eliminate cost sharing for screening mammography.
We conducted a difference-in-differences study of biennial screening mammography among 15,085 women 65 to 74 years of age in 24 Medicare Advantage plans that eliminated cost sharing to provide full coverage for screening mammography, as compared with 52,035 women in 48 matched control plans that had and maintained full coverage.
In plans that eliminated cost sharing, adjusted rates of biennial screening mammography increased from 59.9% (95% confidence interval [CI], 54.9 to 65.0) in the 2-year period before cost-sharing elimination to 65.4% (95% CI, 61.8 to 69.0) in the 2-year period thereafter. In control plans, the rates of biennial mammography were 73.1% (95% CI, 69.2 to 77.0) and 72.8% (95% CI, 69.7 to 76.0) during the same periods, yielding a difference in differences of 5.7 percentage points (95% CI, 3.0 to 8.4). The difference in differences was 9.8 percentage points (95% CI, 4.5 to 15.2) among women living in the areas with the highest quartile of educational attainment versus 4.3 percentage points (95% CI, 0.2 to 8.4) among women in the lowest quartile. As indicated by the difference-in-differences estimates, after the elimination of cost sharing, the rate of biennial mammography increased by 6.5 percentage points (95% CI, 3.7 to 9.4) for white women and 8.4 percentage points (95% CI, 2.5 to 14.4) for black women but was almost unchanged for Hispanic women (0.4 percentage points; 95% CI, -7.3 to 8.1).
The elimination of cost sharing for screening mammography under the ACA was associated with an increase in rates of use of this service among older women for whom screening is recommended. The effect was attenuated among women living in areas with lower educational attainment and was negligible among Hispanic women. (Funded by the National Institute on Aging.).
《平价医疗法案》（ACA）要求大多数保险公司和医疗保险计划取消乳腺钼靶筛查的费用分担。
我们对24个医疗保险优势计划中的15085名65至74岁女性进行了一项双重差分研究，这些计划取消了费用分担，为乳腺钼靶筛查提供全额覆盖，与之相比的是48个匹配对照计划中的52035名女性，这些对照计划拥有并维持全额覆盖。
在取消费用分担的计划中，两年一次乳腺钼靶筛查的校正率从取消费用分担前两年的59.9%（95%置信区间[CI]，54.9至65.0）增至此后两年的65.4%（95%CI，61.8至69.0）。在对照计划中，同期两年一次乳腺钼靶筛查的比率分别为73.1%（95%CI，69.2至77.0）和72.8%（95%CI，69.7至76.0），双重差分结果为5.7个百分点（95%CI，3.0至8.4）。在教育程度处于最高四分位数地区的女性中，双重差分结果为9.8个百分点（95%CI，4.5至15.2），而在最低四分位数地区的女性中为4.3个百分点（95%CI，0.2至8.4）。如双重差分估计所示，取消费用分担后，白人女性两年一次乳腺钼靶筛查的比率增加了6.5个百分点（95%CI，3.7至9.4），黑人女性增加了8.4个百分点（95%CI，2.5至14.4），但西班牙裔女性几乎没有变化（0.4个百分点；95%CI，-7.3至8.1）。
根据《平价医疗法案》取消乳腺钼靶筛查的费用分担与推荐筛查的老年女性中该服务的使用率增加相关。在教育程度较低地区的女性中，这种效果减弱，而在西班牙裔女性中可忽略不计。（由美国国立衰老研究所资助。）
