College of Health Solutions, Arizona State University, Phoenix.
School of Economics, Georgia Institute of Technology, Atlanta.
JAMA Netw Open. 2023 Mar 1;6(3):e234893. doi: 10.1001/jamanetworkopen.2023.4893.
Out-of-pocket costs (OOPCs) have been largely eliminated for screening mammography. However, patients still face OOPCs when undergoing subsequent diagnostic tests after the initial screening, which represents a potential barrier to those who require follow-up testing after initial testing.
To examine the association between the degree of patient cost-sharing and the use of diagnostic breast cancer imaging after undergoing a screening mammogram.
DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study used medical claims from Optum's deidentified Clinformatics Data Mart Database, a commercial claims database derived from a database of administrative health claims for members of large commercial and Medicare Advantage health plans. The large commercially insured cohort included female patients aged 40 years or older with no prior history of breast cancer undergoing a screening mammogram examination. Data were collected from January 1, 2015, to December 31, 2017, and analysis was conducted from January 2021 to September 2022.
A k-means clustering machine learning algorithm was used to classify patient insurance plans by dominant cost-sharing mechanism. Plan types were then ranked by OOPCs.
A multivariable 2-part hurdle regression model was used to examine the association between patient OOPCs and the number and type of diagnostic breast services undergone by patients observed to undergo subsequent testing.
In our sample, 230 845 women (220 023 [95.3%] aged 40 to 64 years; 16 810 [7.3%] Black, 16 398 [7.1%] Hispanic, and 164 702 [71.3%] White) underwent a screening mammogram in 2016. These patients were covered by 22 828 distinct insurance plans associated with 6 025 741 enrollees and 44 911 473 distinct medical claims. Plans dominated by coinsurance were found to have the lowest mean (SD) OOPCs ($945 [$1456]), followed by balanced plans ($1017 [$1386]), plans dominated by copays ($1020 [$1408]), and plans dominated by deductibles ($1186 [$1522]). Women underwent significantly fewer subsequent breast imaging procedures in dominantly copay (24 [95% CI, 11-37] procedures per 1000 women) and dominantly deductible (16 [95% CI, 5-28] procedures per 1000 women) plans compared with coinsurance plans. Patients from all plan types underwent fewer breast magnetic resonance imaging (MRI) scans than patients in the lowest OOPC plan (balanced, 5 [95% CI, 2-12] MRIs per 1000 women; copay, 6 [95% CI, 3-6] MRI per 100 women; deductible, 6 [95% CI, 3-9] MRIs per 1000 women.
Despite policies designed to remove financial barriers to access for breast cancer screening, significant financial barriers remain for women at risk of breast cancer.
对于筛查性乳房 X 光检查，自付费用（OOPCs）已基本消除。然而，患者在初始筛查后进行后续诊断性检查时仍面临 OOPCs，这对于那些在初始检查后需要进行随访检查的人来说，可能是一个障碍。
研究患者自付费用的程度与接受筛查性乳房 X 光检查后使用诊断性乳腺癌成像之间的关联。
设计、设置和参与者： 这是一项回顾性队列研究，使用了 Optum 去识别的 Clinformatics Data Mart 数据库中的医疗索赔，该数据库是从大型商业和 Medicare Advantage 健康计划成员的行政健康索赔数据库中提取的商业索赔数据库。大型商业保险队列包括 40 岁或以上、无乳腺癌既往史的女性患者，进行筛查性乳房 X 光检查。数据收集时间为 2015 年 1 月 1 日至 2017 年 12 月 31 日，分析时间为 2021 年 1 月至 2022 年 9 月。
使用 k-均值聚类机器学习算法对患者保险计划进行分类，按主要自付费用机制进行分类。然后按自付费用对计划类型进行排名。
使用多变量两部分门槛回归模型，研究患者自付费用与随后接受检查的患者接受的诊断性乳房服务数量和类型之间的关联。
在我们的样本中，有 230845 名女性（220023 名[95.3%]年龄在 40 至 64 岁之间；16810 名[7.3%]黑人，16398 名[7.1%]西班牙裔，和 164702 名[71.3%]白人）于 2016 年接受了筛查性乳房 X 光检查。这些患者有 22828 种不同的保险计划，涉及 6025741 名参保人和 44911473 份不同的医疗索赔。发现以共付保险为主的计划自付费用最低（945 美元[1456 元]），其次是平衡计划（1017 美元[1386 元]）、以共付额为主的计划（1020 美元[1408 元]）和以自付额为主的计划（1186 美元[1522 元]）。与共付保险计划相比，以共付额为主和以自付额为主的计划中，女性接受的后续乳房成像检查明显较少，分别为每 1000 名女性 24 次（95%CI，11 至 37）和 16 次（95%CI，5 至 28）。所有计划类型的患者接受的乳房磁共振成像（MRI）扫描都少于自付费用最低的计划患者（平衡计划每 1000 名女性 5 次[95%CI，2 至 12]MRI；共付计划每 100 名女性 6 次[95%CI，3 至 6]MRI；自付额计划每 1000 名女性 6 次[95%CI，3 至 9]MRI）。
尽管政策旨在消除乳腺癌筛查的经济障碍，但对于有患乳腺癌风险的女性来说，仍然存在重大的经济障碍。
