Blustein J
Division of General Medicine, College of Physicians and Surgeons, Columbia University, New York, NY 10032, USA.
N Engl J Med. 1995 Apr 27;332(17):1138-43. doi: 10.1056/NEJM199504273321706.
On January 1, 1991, the Medicare program began offering reimbursement for screening mammography every two years. This study examined the use of mammography in women covered by Medicare during the first two years that the screening benefit was offered.
Medicare bills for 1991 and 1992 from a nationally representative sample of 4110 women 65 years of age or older were examined to determine the degree of compliance with recognized guidelines for screening mammography and the extent to which the use of mammography was associated with having supplemental insurance, which shields patients from the out-of-pocket costs associated with using Medicare benefits.
A total of 36.9 percent of older U.S. women had mammography during the first two years of the Medicare benefit for screening mammography. Only 14.4 percent of the women lacking supplemental insurance had mammography, as compared with 44.7 percent of those with employer-sponsored supplemental insurance, 40.1 percent of those with self-purchased supplemental insurance, and 23.9 percent of those with Medicaid supplemental insurance. These differences persisted in the stratified and multivariate analyses. As compared with women lacking supplemental insurance, women with employment-based supplemental insurance were more likely to undergo mammography (adjusted odds ratio, 3.03; 95 percent confidence interval, 2.17 to 4.23), as were women with self-purchased supplemental insurance (adjusted odds ratio, 2.97; 95 percent confidence interval, 2.13 to 4.15) and women with Medicaid supplemental insurance (adjusted odds ratio, 1.99; 95 percent confidence interval, 1.30 to 3.07).
The use of mammography was substantially below recommended levels during the first two years of Medicare coverage for screening mammography. Women lacking supplemental health insurance were at particularly high risk of failing to undergo mammography. Requiring copayments for preventive services is an obstacle to the effective mass screening of older women for breast cancer.
1991年1月1日，医疗保险计划开始为每两年一次的乳腺钼靶筛查提供报销。本研究调查了在提供筛查福利的头两年中，医疗保险覆盖的女性对乳腺钼靶检查的使用情况。
研究分析了来自4110名65岁及以上具有全国代表性女性样本的1991年和1992年医疗保险账单，以确定符合公认乳腺钼靶筛查指南的程度，以及乳腺钼靶检查的使用与拥有补充保险之间的关联程度，补充保险可使患者免受使用医疗保险福利带来的自付费用。
在医疗保险提供乳腺钼靶筛查福利的头两年中，共有36.9%的美国老年女性进行了乳腺钼靶检查。没有补充保险的女性中只有14.4%进行了乳腺钼靶检查，相比之下，有雇主提供补充保险的女性为44.7%，自行购买补充保险的女性为40.1%，有医疗补助补充保险的女性为23.9%。这些差异在分层分析和多变量分析中仍然存在。与没有补充保险的女性相比，有基于就业的补充保险的女性更有可能接受乳腺钼靶检查（调整后的优势比为3.03；95%置信区间为2.17至4.23），自行购买补充保险的女性（调整后的优势比为2.97；95%置信区间为2.13至4.15）以及有医疗补助补充保险的女性（调整后的优势比为1.99；95%置信区间为1.30至3.07）也是如此。
在医疗保险覆盖乳腺钼靶筛查的头两年中，乳腺钼靶检查的使用率大幅低于推荐水平。缺乏补充健康保险的女性尤其有不接受乳腺钼靶检查的高风险。要求预防性服务自付费用是对老年女性进行有效乳腺癌大规模筛查的障碍。
