The impact of consumer-directed health plans and patient socioeconomic status on physician recommendations for colorectal cancer screening.
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ABSTRACT:
SUBMITTER: Pollack CE
PROVIDER: S-EPMC2533392 | biostudies-other | 2008 Oct
REPOSITORIES: biostudies-other
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Project description:Despite the documented benefits of colorectal cancer screening, patient participation rates remain low. Physician recommendation has been identified as a significant predictor of screening completion.The aim of this study is to investigate how primary care physicians perceive colorectal cancer screening communication tasks, as well as to explore the form and content of actual screening discussions.The research design includes a mailed physician survey and a separate observational study in a sample of videotaped medical encounters. PARTICIPANTS AND DATA SOURCES: The participants were 270 primary care physicians who completed a mailed questionnaire (57.9% response rate) and 18 physician-patient encounters that included discussions of colorectal cancer screening.The questionnaire focused on perceived importance and accomplishment of communication tasks relevant to colorectal cancer screening. Two of the authors reviewed transcripts of videotaped physician encounters to determine whether the same communication tasks assessed in the survey were accomplished. Interrater reliability was high across all of the mutually exclusive coding categories (Kappa > .90).Physicians rated colonoscopy as the most important screening option to discuss; self-reports indicate that colonoscopy (84.8%) is more frequently mentioned than fecal occult blood test (FOBT; 49.4%), flexible sigmoidoscopy (34.1%), or computed tomography (CT) imaging (18.1%). Explaining benefits and risks, describing test procedure and frequency, eliciting patient preferences, and making a plan for screening were all viewed as very important. Self-reported accomplishment of these communication tasks was considerably higher than that observed in our separate videotape sample.Most physicians recognize and espouse the importance of recommending colorectal cancer screening to eligible patients. However, findings from both the physician survey and observational study suggest that physicians tend to overestimate the extent of discussions about screening. Interventions may be warranted to improve clinical practice.
| S-EPMC2219805 | biostudies-other
Project description:ObjectivesTo assess the impact of consumer-directed health plan (CDHP) enrollment on low-value healthcare spending.Study designWe performed a quasi-experimental analysis using insurance claims data from 376,091 patients aged 18 to 63 years continuously enrolled in a plan from a large national commercial insurer from 2011 to 2013. We measured spending on 26 low-value healthcare services that offer unclear or no clinical benefit.MethodsEmploying a difference-in-differences approach, we compared the change in spending on low-value services for patients switching from a traditional health plan to a CDHP with the change in spending on low-value services for matched patients remaining in a traditional plan.ResultsSwitching to a CDHP was associated with a $231.60 reduction in annual outpatient spending (95% CI, -$341.65 to -$121.53); however, no significant reductions were observed in annual spending on the 26 low-value services (--$3.64; 95% CI, -$9.60 to $2.31) or on these low-value services relative to overall outpatient spending (-$7.86 per $10,000 in outpatient spending; 95% CI, -$18.43 to $2.72). Similarly, a small reduction was noted for low-value spending on imaging (-$1.76; 95% CI, -$3.39 to -$0.14), but not relative to overall imaging spending, and no significant reductions were noted in low-value laboratory spending.ConclusionsCDHPs in their current form may represent too blunt an instrument to specifically curtail low-value healthcare spending.
| S-EPMC6132267 | biostudies-literature
Project description:IntroductionThis study aims to quantify out-of-pocket spending associated with respiratory hospitalizations for conditions similar to those caused by coronavirus disease 2019 and to compare out-of-pocket spending differences among those enrolled in consumer-directed health plans and in traditional, low-deductible plans.MethodsThis study used deidentified administrative claims from the OptumLabs Data Warehouse (January 1, 2016-August 31, 2019) to identify patients with a respiratory hospitalization. It compared unadjusted out-of-pocket spending among consumer-directed health plan enrollees with that among traditional plan enrollees using difference of mean significance tests and repeated the analysis separately by age category and calendar year quarter. These data were collected on a rolling basis by OptumLabs and were analyzed in March 2020.ResultsCommercially insured consumer-directed health plan enrollees had significantly higher out-of-pocket spending than traditional plan enrollees, and these differences were largest among younger populations. The largest difference in out-of-pocket spending occurred during the first half of the year.ConclusionsConsumer-directed health plan enrollees may experience differential financial burden from a hospitalization related to coronavirus disease 2019. Although some insurers are waiving cost-sharing payments for coronavirus disease 2019 treatment, self-insured employers remain exempt. As of now, policy responses may be insufficient to reduce the financial burden on consumer-directed health plans enrollees with respiratory hospitalizations related to coronavirus disease 2019.
| S-EPMC7294288 | biostudies-literature
Project description:ImportanceTiered physician network (TPN) health plans sort physicians into tiers based on their cost and quality, and patients pay lower copays for visits with physicians in the lower-cost and better-quality tiers. When the plans are first introduced, they lead patients to seek care from higher-value physicians.ObjectivesTo examine whether TPNs are associated with patient choice of physician when the plans have been in place for 8 to 12 years and whether there are inequities in patient out-of-pocket costs associated with inequities in access to physicians in lower-copay tiers.Design, setting, and participantsThis cross-sectional study comprising 46 645 physicians and 585 399 patients in TPNs, including 54 683 patients who had a new patient visit with a physician in a TPN, used health insurance claims data from a large employer purchaser from July 1, 2014, to June 30, 2019. Statistical analysis was performed from November 2020 to August 2023.ExposureEvaluation and management visit with a physician in a TPN.Main outcomes and measuresMain outcomes were new patient market share per physician-carrier-zip code-year, distance from centroid of patient zip code to centroid of zip code of nearest low- or medium-copay physician, and mean TPN physician office visit copay per patient. A regression discontinuity design was used to estimate the association of a physician's tier ranking, and a difference-in-differences analysis was used to estimate the association of copayment differences across tiers with market share among new patients. Equity in access was measured by comparing travel distance to the nearest physician in a low-copay or medium-copay tier and mean copayments across patient incomes.ResultsThe main analysis sample included 46 645 physician-carrier-zip code-year observations, 9506 (20.4%) of which were in the low-copay tier, 31 798 (68.2%) in the medium-copay tier, and 5341 (11.5%) in the high-copay tier. The 54 683 new patients in the sample had a mean (SD) age of 46.4 (16.7) years and included 33 542 women (61.3%). There was no association of having a worse tier ranking (0.045 percentage points [95% CI, -0.058 to 0.148 percentage points]) or of copayment differences between tiers (0.001 percentage points [95% CI, -0.002 to 0.004 percentage points]) with physician market share among new patients. The patients with the lowest income paid slightly lower mean (SD) copayments for office visits to a TPN physician than the patients with high income ($48.08 [$16.42] vs $51.59 [$16.79], a 6.8% difference).Conclusions and relevanceIn this cross-sectional study of TPN health plans, there was no association between physician tier ranking and physician market share among any group of patients. These findings suggest there are limitations in TPNs' steering of patients toward high-value physicians. These plans were not associated with exacerbated health inequity in this setting.
| S-EPMC10636632 | biostudies-literature
Project description:ObjectiveDespite some progress in recent years, colorectal cancer (CRC) screening adherence in the United States is still suboptimal, particularly among disadvantaged groups. In this study, we assessed the association between socioeconomic status (SES) and self-reported screening non-adherence (SNA) in a sample of racial/ethnic minorities living in San Francisco, California.Design/methodsA total of 376 participants of the San Francisco version of the Health Information National Trends Survey (SF-HINTS) with ages 50-75 years were included in this cross-sectional study. SNA was defined as not reporting blood stool test within the past year and not reporting sigmoidoscopy/colonoscopy within the past 10 years. Poisson regression models with robust variance estimators were used to evaluate the relation of SES with SNA, adjusting for measured confounders. Results are reported as prevalence ratios (PR) and 95% confidence intervals (95% CI).ResultsOverall SNA was 40%. In multivariable models including all respondents, retired participants had significantly lower SNA prevalence than employed participants (PR = 0.46, 95% CI = 0.26 0.83). In stratified analyses by race/ethnicity, Black respondents with less than high school (PR = 1.93, 95% CI = 1.09, 3.43) and those with high school or equivalent (PR = 1.88, 95% CI = 1.16, 3.04) had significantly higher SNA prevalence than those with at least some college. Among non-Hispanic Asian/Pacific Islanders, those disabled had significantly higher prevalence of SNA as compared to employed people (PR = 4.26, 95% CI = 2.11, 8.60). None of the SES indicators were significantly associated to SNA among Hispanics.ConclusionsParticipants with lower SES characteristics were less likely to adhere to CRC screening guidelines and being retired was a predictor of compliance. There was evidence of heterogeneity in associations between SES and CRC screening by race/ethnicity. Life circumstances of retired people could provide insights for designing interventions aimed to improve CRC screening uptake in these priority groups. Future efforts should consider mechanisms underlying differences by race/ethnicity.
| S-EPMC8081754 | biostudies-literature
Project description:BackgroundColorectal cancer (CRC) screening is effective but underutilized. Although physician recommendation is an important predictor of screening, considerable variation in CRC screening completion remains.PurposeTo characterize the influence of patient trust in care providers on CRC screening behavior.MethodsData were collected as part of a cluster-randomized CRC screening intervention trial performed in the San Francisco Community Health Network from March 2007 to January 2012 (analysis, Spring 2012). All study participants received a recommendation to complete CRC screening from their primary care provider (PCP). Included participants were aged 50-79 years, not current with screening, and completed the Wake Forest Trust Scale (WFTS) measuring trust in PCPs and doctors in general. Primary outcome was CRC screening completion (colonoscopy or fecal occult blood testing) within 12 months following enrollment. Multivariable association adjusted for race/ethnicity, language, and other sociodemographics was estimated using generalized estimating equations with logit link and binomial distribution.ResultsWFTS response was 70.3% (701). Most participants (83%) were Latino, Asian, or black. Most had income <$30,000 (96%) and public health insurance (86%). Higher trust in PCP was associated with screening completion (OR=1.11, 95% CI=1.03, 1.17), but trust in doctors was not (OR=1.02, 95% CI=0.82, 1.28). Race, language, and other sociodemographic factors were not significant in multivariable analysis.ConclusionsAfter controlling for traditional factors, trust in PCP remained the only significant driver of CRC screening completion in low-income patients. Interventions to promote CRC screening may be improved by including efforts to enhance patient trust in PCP.
| S-EPMC4171139 | biostudies-literature
Project description:ImportanceGuidelines for colorectal cancer (CRC) screening recommend an individualized approach in older adults that is informed by consideration of life expectancy and cancer risk. However, little is known about how patients perceive individualized screening recommendations.ObjectiveTo assess veterans' attitudes toward and comfort with cessation of low-value CRC screening (defined as screening in a patient for whom the benefit is expected to be small based on quantitative estimates from hypothetical risk calculators).Design, setting, and participantsThis survey study included patients older than 50 years who had undergone prior screening colonoscopy with normal results at the Veterans Affairs Ann Arbor Healthcare System. A total of 1500 surveys were mailed to potential participants from November 1, 2010, to January 1, 2012. Survey data were analyzed from January 1, 2016, to December 31, 2017.Main outcomes and measuresResponse to the question, "If you personally had serious health problems that were likely to shorten your life and your doctor did not think screening would be of much benefit based on the calculator, how comfortable would you be with not getting any more screening colonoscopies?"ResultsOf the 1500 surveys mailed, 85 were returned to sender, leaving 1415 potential respondents; 1054 of these respondents (median age range, 60-69 years; 884 [85.9%] white and 965 [94.2%] male) completed the survey (response rate, 74.5%). A total of 300 (28.7%) were not at all comfortable with cessation of low-value CRC screening, and 509 (49.3%) thought that age should never be used to decide when to stop screening. In addition, 332 (31.7%) thought it was not at all reasonable to use life expectancy calculators, and 255 (24.3%) thought it was not at all reasonable to use CRC risk calculators to guide these decisions. In ordered logistic regression analysis, factors associated with more comfort with screening cessation were (1) higher trust in physician (odds ratio [OR], 1.19; 95% CI, 1.07-1.32), (2) higher perceived health status (OR, 1.41; 95% CI, 1.23-1.61), and (3) higher barriers to screening (OR, 1.20; 95% CI, 1.11-1.30). Factors that were associated with less comfort with screening cessation included (1) greater perceived effectiveness of screening (OR, 0.86; 95% CI, 0.80-0.94) and (2) greater perceived threat of CRC (OR, 0.81; 95% CI, 0.73-0.89).Conclusions and relevanceThe findings suggest that many veterans have strong preferences against screening cessation even when given detailed information about why the benefit may be low. Efforts to tailor screening recommendations may be met by resistance unless they are accompanied by efforts to address underlying perceptions about the benefit of screening.
| S-EPMC6324357 | biostudies-literature
Project description:BackgroundScreening reduces colorectal cancer mortality, but effective screening tests remain underused. Systematic reminders to patients and physicians could increase screening ratesMethodsWe conducted a randomized controlled trial of patient and physician reminders in 11 ambulatory health care centers. Participants included 21 860 patients aged 50 to 80 years who were overdue for colorectal cancer screening and 110 primary care physicians. Patients were randomly assigned to receive mailings containing an educational pamphlet, fecal occult blood test kit, and instructions for direct scheduling of flexible sigmoidoscopy or colonoscopy. Physicians were randomly assigned to receive electronic reminders during office visits with patients overdue for screening. The primary outcome was receipt of fecal occult blood testing, flexible sigmoidoscopy, or colonoscopy over 15 months, and the secondary outcome was detection of colorectal adenomas.ResultsScreening rates were higher for patients who received mailings compared with those who did not (44.0% vs 38.1%; P < .001). The effect increased with age: +3.7% for ages 50 to 59 years; +7.3% for ages 60 to 69 years; and +10.1% for ages 70 to 80 years (P = .01 for trend). Screening rates were similar among patients of physicians receiving electronic reminders and the control group (41.9% vs 40.2%; P = .47). However, electronic reminders tended to increase screening rates among patients with 3 or more primary care visits (59.5% vs 52.7%; P = .07). Detection of adenomas tended to increase with patient mailings (5.7% vs 5.2%; P = .10) and physician reminders (6.0% vs 4.9%; P = .09).ConclusionsMailed reminders to patients are an effective tool to promote colorectal cancer screening, and electronic reminders to physicians may increase screening among adults who have more frequent primary care visits.
| S-EPMC2683730 | biostudies-literature
Project description:ObjectiveTo identify the degree of selection into consumer-directed health plans (CDHPs) versus traditional plans over time, and factors that influence choice and temper risk selection.Data sources/study settingSixteen large employers offering both CDHP and traditional plans during the 2004–2007 period, more than 200,000 families.Study designWe model CDHP choice with logistic regression; predictors include risk scores, in addition to family, choice setting, and plan characteristics. Additional models stratify by account type or single enrollee versus family.Data collection/extraction methodsRisk scores, family characteristics, and enrollment decisions are derived from medical claims and enrollment files. Interviews with human resources executives provide additional data.Principal findingsCDHP risk scores were 74 percent of traditional plan scores in the first year, and this difference declined over time. Employer contributions to accounts and employee premium savings fostered CDHP enrollment and reduced risk selection. Having to make an active choice of plan increased CDHP enrollment but also increased risk selection. Risk selection was greater for singles than families and did not differ between HRA and HSA-based CDHPs.ConclusionsRisk selection was not severe and it was well managed. Employers have effective methods to encourage CDHP enrollment and temper selection against traditional plans.
| S-EPMC3976189 | biostudies-literature
Project description:ImportanceColorectal cancer (CRC) screening is underused in the US. Tailored message interventions have shown benefit for increasing screening uptake of mammography and Papanicolaou testing, but their role in CRC screening is less clear.ObjectiveTo evaluate the effectiveness of a tailored message telephone intervention prior to scheduling of a screening or surveillance colonoscopy and its effect on CRC screening completion rates.Design, setting, and participantsThis randomized clinical trial was conducted from July 2017 through August 2018 at the University of Pennsylvania Health System (UPHS), an urban academic medical center. Participants were asymptomatic patients aged 50 to 75 years who were eligible for CRC screening or surveillance, had been referred for colonoscopy, and did not have a scheduled colonoscopy appointment. Data analysis was conducted from January to September 2019.InterventionsPatients underwent block randomization in a 1:1:1 ratio to 1 of 3 study arms. Participants in the usual care group were contacted via a mailed letter and instructed to call to schedule a colonoscopy. In the generic message group, participants were contacted by telephone, completed an assessment, and received a uniform, nontailored message encouraging colonoscopy scheduling. Participants in the tailored message group were contacted by telephone, completed an assessment, and received a tailored message encouraging colonoscopy scheduling based on their identified assessment cohort.Main outcomes and measuresThe primary outcome was colonoscopy completion rate within 120 days of enrollment. The secondary outcome was colonoscopy scheduling rate appointment within 120 days of enrollment.ResultsA total of 600 participants (median [IQR] age, 56 [51-63] years; 373 women [62.2%]) were enrolled, including 200 participants randomized to usual care, 200 participants randomized to the generic message, and 200 participants randomized to the tailored message. The total sample included 12 Asian participants (2.0%), 324 Black participants (54.0%), and 227 White participants (37.8%), and 9 participants (1.5%) were of Latino or Hispanic ethnicity. Colonoscopy completion was significantly higher for both the tailored message group (69 participants [34.5%]) and the generic message group (64 participants [32.0%]) compared with the usual care group (37 participants [18.5%]) (P < .001 and P = .002, respectively). Scheduling rates were also significantly higher in both groups, with 106 participants (53.0%) in the tailored message group and 105 participants (52.5%) in the generic message group scheduling appointments, compared with 54 participants (27.0%) in the usual care arm (P < .001 for both).Conclusions and relevanceIn this randomized clinical trial among individuals whose CRC screening was not up to date, both a tailored message intervention and a generic message intervention were significantly more effective at increasing colonoscopy scheduling and completion rates compared with usual care. These findings suggest that individualized health communications can increase individual motivation to obtain CRC screening.Trial registrationClinicalTrials.gov Identifier: NCT03310892.
| S-EPMC8972032 | biostudies-literature