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DataWatch

Does Medicare Coverage Of Colonoscopy Reduce Racial/Ethnic Disparities In Cancer Screening Among the Elderly?

Abstract

 
Racial and ethnic disparities in colorectal cancer screening have been documented extensively in the literature. In July 2001 Medicare began covering colonoscopy for average-risk beneficiaries. We examined the effect of Medicare reimbursement on the rate and disparity of colorectal cancer screening among the elderly in the United States. This policy alleviated the screening disparity between non-Hispanic whites and blacks, but the gap between Hispanics and non-Hispanic whites has widened. Overall, fewer than half of the elderly are screened, even though Medicare now covers colonoscopy.

Racial and ethnic disparities in colorectal cancer screening have been documented extensively; most studies have found a lower rate of screening among racial/ethnic minorities.⁴ Lack of health insurance and variations in coverage are two of the most frequently cited reasons for the observed racial/ethnic disparities in use of or access to health care.⁵ Disparities in colorectal cancer screening have persisted among Medicare beneficiaries.⁶ One plausible explanation is that previous studies reporting racial/ethnic disparities in colorectal cancer screening were based on data collected in the 1980s or 1990s, when Medicare coverage of colorectal cancer screening was limited to "high-risk" beneficiaries. The lack of insurance coverage for colonoscopy for those of average risk might have created access barriers for the lower-income elderly, and it likely led to the previously observed racial/ethnic disparities in screening among Medicare beneficiaries.

Medicare began paying for colonoscopy screening for average-risk beneficiaries on 1 July 2001.⁷ Medicare reimbursement for this screening procedure had been limited to those at high risk, whereas fecal occult blood test and flexible sigmoidoscopy were covered for all elderly beneficiaries.⁸ Medicare’s reimbursement for colonoscopy reduces financial barriers to screening and should increase its use among the elderly. Two studies have documented an increase in the rate of endoscopic colorectal cancer screening among Medicare beneficiaries and those ages 50–64.⁹ One reported a significant (p < .01) increase in use of colonoscopy in a tertiary institution within six months after the policy went into effect.¹⁰ The other observed an increase in the rate of screening from 4.6 percent before to 14.2 percent after the coverage change among average-risk patients in a large network of gastrointestinal physicians.¹¹ To our knowledge, no studies have examined the effect of this Medicare policy on the rate of colorectal cancer screening in a nationally representative sample of the U.S. elderly population or its impact on screening disparities among the elderly in various racial/ethnic groups. Our study is intended to fill that gap.

Study Data And Methods

Top Study Data And Methods Study Results Discussion NOTES

 
Data source. For this study, we used the 2000 Cancer Control Module (CCM) and 2003 Cancer Screening Supplement (CSS) of the NHIS. The NHIS is a nationally representative probabilistic annual health survey.¹² It has been the primary source of information on the health of civilian, noninstitutionalized U.S. households since 1957. A CCM was administered in the 2000 NHIS to examine cancer-screening behavior and cancer risk factors such as diet, nutrition, physical activity, and family history. The 2003 NHIS also fielded a CSS, but it covered only some of the questions asked in 2000. To examine whether Medicare coverage of colonoscopy changed the pattern of screening colonoscopy use among the elderly, we selected two years of NHIS data, 2000 and 2003, which contain information on the use of colonoscopy. The two years represent pre- and postcoverage periods. Our study was limited to respondents age sixty-five and older.

Key variables. The key variables for the study were the use of endoscopic colorectal cancer screening (the outcome of interest), and Medicare beneficiaries’ racial and ethnic characteristics (the explanatory factors of interest). We identified the use of colorectal cancer screening from the NHIS survey question, "Have you EVER HAD a sigmoidoscopy, colonoscopy, or proctoscopy?" If a respondent answered "yes," we considered him or her to have been screened. Race/ethnicity was classified into four categories: Hispanic, non-Hispanic white, non-Hispanic black, and non-Hispanic other races; included in the "other races" were American Indians/Alaska Natives, Asians, Native Hawaiians and other Pacific Islanders.

Other explanatory variables. We included age and sex in addition to race/ethnicity. Age was categorized into three groups: 65–74, 75–84, and 85+, since studies have shown a nonlinear relationship between age and screening.¹³ We described geographic characteristics by census region and location in a metropolitan statistical area (MSA). Because of confidentiality concerns, the MSA variable is no longer available in the 2003 NHIS. Education attainment was categorized into four groups; we dichotomized marital status as married or not married and place of birth as U.S.-born or foreign-born. Income was classified in four income levels and unknown.¹⁴ Barriers to access included the lack of a usual source of care or lack of supplemental insurance (private insurance or Medicaid). Health status was measured as self-perceived health and self-reported cancer history (yes or no). All explanatory variables are listed in Exhibit 1.

Study Results

Top Study Data And Methods Study Results Discussion NOTES

 
Descriptive statistics. Exhibit 1 compares the characteristics of the 2000 and 2003 NHIS populations. On average, a significantly higher proportion of the elderly in 2003 were in the oldest age group (eighty-five years and older), and a lower proportion were at the lowest education level (less than high school) or in the poor/near-poor income group. No differences were found in the distribution of other population characteristics.

Racial/ethnic groups. In 2003, the rate of endoscopic colorectal cancer screening was significantly higher than in 2000 (p < .001) (Exhibit 1). Across the four racial/ethnic groups, we found a significant increase in the rate of screening from 2000 to 2003 for non-Hispanic whites (p < .01) and non-Hispanic blacks (p = .022) (Exhibit 2). Differences between 2000 and 2003 were not statistically significant among Hispanics or non-Hispanic other races. In both years, the Hispanic elderly had the lowest rate of endoscopic colorectal cancer screening among the elderly studied.

View larger version (14K): [in this window] [in a new window] EXHIBIT 2 Rate Of Colorectal Cancer Screening Among U.S. Elderly, By Race/Ethnicity, 2000 And 2003

Discussion

Top Study Data And Methods Study Results Discussion NOTES

 
The expansion of Medicare reimbursement of colonoscopy to the average-risk population on 1 July 2001 was intended to reduce the economic access barrier to colorectal cancer screening, including that associated with race/ethnicity. We conclude that although the above goal has been achieved overall, all sectors of the population have not benefited equally; there is still room for improvement. We found that even after Medicare began covering colonoscopy, more than half of elderly respondents reported never having this screening procedure. The disparities in screening rates between non-Hispanic whites and non-Hispanic blacks have been reduced: They were no longer statistically significant after Medicare began covering colonoscopy. However, the disparities between the non-Hispanic whites and Hispanics became significant after Medicare coverage began.

A number of factors might have contributed to a lower rate of endoscopic colorectal cancer screening among elderly Hispanics and a slower rate of catching up after Medicare coverage became available. First, a disproportionately higher percentage of Hispanics were in the poor/near-poor income group; Hispanics accounted for less than 6 percent of the U.S. elderly population, but approximately 10 percent of the elderly in this income group were Hispanic. Also, a large percentage of Hispanics were foreign-born. Additionally, Hispanic beneficiaries were less likely than others to have a usual source of care or private supplemental insurance. All of these factors might have contributed to the lower rate of screening observed in both years. After controlling for these and other factors, we found no significant association between Hispanic ethnicity and endoscopic colorectal cancer screening in 2000 but strong evidence of disparities in screening among Hispanics in 2003. This suggests that factors uniquely associated with a lower rate of screening among Hispanic Medicare beneficiaries make this population more vulnerable even after economic barriers to screening have been removed. These might include a lack of awareness of the availability of Medicare coverage or cultural factors.

There are certainly cultural differences between Hispanics and blacks that could lead to the observed findings. These include barriers to seeking health care such as language and health literacy, a nihilistic view of a cancer diagnosis (as a death sentence), preference for not knowing about the disease before it becomes symptomatic, and many others.¹⁶ However, in most studies, the most consistent predictor of cancer screening use is a recommendation from the health care provider.¹⁷ The second most consistent predictor is the patient’s perception of risk. Both of these factors are strongly influenced by the prevalence of the disease in the population of interest. Therefore, it is important to note that both the incidence (39.0 per 100,000) and the mortality (14.2 per 100,000) associated with colorectal cancer among U.S. Hispanics are much lower than those observed among non- Hispanic whites (53.6 and 20.1 per 100,000, respectively) and blacks (62.4 and 27.9 per 100,000, respectively).¹⁸ Given the high incidence and mortality of colorectal cancer among blacks, it is perhaps not surprising that their physicians would be more likely to recommend screening and that these patients would more likely comply, compared with Hispanics. This is a possible explanation, although not a justification, for the low rates of colorectal cancer screening among Hispanics. However, this observation points to the importance of tailoring interventions to specific populations. Specifically, among Hispanics and their physicians, awareness of risk could be an important target for intervention.

Although the coverage of colonoscopy was intended to reduce the economic burden of colorectal cancer screening for Medicare beneficiaries, such benefits are subject to the Part B deductible and a 20 percent copayment. The estimated cost of a colonoscopy, based on Medicare-allowable payments in 2000, was $695.95 without a biopsy and $1,003.76 with a biopsy.¹⁹ Therefore, beneficiaries paid a $139.20 copayment or more, depending on whether a biopsy was performed, plus an annual deductible of $110 (in 2005) for Part B services. This out-of-pocket amount could be prohibitive for poor and near-poor beneficiaries. Some dually eligible beneficiaries avoid the out-of-pocket expenses through Medicaid coverage; however, as of 2004, screening colonoscopy was not covered by Medicaid in thirty-two states.²⁰ The lack of Medicaid coverage in many states probably explains the lack of association between Medicaid supplemental insurance and screening while private supplemental insurance was positively associated with screening. The increasing odds of screening found among beneficiaries in the low-income group, compared with those in the poor/near-poor group, suggest that the coverage of colonoscopy might have been effective in increasing the rate of screening among people in the former group but has remained ineffective for those in the latter.

Study limitations. We examined the impact of the expansion of Medicare coverage of colonoscopy on the rate of screening by comparing the rate before and after the coverage policy took effect. Because other time-varying factors such as an increasing awareness of the importance of colorectal cancer screening or a change in diet and physical activity might have also contributed to a higher rate of screening in 2003, our findings are best interpreted as variations in the odds of screening when the economic barrier of screening was reduced. It is difficult to quantify the extent to which these variations were attributable to the Medicare policy.

Our analysis assumed that nearly all elderly are covered by Medicare. Although this assumption was supported in the published statistics, studies have found that Hispanics are overrepresented among the uninsured elderly.²¹ Therefore, some of the observed disparity in colorectal cancer screening between the Hispanic and non-Hispanic white elderly could have been attributable to a lack of Medicare insurance among Hispanics. We could not address this issue because the low uninsurance rate (less than 5 percent) in the elderly population left us with an extremely small number of observations for the uninsured subgroup in each racial/ethnic group. Future studies should consider combining several years of NHIS data to explore this issue.

We defined colorectal cancer screening as ever having had an endoscopic examination. The NHIS also asked those who had received an examination the main reason for their most recent examination, in an attempt to differentiate examinations performed for screening from those for diagnosis or confirmation. Our analysis did not make such distinctions for two reasons. First, recent receipt of a confirmatory or diagnostic test does not necessarily imply that no earlier screening examination was done. Second, we believe that the elderly who have never had any examination pose the greatest public health concern. However, if we redefined our outcome of interest as endoscopic examinations for screening purposes only, we would have to combine two very heterogeneous groups, those never screened and those with an examination for nonscreening purposes, as the "no screening" group. Future studies are recommended to further explore this topic using more advanced multivariate methods such as ordered logit models.

Policy implications. On 15 September 2004 the Centers for Medicare and Medicaid Services elicited participation from health care providers and organizations in the Cancer Prevention and Treatment Demonstration for Ethnic and Racial Minorities. African American, Hispanic, Asian American, Pacific Islander, and American Indian Medicare beneficiaries are eligible for recruitment. One of the purposes of this project is to "eliminate disparities in the rate of preventive cancer screening measures."²² Our study makes a timely observation to inform this demonstration: It identifies Hispanic beneficiaries as those most urgently in need of increased colorectal cancer screening. Further, we have shown that demonstrations focusing on Hispanics should explore whether the rate of screening can be improved by waiving the Medicare copayment and deductible for colonoscopy.

Editor's Notes

 
Ya-Chen Tina Shih (yashih{at}mdanderson.org) is an associate professor in the Section of Health Services Research, Department of Biostatistics and Applied Mathematics, M.D. Anderson Cancer Center at the University of Texas in Houston. Lirong Zhao is a statistical analyst there, and Linda Elting is a professor.

The authors gratefully acknowledge editors of Health Affairs and two anonymous reviewers for their valuable comments on an earlier draft.

NOTES

Top Study Data And Methods Study Results Discussion NOTES

 

1. American Cancer Society, Colorectal Cancer Facts and Figures—Special Edition 2005 (Atlanta: ACS, 2005).
2. M. Pignone et al., "Screening for Colorectal Cancer in Adults at Average Risk: A Summary of the Evidence for the U.S. Preventive Services Task Force," Annals of Internal Medicine 137, no. 2 (2002): 132–141.[Abstract/Free Full Text]
3. N. Breen et al., "Progress in Cancer Screening over a Decade: Results of Cancer Screening from the 1987, 1992, and 1998 National Health Interview Surveys," Journal of the National Cancer Institute 93, no. 22 (2001): 1704–1713.[Abstract/Free Full Text]
4. L.F. McMahon Jr. et al., "Racial and Gender Variation in Use of Diagnostic Colonic Procedures in the Michigan Medicare Population," Medical Care 37, no. 7 (1999): 712–717[CrossRef][Web of Science][Medline]; L.C. Seeff et al., "Patterns and Predictors of Colorectal Cancer Test Use in the Adult U.S. Population," Cancer 100, no. 10 (2004): 2093–2103[CrossRef][Web of Science][Medline]; Y.C. Shih, L.S. Elting, and B. Levin, "Disparities in Colorectal Screening between US-Born and Foreign-Born Populations: Evidence from the 2000 National Health Interview Survey," Journal of Cancer Education (forthcoming).
5. S.H. Zuvekas and G.S. Taliaferro, "Pathways to Access: Health Insurance, the Health Care Delivery System, and Racial/Ethnic Disparities, 1996–1999," Health Affairs 22, no. 2 (2003): 139–153[Abstract/Free Full Text]; and M. Lillie-Blanton and C. Hoffman, "The Role of Health Insurance Coverage in Reducing Racial/Ethnic Disparities in Health Care," Health Affairs 24, no. 2 (2005): 398–408.[Abstract/Free Full Text]
6. See McMahon et al., "Racial and Gender Variation"; C.W. Ko, W. Kreuter, and L.M. Baldwin, "Effect of Medicare Coverage on Use of Invasive Colorectal Cancer Screening Tests," Archives of Internal Medicine 162, no. 22 (2002): 2581–2586[Abstract/Free Full Text]; and G.S. Cooper and S.M. Koroukian, "Racial Disparities in the Use of and Indications for Colorectal Procedures in Medicare Beneficiaries," Cancer 100, no. 2 (2004): 418–424.[CrossRef][Web of Science][Medline]
7. The American Gastroenterological Association considered people with one of the following risk factors at "high risk" for colorectal cancer: positive occult blood or frank bleeding, iron deficiency anemia, history of colonic adenomas, family history of colon cancer, ulcerative colitis, or history of colon cancer. People age fifty and older with no risk factors are considered "average risk." See S. Winawer et al., "Colorectal Cancer Screening and Surveillance: Clinical Guidelines and Rationale—Update Based on New Evidence," Gastroenterology 124, no. 2 (2003): 544–560.[CrossRef][Web of Science][Medline]
8. J.L. Freeman et al., "Measuring Breast, Colorectal, and Prostate Cancer Screening with Medicare Claims Data," Medical Care 40, no. 8 Supp. (2002): IV-36–IV-42.
9. D.N. Prajapati et al., "Volume and Yield of Screening Colonoscopy at a Tertiary Medical Center after Change in Medicare Reimbursement," American Journal of Gastroenterology 98, no. 1 (2003): 194–199[CrossRef][Web of Science][Medline]; and G.C. Harewood and D.A. Lieberman, "Colonoscopy Practice Patterns since Introduction of Medicare Coverage for Average-Risk Screening," Clinical Gastroenterology and Hepatology 2, no. 1 (2004): 72–77.
10. Prajapati et al., "Volume and Yield."
11. Harewood and Lieberman, "Colonoscopy Practice Patterns."
12. National Center for Health Statistics, "Data File Documentation, National Health Interview Survey, 2000 (Machine Readable Data File and Documentation)" (Hyattsville, Md.: NCHS, 2002).
13. Seeff et al., "Patterns and Predictions."
14. The income level in both the 2000 and 2003 NHIS was reported as a percentage in reference to the federal poverty level from the previous year (1999 and 2002, respectively), according to the U.S. Census Bureau. Specifically, the five income categories in the NHIS are poor/near-poor (less than 200 percent of the poverty level), low income (200–299 percent), middle income (300–399 percent), upper income (400 percent and above), or unknown.
15. We employed the Surveyfreq procedure in SAS 9.1 to perform comparisons across years while accounting for the complex sample design in each year of the NHIS.
16. J.S. Mandelblatt, K.R. Yabroff, and J.F. Kerner, "Equitable Access to Cancer Services: A Review of Barriers to Quality Care," Cancer 86, no. 11 (1999): 2378–2390.[CrossRef][Web of Science][Medline]
17. Ibid.
18. L.A.G. Ries et al., eds., SEER Cancer Statistics Review, 1975–2002, 2005, http://seer.cancer.gov/csr/1975_2002 (accessed 24 April 2006).
19. A. Sonnenberg, F. Delco, and J.M. Inadomi, "Cost-Effectiveness of Colonoscopy in Screening for Colorectal Cancer," Annals of Internal Medicine 133, no. 8 (2000): 573–584.[Abstract/Free Full Text]
20. National Colorectal Cancer Research Alliance and American Gastroenterological Association, "2004 Colorectal Cancer Legislation Report Card," http://www.nccrt.org/Documents/NewsArticles/NCCRAReportCardFinal.pdf (accessed 24 April 2006).
21. According to the Employee Benefit Research Institute fact sheet, "Health Insurance and the Elderly" (August 2003), Medicare covered more than 96 percent of the elderly in 2001. EBRI, "Facts from EBRI," http://www.ebri.org/publications/facts (accessed 24 April 2006).On representation of Hispanics, see J.W. Mold, G.E. Fryer, and C.H. Thomas, "Who Are the Uninsured Elderly in the United States?" Journal of the American Geriatrics Society 52, no. 4 (2004): 601–606.[CrossRef][Web of Science][Medline]
22. Centers for Medicare and Medicaid Services, 2005 Edition—Initial Announcement: Cancer Prevention and Treatment Demonstration for Ethnic and Racial Minorities, 23 December 2004, http://www.cms.hhs.gov/DemoProjectsEvalRpts/downloads/CPTD_Cancer_Funding.pdf (accessed 23 May 2006).

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