People without health insurance in rural areas are less likely to be up-to-date for routine health check-ups and cancer screening than those with coverage, according to a new study.
Cancer screening has been a contentious issue in recent years. Even by government-backed U.S. Preventative Services Task Force (USPSTF) standards, which some consider to be relatively conservative, screening rates for breast and cervical cancer were low in the study. Only about half of women in the Oregon-based research met USPSTF recommendations.
“People in rural areas tend to go to the doctor only when they are ill, so they don’t get the chance to talk about cancer screenings,” said Dr. Patricia Carney, a researcher at Oregon Health and Science University, Portland, who led the study.
Previous studies have shown that screening rates are lower among the uninsured, but that research has focused on people in towns and cities.
For the new study, partially funded by the American Cancer Society (ACS), researchers analyzed a decade of medical charts at two private health practices, and two federally funded public health centers in rural Oregon. The study included more than 3,000 men and women, all aged 55 or over when the study began.
They found that about 10 percent of patients lacked insurance coverage. Those with coverage had either private insurance, or a combination of private insurance, Medicare and Medicaid. The insurance status of about 16 percent of patients was unknown.
According to the report in the journal Cancer, people with private insurance were much more likely to be up-to-date for some ACS recommended cancer screenings than people without insurance.
While 56 percent of women with insurance went without recommended mammograms, which the ACS recommends beginning at age 40, 78 percent of uninsured women, and 70 percent of those with Medicare or Medicaid, did.
Similarly, for colon cancer screening, 58 percent of women with private insurance did not meet ACS guidelines - which recommend screening starting at the age of 50, just as the USPSTF does - compared to 87 percent of women without coverage, and about 57 percent of those with Medicare or Medicaid.
About half of insured men were not up-to-date for colon cancer screening, compared to almost 90 percent of uninsured men, but the difference could have been due to chance, according to the researchers.
When the findings were adjusted to reflect USPSTF guidelines, which recommend mammograms every other year starting at 50, the likelihood of women being not being up to date for breast and cervical cancer screening fell from 70 percent to 48 percent.
“The truth is, the people with insurance had appallingly low screening rates, too,” said Dr. Alfred Neugut, an epidemiologist and oncologist from Columbia University in New York, who wasn’t part of the study team.
LINK TO ANNUAL HEALTH VISITS
Carney and Neugut agreed that there are likely many reasons why screening rates are low, anything from long driving distances to the nearest health center to lack of interest in health care. But in the new study, cancer screening seemed to be linked to annual health visits.
“If you have insurance of any kind, you are more likely to go for a health visit, and if you have a health visit, you’re more likely to be up to date for cancer screening,” said Carney.
Even so, researchers found very low rates of health check-ups among the people they surveyed: more than half hadn’t been for a check-up in the last two years.
Women over 50 years of age who are enrolled in health maintenance organizations (HMO) are more likely to receive cancer screening procedures than women with fee-for-service coverage, according to a report released by the National Center for Health Statistics (NCHS).
The report, Health Insurance and Cancer Screening among Women, show that among women 50-64 years of age with 12 years or less education, HMO enrollees reported higher levels of mammography and Pap testing than did those with fee-for-service coverage.
Higher rates of cancer screening were also shown for women aged 65 years and older in HMO’s, regardless of educational level.
In 1992 three out of five women aged 50-64 years, who were enrolled in HMO’s reported having a recent mammogram and a recent Pap test, regardless of their educational level.
In contrast, among women aged 50-64 years with 12 or fewer years of education and fee-for-service coverage, only one out of two women reported recent mammography and Pap testing.
In 1992 only half of all women aged 50-64 years reported a mammogram within the past year, while 53 percent reported a Pap test, and 61 percent reported a clinical breast examination. The percent of women reporting these procedures was lowest for uninsured women and highest for women enrolled in HMO’s. Only 19 percent of uninsured women aged 50-64 years reported recent mammography, 32 percent reported Pap testing, and 38 percent reported clinical breast examination.
The report also shows that screening levels for Pap testing, mammography, and clinical breast examination were 11 to 18 percentage points lower for women 65 years and over than for women aged 50-64 years, despite the higher risk of disease among older women.
Women age 65 years and over with only Medicare coverage were also substantially less likely to report any of the three screening techniques than women with Medicare and private insurance.
For Carney, the message is clear: more health insurance means more health visits and more screening, and the Affordable Care Act could lead to improvements. Later this month, the Supreme Court will rule on the act, which eliminates the need to pay a deductible, co-pay or coinsurance for preventative cancer screening.
“If the healthcare act is implemented, it could really change people’s ability to get cancer screenings…They would not be influenced anymore by all these out of pocket costs,” said Carney.
State efforts to ensure private health insurance coverage of mammography
Many states require that private insurance companies, Medicaid, and public employee health plans provide coverage and reimbursement for specific health services and procedures. The American Cancer Society (ACS) supports these kinds of patient protections, particularly when it comes to evidence-based cancer prevention, early detection, and treatment services.
The only state without a law ensuring that private health plans cover or offer coverage for screening mammograms is Utah. Of the remaining 49 states that have enacted either assured benefits or ensured offerings for mammography coverage, many states do not conform to ACS guidelines and are either more or less “generous” than ACS recommendations. Some states like Rhode Island, however, specifically state in their legislative language that mammography screening should be covered according to the ACS guidelines.
SOURCE: Cancer, online May 30, 2012
Influence of health insurance coverage on breast, cervical, and colorectal cancer screening in rural primary care settings
The majority of patients were women aged 55 years to 70 years, employed or retired, and who had private health insurance and an average of 2.5 comorbid conditions. The overall percentage of eligible women who were up-to-date for cervical cancer screening was 30%; approximately 27% of women were up-to-date for clinical breast examination, 37% were up-to-date for mammography, and 19% were up-to-date for both mammography and clinical breast examination. Approximately 38% of men and 35% of women were up-to-date for colorectal cancer screening using any test at appropriate screening intervals. In general, having any insurance versus being uninsured was associated with undergoing cancer screening. For each type of screening, patients who had at least 1 health maintenance visit were significantly more likely to be up-to-date compared with those with no health maintenance visits. A significant interaction was found between having health maintenance visits, having any health insurance, and being up-to-date for cancer screening tests.
Overall, the percentage of patients who were up-to-date for any cancer screening, especially cervical cancer screening, was found to be very low in rural Oregon. Patients with some form of health insurance were more likely to have had a health maintenance visit within the previous 2 years and to be up-to-date for breast, cervical, and/or colorectal cancer screening.
Patricia A. Carney PhD,
Jean O’Malley MPH,
David I. Buckley MD, MPH,
Motomi Mori PhD,
David A. Lieberman MD,
Lyle J. Fagnan MD,
James Wallace BA,
Betty Liu MD, MPH,
Cynthia Morris MPH, PhD
Article first published online: 30 MAY 2012