Disparities in Routine Breast
Cancer Screening for Medicaid
Managed Care Members with a
Work-Limiting Disability
Sharada Weir, DPhil
Disability Research Interest Group Meeting
June 29, 2010
Study Coauthors and Collaborators
- Center for Health Policy and Research, UMMS:
- Sharada Weir, DPhil
- Heather Posner, MSPH
- Jianying Zhang, MPH
- Whitney Jones, MSPA
- Georgianna Willis, PhD
- Jeffrey Baxter, MD
- Robin Clark, PhD
- CHPR Office of Clinical Affairs
- MassHealth Office of Acute and Ambulatory Care
- MassHealth Behavioral Health Program
- MassHealth Information Analysis
Importance of Breast Cancer
Screening
- Breast Cancer ranks as the second most deadly
cancer among women after lung cancer
- Mammography is currently the gold standard for
early detection of breast cancer
- Routine screening has been associated with
significantly lower risk of being diagnosed with late
stage disease
- Evidence from randomized controlled trials show
significant long-term reductions in breast cancer
mortality owing to mammography screening
HEDIS Breast Cancer Screening
Measure
- National Committee for Quality Assurance’s
(NCQAs) Healthcare Effectiveness Data and
Information Set (HEDIS) is the standard by
which health plans are compared on quality
- As of 2007, measure reported by age cohort:
42-51 and 52-69
- Measure essentially compatible with assessing
Healthy People 2010 goal: 70% of women 40+
to have had a mammogram in prior 2 years
HEDIS Breast Cancer Screening
Measure
Component
Criteria
Denominator
Being female, aged between 42-69 at the end of the
2006, and being continuously enrolled in a
MassHealth managed care plan during 2005 and
2006 with at most one gap in enrollment of no more
than 45 days during each calendar year.
Numerator
The numerator event was having at least one claim
for a mammogram during CY2005 or CY2006.
Denominator Exclusions Optionally, health plans may exclude women with a
double mastectomy and no claim for a mammogram
during the period.
Massachusetts and National
Medicaid Managed Care HEDIS 2007
Breast Cancer Screening Rates
Plan† Mean
Plan† Range
MassHealth: Ages 42-51
59%
57 - 64%
MassHealth: Ages 52-69
68%
67 - 76%
National: Ages 42-51
49%
National: Ages 52-69
55%
Population
† Five
health plans serve Massachusetts Medicaid Managed Care Members
Medicaid Study Population
- Medicaid women eligible for routine mammography
screening are insured but vulnerable
- 67%: Disability basis for Medicaid eligibility
- Different types of disability associated with
various barriers to care
- Unfortunately, our data do not allow us to
identify type of disability or determine how long
a person has been living with a disability
- 33%: Low income basis for Medicaid eligibility
Research Questions
• Are women who qualify for Medicaid
because of a work-limiting disability less
likely to receive mammography
screening?
• What factors are associated with
screening for women with versus
without a disability?
Conceptual (Andersen) Model
Predisposing
Characteristics
•Age cohort
•Race/ethnicity
•Primary
language
•Neighborhood
educational
attainment
Enabling
Resources
Community
•Residential county
•Neighborhood
income
•Distance to
screening facility
Insurance
•Health plan
Need for Care
•CDPS illness
burden score†;
•Diagnoses†:
substance abuse,
mental health
disorders
•Domestic violence
•Tobacco use
Breast
Cancer
Screening
Provider
•Provider type
•Setting (ED vs.
office)
† Andersen considered past medical history to be a ‘predisposing’ factor and current symptoms and
diagnoses as ‘need’. Our data on illness burden and specific (generally, chronic) diagnoses were collected
within the two-year HEDIS data collection period and may be expected to affect contemporaneous
perceived need for screening.
Data
- Working with the MassHealth plans, CHPR
was able to access member-level HEDIS data
- Dependent variable: numerator hit status
- Indicates whether the member met the
measure’s requirements
- Independent variables:
- Individual, family and neighborhood
characteristics; diagnoses; disability status;
health care utilization; region; provider
type; and health plan
Analysis
- Multivariate logistic regression using STATA
version 9.2
- Adjusted odds ratios presented
- Standard errors adjusted with robust
Huber-White Sandwich variance estimator
- Significance evaluated at alpha≤0.05
- Approx. 70% of cases correctly classified
- 3 models: (1) full population; (2) women with
a disability; (3) women without a disability
Sample Description
- Two-thirds of women in our population qualified for
Medicaid because of a work-limiting disability
- Women with disabilities had higher rates of:
-
substance use disorders (17% vs. 8%);
tobacco use recorded in claims (16% vs. 10%);
domestic violence recorded in claims (1% vs. 0.7%); and
severe mental illness (45% vs. 15%)
- No difference between women with and without
disability in the unadjusted probability of meeting the
HEDIS breast cancer screening measure
- Overall, and by disability status, 63% of women had a
mammogram in the prior 2 years
Full Population Findings
- Vulnerable groups less likely to be screened
-
Women with work-limiting disabilities (OR=0.74)
Women who abuse alcohol/drugs (OR=0.52)
Women with diagnosed tobacco use (OR=0.85)
Diagnosed victims of domestic violence (OR=0.66)
- Younger women less likely to be screened
- Source of care is important (ED, Office)
- Access to screening facilities significant
Adjusted Odds Ratios (OR) for Breast Cancer Screening
Women with a
Disability
Women without
a Disability
Predisposing
Individual Characteristics
52 <= Age <= 69
1.46 ***
1.22 ***
Black race
0.94
0.96
Hispanic ethnicity
1.31 *
1.57 ***
Other race/ethnicity
1.08
1.93 ***
Unknown race/ethnicity
1.27 **
1.35 ***
Spanish primary language
1.56 ***
1.73 ***
Other primary language
1.23 ***
1.09
High school grad ≥ 75th percentile
0.87 *
1.01
College grad ≥ 75th percentile
1.03
1.10
Neighborhood Characteristics
Continued…
Continued from previous slide…
Women with a
Disability
Women without
a Disability
Enabling
Health Care Utilization
≥ 1 ED visit
0.78 ***
0.75 ***
Ambulatory Office Visits
1.17 ***
1.21 ***
Ambulatory Office Visits, Squared
<1.00 ***
0.99 ***
Ambulatory Office Visits, Cubed
>1.00 ***
>1.00 **
Provider: Community Health Center
1.07
0.74 ***
Provider: Single-practice
0.91
0.90
Provider: Other type
1.43 ***
1.01
0.97 **
1.00
Household income 25-50th percentile
0.97
1.03
Household income >50-75th percentile
0.92
1.12
Household income ≥ 75th percentile
1.02
1.17
Minority race/ethnicity ≥ 75th percentile
0.98
0.98
Access to Screening Facilities
Distance, Miles
Neighborhood Characteristics
Continued…
Continued from previous slide…
Women with a
Disability
Need
Overall Illness Burden
CDPS Illness Burden Score
CDPS Illness Burden Score, Squared
CDPS Illness Burden Score, Cubed
Diagnoses
Alcohol/drug abuse
Tobacco use
Severe mental illnessa
Other mental illnessb
Domestic violence
Percent of cases correctly classified
Number of observations
Women without
a Disability
1.28 *
0.82 ***
1.02 ***
1.80 ***
0.79 **
1.02 *
0.52 ***
0.85 ***
1.18 ***
0.53 ***
0.83 **
0.92
1.04
0.58 ***
0.90 *
1.02
70.5%
24,160
69.7%
11,718
Note. Reference groups for odds ratios in the table are: age cohort, 42-51 years old; race/ethnicity, white; primary
language, English; neighborhood high school education: <75th percentile with high school completed; neighborhood
college education: <75th percentile with college completed; provider type, group practice; neighborhood income:
<25th percentile of median household income; neighborhood minority race/ethnic status: <75th percentile in terms of
minority race/ethnicity. All equations are also adjusted for county of residence and health plan.
a Major depression, schizophrenia, and bipolar disorder
b Other depression, anxiety disorder and other mental illness
*<0.05; **<0.01; ***<0.001
Differences in Findings for Women
With vs. Without Disability
- Ambulatory visits are initially similarly useful for
women with and without a work-limiting disability, but
after a certain point, women with a disability benefit
more from extra visits
- Illness burden has a more negative effect on
screening for women with disability than for others
- Distance to mammography centers is significant for
women with disabilities but not for those without
- Domestic violence is significant for women with
disabilities but for not those without
Study Limitations
- Findings may not be generalizable to other
states with different Medicaid benefit
structures or population characteristics
- Use of administrative data
- Some member characteristics unobserved
or poorly observed (e.g., substance use,
race, domestic violence)
- No data on individual circumstances and
type of disability to better understand our
findings for women with a disability
Data Strengths
- Administrative claims data offer an advantage
over survey data by eliminating recall and
social desirability biases, allowing for
relatively long, accurate look back periods
- Self-reported mammography data have
been found to overstate screening rates
- Claims data contain rich information on
comorbid diagnoses, usual source of care,
and other variables that may drive results
Discussion
- Prior research showed that women with disabilities
have no higher incidence of breast cancer but tend to
be diagnosed later and treated less aggressively
- After controlling for various characteristics, a screening
disparity emerges for women with a disability
- Some factors affect women with and without disability
similarly (e.g., substance abuse/dependence), but
other factors are negatively associated with screening
only for women with disabilities (e.g., facility distance)
- Physician contacts may be key to increasing routine
screening in this population and reducing preventable
morbidity
Conclusion
- Given the high prevalence of disability in
the Medicaid population, and the
screening disparity for women with
disabilities, a focus on improving access
to breast cancer screening for women
with a range of disabling conditions is
warranted