Prepared by Arnie Brooks
Kennell and Associates
Prepared For TRICARE Management Activity

• 150,000 people/year are diagnosed & 50,000 die of CRC.
– CRC is the second leading cause of cancer death in US.
• U.S. Preventive Services Task Force, the American Cancer
Society, and others recommend regular interval CRC screenings for people age 50+.
• The National Commission on Prevention Priorities found:
– CRC screening is among the most cost-effective of all preventive services.
– Up to 30k additional lives/year could be saved in US if more adults were up-to-date with CRC screenings.
• Would reduced cost sharing increase CRC screenings?
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No Published Articles Found Directly Addressing
Relationship Between Cost Sharing & CRC Screenings
• However, analytic studies over three decades confirm that lower cost sharing results in higher medical care use.
• RAND HIE:
– patients with no cost sharing had 37% more office visits than patients who paid 25% of cost.
– within 0-25% cost sharing ranges, price responsiveness was similar for different types of care (chronic/acute/preventive).
• Cherkin et al. (1990): with the imposition of a $5 copayment, preventive visits fell by 14%.
• Trivedi et al. (2008): mammography screening rates were 8.3% lower in plans that required $10+ copays.
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• “Gold Standard” colonoscopies have had large patient cost sharing for some TRICARE beneficiaries, which may have significantly deterred screening compliance.
• TRICARE legislation (NDAA 09) eliminated cost sharing for colorectal , breast, cervical, & prostate cancer preventive screenings.
• Key Questions: Will colonoscopy cost sharing elimination significantly increase screening rates?
– and if so, by how much?
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• TRICARE civilian “purchased care” claims offer a unique opportunity for analysis of the effects of cost sharing.
• In TRICARE, two groups paid no cost sharing for preventive services provided in the civilian “purchased care” market:
– Civilian HMO Enrollees
– Non-enrollees who have other health insurance (OHI)
• Alternatively, another full cost sharing group (non-HMO patients without OHI) paid $100-$150 per colonoscopy:
– Allowed cost of $500-$600, coinsurance of 20% to 25%
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• Age 50+ active duty family members and non-Medicare eligible retirees & dependents are included in the population:
• Active duty service members & Medicare eligibles are excluded because they have no variation in cost sharing.
• All care from Military Treatment Facilities (MTFs) excluded.
– MTF care is free, so no MTF user cost sharing variation.
• Included only civilian “purchased care” utilization for non-
MTF users living far from MTFs.
• Users are those who had one+ E&M visit in FY06 or FY07.
• Sample: 611,584 lives age 50+ living far from MTFs.
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• Kept users’ first CRC screening test in FY06 & FY07.
All later tests excluded because most likely diagnostic.
• Few barium enema & virtual colonoscopy claims and thus both were excluded from sample .
• FOBT tests also excluded since cost sharing on a $4.69 test would be inconsequential to patient decision.
• Thus we analyze invasive CRC screenings. Colonoscopy cost sharing can be about $100-$150/procedure.
• Colonoscopies reflect true patient choice: they have several weeks to consider cost/benefit consequences.
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• CostShr: non-HMO users without OHI—patient paid TRICARE cost sharing of 20% to 25% of allowed costs—$100-$150 for colonoscopies.
• NonHMONoCstShr: non-HMO users with OHI, so almost always the patient paid no cost sharing.
• HMONoCstShr: HMO enrollees—TRICARE charges no cost sharing for any preventive benefits.
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• Reported CRC History : A claim record coded for family history; implies greater propensity for colon screenings.
• Screening Year : Expect use in FY07 > FY06 given general medical utilization increases over time.
• Age and Gender :
– CRC incidence increases with age; expect screening rates to increase with age up to a point.
– Gender often plays a role in medical services use.
• Military Rank of Sponsor: Rank is a surrogate for income/education; possibly related to colonoscopy use.
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• Dichotomous choice, cross-section time-series logistic regression.
• Dependent variable is the natural log of the odds of a
TRICARE user choosing a screening colonoscopy:
– constrains use probability to be between 0 & 1.
• Model output: expected probability of use for three cost sharing groups, controlling for other measured independent effects.
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Model Estimated Annual Preventive Colonoscopy
Use Rates in FY06 & FY07
CostShr NonHMONoCstShr HMONoCstShr
Use Rate
Incr. vs. CostShr
7.66% 10.26%
34% 1/
11.44%
49% 1/
1/ P < .0001
• Other variables that have a statistically significant affect on use :
– users with CRC family history
– users with officer sponsors
– users who are older up to age 65
– women
– FY 07 use
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(Continued)

• $100-$150 cost sharing for colonoscopy screenings has likely greatly reduced compliance rates.
• NDAA09 could increase screening rates by as much as 35%-50% for those who paid cost sharing.
• This result would result in greater compliance with recommended colonoscopy screenings of once every 10 years.
• Added CRC screenings are very cost-effective.
– Cost impact is minimal on Defense Health budget.
– Many lives could be saved each year.
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• CRC family history, high risk patients, or diagnostic testing not well known with TRICARE administrative claims data.
• Income, education, ethnicity levels unknown.
• Potential for user group selection bias, particularly in HMO plan:
– Patients may select HMOs for preventive benefits.
– HMO providers may recommend colonoscopies more often.
– Schneider et al. (2008) suggests FFS Medicare group without supplemental insurance generally seek less medical care.
– Pseudo-randomization not feasible--data does not predict group selection (e.g. officer status, age/gender not related to plan choice).
– But some CostShr supplemental coverage may offset possible bias.
• Will be able to conduct natural experiment to test conclusions.
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