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OBJECTIVE: To measure the extent to which the provision of mammograms was impacted by the COVID‐19 pandemic and surrounding guidelines. DATA SOURCES: De‐identified summary data derived from medical claims and eligibility files were provided by Independence Blue Cross for women receiving mammograms. STUDY DESIGN: We used a difference‐in‐differences approach to characterize the change in mammograms performed over time and a queueing formula to estimate the time to clear the queue of missed mammograms. DATA COLLECTION: We used data from the first 30 weeks of each year from 2018 to 2020. PRINCIPAL FINDINGS: Over the 20 weeks following March 11, 2020, the volume of screening mammograms and diagnostic mammograms fell by 58% and 38% of expected levels, on average. Lowest volumes were observed in week 15 (April 8 to 14), when screening and diagnostic mammograms fell by 99% and 74%, respectively. Volumes began to rebound in week 19 (May), with diagnostic mammograms reaching levels to similar to previous years’ and screening mammograms remaining 14% below expectations. We estimate it will take a minimum of 22 weeks to clear the queue of missed mammograms in our study sample. CONCLUSIONS: The provision of mammograms has been significantly disrupted due to the COVID‐19 pandemic.

Objective To better determine the relationship between spatial access to colonoscopy and colorectal cancer (CRC) outcomes, our objective was to examine the agreement of the classic, enhanced, and variable two‐step floating catchment area (2SFCA) methods in evaluating spatial access to colonoscopy and to compare the predictive validity of each method related to late‐stage CRC. 2SFCA methods simultaneously consider supply/demand of services and impedance (ie, travel time). Data Sources Colonoscopy provider locations were obtained from the South Carolina Ambulatory Surgery Database. ZIP code tabulation area (ZCTA) level population estimates and area‐level poverty level were obtained from the American Community Survey. Rurality was determined by the United States Department of Agriculture's Rural‐Urban Commuting Area codes. Individual‐level CRC data were obtained from the South Carolina Central Cancer Registry. Study Design Using the classic, enhanced, and variable 2SFCA methods, we calculated ZCTA‐level spatial access to colonoscopy. We assessed agreement between the three methods by calculating Spearman's rank coefficients and weighted Kappas (Κ). Global and Local Moran's I were used to assess spatial clustering of accessibility scores across 2SFCA methods. We performed multilevel logistic regression analyses to examine the association between spatial accessibility to colonoscopy, area‐ and individual‐level factors, and late‐stage CRC. Principal Findings We found strong agreement (Weighted Κ = 0.82; 95% CI = 0.79‐0.86) and identified similar clustering patterns with the classic and enhanced 2SFCA methods. There was negligible agreement among the classic/enhanced 2SFCA and the variable 2SFCA. Across all 2SFCA methods, regression models showed that spatial access to colonoscopy, rurality, and poverty level were not associated with greater odds of late‐stage CRC, though Black race was associated with late‐stage CRC across all models. Conclusions None of the 2SFCA methods showed an association with late‐stage CRC. Future studies should explore which elements (spatial or nonspatial) of access to care have the greatest impact on CRC outcomes.

OBJECTIVE: To quantify the impact of Medicaid enrollment on access to care and adherence to recommended preventive services. DATA SOURCE: 2005‐2015 Medical Expenditure Panel Survey Household Component. STUDY DESIGN: We examined several access measures and utilization of several preventive services within the past year and within the time frame recommended by the United States Preventive Services Task Force, if more than a year. We estimated local average treatment effects of Medicaid enrollment using a new, two‐stage regression model developed by Nguimkeu, Denteh, and Tchernis. This model accounts for both endogenous and underreported Medicaid enrollment by using a partial observability bivariate probit regression as the first stage. We identify the model with an exogenous measure of Medicaid eligibility, the simulated Medicaid eligibility rate by state, year, and parents vs childless adults. A wide range of changes in Medicaid eligibility occurred during the time period studied. DATA COLLECTION/EXTRACTION METHODS: Sample of low‐income, nonelderly adults not receiving disability benefits. PRINCIPAL FINDINGS: Medicaid enrollment decreased the probability of having unmet needs for medical care by 7.5 percentage points and the probability of experiencing delays getting prescription drugs by 7.7 percentage points. Medicaid enrollment increased the probability of having a usual source of care by 16.5 percentage points, the probability of having a routine checkup by 17.1 percentage points, and the probability of having a flu shot in past year by 12.6 percentage points. CONCLUSION: Medicaid enrollment increased access to care and use of some preventive services. Additional research is needed on impacts for subgroups, such as parents, childless adults, and the smaller and generally older populations for whom screening tests are recommended.

RESEARCH OBJECTIVE: The Million Hearts ® Cardiovascular Disease (CVD) Risk Reduction Model aims to reduce first‐time incidence of heart attacks and strokes among Medicare beneficiaries through improvements in CVD preventive care. The model pays providers (1) to assess each of their Medicare beneficiary’s risk of having a CVD event in 10 years and (2) to reduce risk among their high‐risk cohort. As risk stratification is central to clinical guidelines for CVD prevention, it is unclear whether the model’s modest incentives would change care beyond what practices would already provide. We assess whether the model has improved providers’ delivery of CVD preventive care. STUDY DESIGN: A survey of providers from organizations in a randomized trial. CMS enrolled 516 organizations (primary care and specialty practices, health centers, and hospitals) throughout the country and randomly assigned half to the intervention group. We surveyed randomly selected providers within each of 283 organizations participating after one and a half years of model implementation (45% of organizations from both groups either withdrew or did not enroll any beneficiaries, mainly due to burdensome reporting requirements). We estimated impacts as regression‐adjust differences in intervention and control providers’ responses to survey questions about CVD preventive care provided to their patients (survey response rate: 72%). POPULATION STUDIED: 261 providers in 245 organizations who enrolled beneficiaries and responded to the survey. Most respondents (77%) were physicians, 17% were nurse practitioners, and 6% were physician assistants. Despite high attrition rates, respondents in the intervention (N = 138) and control groups (N = 123) were well balanced on specialty and organization type. PRINCIPAL FINDINGS: Relative to the control group, the model increased by 31% percentage points the share of providers reporting they risk stratify at least half of their Medicare beneficiaries (71% in the intervention group versus 39% in the control, P

RESEARCH OBJECTIVE: In August 2012, Oregon began enrolling Medicaid beneficiaries in coordinated care organizations (CCOs), a unique mandatory‐enrollment accountable care organization (ACO) model with payment methods strongly tied to preventive care and care coordination through patient‐centered medical homes. No study has examined the impact of CCOs on preventive care utilization among infants. The main goal of this study was to examine the impact of this new delivery model on the utilization of preventive care services among infants enrolled in Medicaid during 2 years after birth. We also investigated heterogeneous impacts of the CCO model for preterm and full‐term infants as well as over time. STUDY DESIGN: We linked Oregon 2008‐14 birth certificates to Medicaid eligibility and claims data, and created the pre‐ and post‐CCO cohorts of Medicaid infants. Medicaid infants were defined as being enrolled in Medicaid for at least 80% of the two years after birth. Pediatric preventive care outcomes included indicators of preventive care adequacy as recommended by American Academy of Pediatrics: six well‐child visits by the first birthday, nine well‐child visits by the second birthday, and annual developmental screening. We estimated logistic regression models and linear probability models, adjusting for time trends of outcomes and a comprehensive set of maternal and infant characteristics. We utilized a difference‐in‐differences approach to examine heterogeneous effects of CCOs for preterm and full‐term infants. Spline regression was used to test the effect of CCOs on the outcomes for every six months from the start of the CCO implementation. We conducted a range of sensitivity analyses, such as different thresholds of Medicaid enrollment for the definition of Medicaid infants and excluding infants of mothers in the Medicaid expansion group. POPULATION STUDIED: 36 546 pre‐CCO infants born between August 2008 and July 2010 and 47 973 post‐CCO infants born between August 2012 and December 2014 PRINCIPAL FINDINGS: During the 2 years after birth, infants enrolled in Medicaid CCOs had higher probability of well‐child visit adequacy: 10% points (95%CI: 8.2; 11.8) by the first birthday and 5.7% point (95%CI: 4.3; 7.1) by the second birthday. Annual probability of developmental screening increased by 23.1% points (95%CI: 21.6; 24.6) after the CCO implementation. No difference in the CCOs’ impact was found between preterm infants and full‐term infants. Increase in preventive care was found to start in the second year of the CCO implementation. CONCLUSIONS: The CCO model was associated with an increase in preventive care utilization among infants enrolled in Medicaid during the first 2 years of birth. IMPLICATIONS FOR POLICY OR PRACTICE: Increase in preventive services among low‐income infants after CCO implementation implies that the Oregon Medicaid ACO model could improve quality of care for infants in their early years. A growing number of states have been adopting accountable care models for their Medicaid enrollees. Our findings suggest that other states benefit from studying the Oregon approach to accountable care for Medicaid enrollees that integrates financing and delivery of care, and implements a payment methodology with clear performance targets for pediatric preventive services. PRIMARY FUNDING SOURCE: Centers for Disease Control and Prevention.

Objective To examine the impacts of job insecurity during the recession of 2007–2009 on health care utilization among a panel of U.S. employees. Data Sources/Study Setting Linked administrative and claims datasets on a panel of continuously employed, continuously insured individuals at a large multisite manufacturing firm that experienced widespread layoffs (N = 9,486). Study Design We employed segmented regressions to examine temporal discontinuities in utilization during 2006–2012. To assess the effects of job insecurity, we compared individuals at high- and low-layoff plants. Because the dataset includes multiple observations for each individual, we included individual-level fixed effects. Principal Findings We found discontinuous increases in outpatient (3.5 visits/month/10,000 individuals, p = .002) and emergency (0.4 visits/month/10,000 individuals, p = .05) utilization in the panel of all employees. Compared with individuals at low-layoff plants, individuals at high-layoff plants decreased outpatient utilization (−4.0 visits/month/10,000 individuals, p = .008), suggesting foregone preventive care, with a marginally significant increase in emergency utilization (0.4 visits/month/10,000 individuals, p = .08). Conclusions These results suggest changes in health care utilization and potentially adverse impacts on employee health in response to job insecurity during the latest recession. This study contributes to our understanding of the impacts of economic crises on the health of the U.S. working population.

To compare utilization and preventive care receipt among patients of federal Section 330 health centers (HCs) versus patients of other settings.A nationally representative sample of adults from the Medical Expenditure Panel Survey (2004-2008).HC patients were defined as those with ≥50 percent of outpatient visits at HCs in the first panel year. Outcomes included utilization and preventive care receipt from the second panel year. We used negative binomial and logistic regression models with propensity score adjustment for confounding differences between HC and non-HC patients.Compared to non-HC patients, HC patients had fewer office visits (adjusted incidence rate ratio [aIRR], 0.63) and hospitalizations (aIRR, 0.43) (both p.001). HC patients were more likely to receive breast cancer screening than non-HC patients (adjusted odds ratio [aOR] 2.78, p.01). In subgroup analyses, uninsured HC patients had fewer outpatient and emergency room visits and were more likely to receive dietary advice and breast cancer screening compared to non-HC patients.Health centers add value to the health care system by providing socially and medically disadvantaged patients with care that results in lower utilization and maintained or improved preventive care.

ObjectiveTo study the association between macroeconomic conditions and preventive medical service utilization. Data Sources/Study SettingSecondary data collection of a survey of the civilian, non-institutionalized population of adults (age 18 and older) in the United States between 1987 and 2010. Study DesignRegression analyses that adjust for individual-level demographic and socioeconomic determinants, state and time-fixed effects, and state-specific time trends. Data Collection/Extraction MethodsState health departments, with technological and methodological assistance from the Centers for Disease Control and Prevention, conducted a cross-sectional yearly telephone survey using a standardized questionnaire. Principal FindingsThe use of preventive medical services is procyclical: a 1 percentage point increase in the state-level unemployment rate is associated with a 1.58 percent decrease in the quantity of distinct preventive care services utilized. Women and economically disadvantaged populations are shown to be especially sensitive to macroeconomic fluctuations. ConclusionsPolicy makers should be aware of cyclical changes in preventive care use, particularly among disadvantaged populations, when making challenging budgetary decisions during economic downturns. As physician recommendations can have a strong impact on patients’ use, health care providers could increase efforts to persuade patients to seek screening exams and necessary vaccinations during periods of high unemployment.

Access to health care is a leading indicator for Healthy People 2010 (USDHHS 2000). Access is “the timely use of personal health services to achieve the best possible health outcomes” (Millman 1993). For children, routine visits are an important indicator of realized access to care, in contrast to health insurance and regular source of care, which measure potential access (Sissman 1992; Andersen 1995). Preventive visits are important for many reasons, including the opportunity to provide immunizations, check for appropriate development, screen for problems such as lead exposure, and address parental concerns. They also enable early intervention when problems are identified and they reduce hospitalization (Hakim and Bye 2001). The American Academy of Pediatrics (AAP) recommends annual well-child visits from ages 3 to 20, except for ages 7 and 9 (AAP 1995). Yet, nationally representative surveys have shown that 19–26 percent of children lacked routine care in the past year (St. Peter, Newacheck, and Halfon 1992; Ronsaville and Hakim 2000; Yu et al. 2002). Improving access has been a goal of health care reform, including the State Children's Health Insurance Program to extend health insurance to uninsured children. Health insurance has been linked to use of routine services (Wood et al. 1990; St. Peter, Newacheck, and Halfon 1992; Holl et al. 1995; Tallon and Sandman 1998; Eisert and Gabow 2002; Yu et al. 2002). Insurance is one piece of the access-to-care puzzle; nonfinancial barriers must be also addressed (Sissman 1992; Loue 1993; Kohrman 1994; Perrin et al. 1994; Zuvekas and Weinick 1999; Fry-Johnson et al. 2005). The behavioral model of health services utilization describes utilization as a function of predisposing, enabling, and need characteristics (Aday and Andersen 1974). The literature on preventive care suggests that utilization depends on predisposing factors such as child's age, race/ethnicity, and parental education; enabling factors such as family income, health insurance, and regular source of care; and need factors such as child's health status (Wood et al. 1990; Short and Lefkowitz 1992; St. Peter, Newacheck, and Halfon 1992; Cornelius 1993; Holl et al. 1995; Tallon and Sandman 1998; Eisert and Gabow 2002; Yu et al. 2002; Buescher et al. 2003; Alio and Salihu 2005; Kempe et al. 2005; Chung et al. 2006; Selden and Hudson 2006). Children depend on their parents for health care, yet little is known about the role of parental beliefs and routine care. Andersen (1995) has described health beliefs as “attitudes, values, and knowledge that people have that might influence their subsequent perceptions of need and use of health services.”. It is unclear whether parents perceive regular preventive visits as unimportant or if they are deterred by obstacles. The few studies of parental beliefs and preventive care have been limited to immunizations for young children and have shown mixed results (Becker et al. 1977; Kviz, Dawkins, and Ervin 1985; Strobino et al. 1996; Prislin et al. 1998). The present study examined whether parental beliefs about the frequency of checkups were related to children's timely utilization of routine care. Because there have been very few multivariable analyses of predictors of routine visits among children from 3 to 18 years of age, a secondary aim was to elucidate which factors, besides parental beliefs, were independently related to children's receipt of routine care.

Colorectal cancer (CRC), a highly prevalent condition and a leading cancer-related cause of death in the elderly (Jemal et al. 2005), is potentially curable when detected early (Smith, Cokkinides, and Eyre 2005). In addition, when surgery for CRC is of an emergency and/or palliative nature, it is associated with a substantially elevated risk of mortality (McArdle and Hole 2004), especially in the frail elderly (Koperna, Kisser, and Schulz 1997). Consequently, the benefits of screening may not necessarily be limited to those who are healthy, but are likely to extend to older individuals, and to those with compromised health as well (Clark et al. 2004). The U.S. Preventive Services Task Force (USPSTF) recommends fecal occult blood test (FOBT) to be performed on an annual basis, and flexible sigmoidoscopy (FLEX) and colonoscopy at 10-year intervals (The U.S. Preventive Services Task Force 2005). It further recommends initiating CRC screening at 50 years of age in men and women at average risk for CRC, and earlier in individuals at higher risk for the disease, although there is no consensus on the age at which CRC screening should be discontinued. Despite the higher yield of CRC screening in older individuals, its benefits may be considered limited because of competing causes of death. Given the changing demographics, however, and the increasingly greater representation of healthier individuals in the older age groups, there may be less of a tendency to set an age limit beyond which CRC screening is no longer recommended. Also, because of the greater morbidity and mortality in patients presenting with emergency CRC resection, generally resulting from screening failure, the recommendation and practice of CRC screening in the context of age and the presence of comorbid conditions are likely to be reconsidered. Dually eligible Medicare–Medicaid beneficiaries (hereafter referred to as “duals”) represent the oldest, poorest, and frailest of the elderly population (The Henry J. Kaiser Family Foundation 2004; Murray and Shatto 1998). For example, whereas 73 percent of duals have annual incomes of $10,000 or less, only 12 percent of nonduals may be identified with such income levels. Similarly, duals are considerably more likely than nonduals to rate their health as poor or fair (52 versus 26 percent, respectively), to present significant limitations in activities of daily living (over 30 versus 11 percent), or to reside in nursing homes (19 versus 3 percent; The Henry J. Kaiser Family Foundation 2005). On the other hand, the above statistics imply that nearly 50 percent rate their health as good, very good, or excellent; two thirds report no limitations in their activities of daily living; and 80 percent are community-dwelling—suggesting that a sizable proportion of duals may in fact benefit from preventive care. Also, while most duals have low incomes, enrollment in Medicaid is likely to give them considerable leverage to access health services that they could not afford otherwise. The above descriptions attest to the complexity of issues in studying the health care needs of duals as a subgroup of Medicare beneficiaries at large, and illustrate the diversity in this population, especially relative to their health and functional status. In comparing the use of cancer screening between duals and nonduals, several factors need to be accounted for in formulating research hypotheses. First, considering differentials in health status between duals and nonduals, we can posit that because of competing priorities in addressing the complex health care needs in a sizable proportion of duals, management of acute and/or chronic ailments—rather than prevention—becomes the focus of care—hence the lower likelihood of undergoing cancer screening tests. Second, from the perspective of income, we postulate, based on previous studies, that lower income—and potentially lower educational attainment—is associated with underuse of preventive services (Katz and Hofer 1994; Katz, Zemencuk, and Hofer 2000), even if enrollment in Medicaid is conducive to greater access to health care. We therefore hypothesize that duals would experience a significantly lower rate of cancer screening than their nondual counterparts. The present study examines the use of CRC screening services among Medicare beneficiaries by dual Medicare–Medicaid enrollment status, an attribute largely understudied in the disparities literature. More specifically, we compare receipt of CRC screening by duals and nonduals 65 years of age or older, after adjusting for individual-level characteristics. Given the previously documented associations between county-level socioeconomic and health systems attributes with the use of CRC screening (Koroukian et al. 2005), relevant contextual variables are also accounted for in the analysis.

ObjectiveStudies have shown that there is sufficient availability of mammography; however, little is known about geographic variation in capacity. The purpose of this study was to determine the locations and extent of over/undersupply of mammography in 14 southern states from 2002 to 2008. Data SourcesMammography facility data were collected from the U.S. Food and Drug Administration (FDA). Population estimates, used to estimate the potential demand for mammography, were obtained from GeoLytics Inc. Study DesignUsing the two-step floating catchment area method, we calculated spatial accessibility at the block group level and categorized the resulting index to represent the extent of under/oversupply relative to the potential demand. Principal FindingsResults show decreasing availability of mammography over time. The extent of over/undersupply varied significantly across the South. Reductions in capacity occurred primarily in areas with an oversupply of machines, resulting in a 68 percent decrease in the percent of women living in excess capacity areas from 2002 to 2008. The percent of women living in poor capacity areas rose by 10 percent from 2002 to 2008. ConclusionsOur study found decreasing mammography availability and capacity over time, with substantial variation across states. This information can assist providers and policy makers in their business planning and resource allocation decisions.