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Purpose: Poor women with breast cancer have worse survival than others, and are more likely to undergo surgery in low-volume facilities. We leveraged a natural experiment to study the effectiveness of a policy intervention undertaken by New York (NY) state in 2009 that precluded payment for breast cancer surgery for NY Medicaid beneficiaries treated in facilities performing fewer than 30 breast cancer surgeries annually., Methods: We identified 37,822 women with stage I-III breast cancer during 2004-2008 or 2010-2013 and linked them to NY hospital discharge data. A multivariable difference-in-differences approach compared mortality of Medicaid insured patients with that of commercially or otherwise insured patients unaffected by the policy., Results: Women treated during the postpolicy years had slightly lower 5-year overall mortality than those treated prepolicy; the survival gain was significantly larger for Medicaid patients ( P = .018). Women enrolled in Medicaid had a greater reduction than others in breast cancer-specific mortality ( P = .005), but no greater reduction in other causes of death ( P = .50). Adjusted breast cancer mortality among women covered by Medicaid declined from 6.6% to 4.5% postpolicy, while breast cancer mortality among other women fell from 3.9% to 3.8%. A similar effect was not observed among New Jersey Medicaid patients with breast cancer treated during the same years., Conclusion: A statewide centralization policy discouraging initial care for breast cancer in low-volume facilities was associated with better survival for the Medicaid population targeted. Given these impressive results and those from prior research, other policymakers should consider adopting comparable policies to improve breast cancer outcomes.[Media: see text].

Background: Racial and socioeconomic disparities have been identified in osteoporosis screening., Objective: To determine whether racial and socioeconomic disparities in osteoporosis screening diminish after hip fracture., Design: Retrospective cohort study of female Medicare patients., Setting: Entire states of Illinois, New York, and Florida., Participants: Female Medicare recipients aged 65-89 years old with hip fractures between January 2001 and June 2003., Measurements: Differences in bone density testing by race/ethnicity and zip-code level socioeconomic characteristics during the 2-year period preceding and the 6-month period following a hip fracture., Results: Among all 35,681 women with hip fractures, 20.7% underwent bone mineral density testing in the 2 years prior to fracture and another 6.2% underwent testing in the 6 months after fracture. In a logistic regression model adjusted for age, state, and comorbidity, women of black race were about half as likely (RR 0.52 [0.43, 0.62]) and Hispanic women about 2/3 as likely (RR 0.66 [0.54, 0.80]) as white women to undergo testing before their fracture. They remained less likely (RR 0.66 [0.50, 0.88] and 0.58 [0.39, 0.87], respectively) to undergo testing after fracture. In contrast, women residing in zip codes in the lowest tertile of income and education were less likely than those in higher-income and educational tertiles to undergo testing before fracture, but were no less likely to undergo testing in the 6 months after fracture., Conclusions: Racial, but not socioeconomic, differences in osteoporosis evaluation continued to occur even after Medicare patients had demonstrated their propensity to fracture. Future interventions may need to target racial/ethnic and socioeconomic disparities differently.

Background: Colorectal cancer is the third most common cancer in the United States, but the rate of screening remains low. Since 2001, Medicare has provided coverage of colonoscopy for colorectal cancer screening in individuals at average risk, but little is known about the effect of this coverage on screening or disparities in screening practices., Methods: We examined the Medicare physician/supplier billing claims file for New York, Florida, and Illinois for the years 2002 and 2003. Using a previously employed algorithm, we identified the rates of colorectal screening tests in individuals at average risk. We performed multivariate logistic regression analysis to calculate the effects of sex, racial/ethnic, and socioeconomic characteristics on screening. We also looked for interactions between socioeconomic and demographic variables., Results: A total of 596 470 Medicare beneficiaries were included in the study. Approximately 18.3% of the population had undergone a screening colon test during the study period. Nonwhite persons were less likely to be screened for colorectal cancer than were white persons (relative risk [RR], 0.52; 95% confidence interval [CI], 0.50-0.53). The lowest RR of screening colonoscopy in women compared with men was in the oldest age group and the highest income tertile (RR for whites, 0.64; 95% CI, 0.59-0.70). Higher income level was associated with screening colonoscopy in white patients (men: RR, 1.19; 95% CI, 1.14-1.25; women: RR, 1.09; 95% CI, 1.05-1.15) but not in nonwhite patients (men: RR, 0.97; 95% CI, 0.78-1.22; women: RR, 0.94; 95% CI, 0.78-1.14)., Conclusion: Despite the expansion of Medicare coverage for colorectal cancer screening, there still remain significant disparities between sex and racial/ethnic groups in screening practices.