Primary Care, Economic Barriers to Health Care, and Use of Colorectal Cancer Screening Tests Among Medicare Enrollees Over Time

Chyke A. Doubeni; Adeyinka O. Laiyemo; Angela C. Young; Carrie N. Klabunde; George Reed; Terry S. Field; Robert H. Fletcher

doi:10.1370/afm.1112

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Figure 1.
Patterns of colorectal testing by usual place of medical care among Medicare enrollees aged 65 to 80 years: MCBS 2000–2005.
Endoscopy = sigmoidoscopy or colonoscopy; FOBT = home fecal occult blood test; MCBS = Medicare Current Beneficiary Survey; unscreened = enrollees who had never before been screened or only reported FOBT more than 2 years previously.
Note: colorectal cancer testing categories are mutually exclusive.
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Figure 2.
Patterns of colorectal testing by type of insurance coverage among Medicare enrollees aged 65 to 80 years: MCBS 2000–2005.
Endoscopy = sigmoidoscopy or colonoscopy; FOBT = home fecal occult blood test; MCBS = Medicare Current Beneficiary Survey; unscreened = enrollees who had never before been screened or only reported FOBT more than 2 years previously.
Note: The colorectal cancer testing categories are mutually exclusive.

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Table 1.

Characteristics of the Study Population: MCBS 2000–2005

	Survey Year^a
Characteristics	2000 (n=8,330)	2003 (n=7,889)	2005 (n=7,614)	PValue
FOBT = home fecal occult blood test; MCBS = Medicare Current Beneficiary Survey.
^a The weighted population estimates for those included in the analyses were for year 2000, N = 22,329,320; year 2003, N = 22,601,377; year 2005, N = 22,548,092. Column percents may not sum to 100% because of rounding error.
^b Colorectal cancer testing categories are mutually exclusive.
Age groups, %
65–69 y	33.5	35.0	35.5	.01
70–74 y	36.5	35.1	34.4	.01
75–80 y	30.1	30.0	30.1	>.99
Race-ethnicity, %
White	81.0	79.7	79.2	.15
Blacks	8.2	8.2	8.2	>.99
Hispanic	7.0	7.7	7.7	.44
others	3.8	4.4	4.9	.02
Sex, women, %	55.8	54.9	54.8	.17
Marital status, %
Married	61.3	61.7	62.4	.21
Widowed	25.4	24.9	23.2	.01
Divorced/separated	9.7	10.4	11.3	.001
Never married	3.6	3.0	3.1	.10
Body mass index, kg/m², %
<25	39.4	37.6	37.1	.02
25–30	38.9	38.3	38.5	.43
>30	21.7	24.1	23.5	<.001
Language of interview, English, %	96.5	95.9	95.9	.18
Less than high school, %	30.1	27.4	24.5	<.01
Annual household income <$25,000, %	57.7	52.1	48.9	<.01
Residing in a metropolitan area, %	76.3	76.8	76.4	.90
Medicare insurance type, %
Medicare part B only	9.3	12.4	12.3	<.01
Medicare-Medicaid	9.6	11.4	11.3	.02
Medicare with supplemental insurance	81.1	76.2	76.4	<.01
Usual place of medical care and physician, %
Primary care	78.1	82.4	82.0	<.01
Non–primary care	14.7	12.0	12.5	.01
No usual place of care	7.1	5.7	5.5	.001
Delayed medical care due to cost	7.3	8.2	7.6	.42
History of non–skin cancer except CRC	15.1	15.8	15.8	.22
General health fair-to-poor	21.7	21.5	19.9	.04
Colorectal cancer testing, %^b
Unscreened	39.2	35.0	31.7	<.01
Endoscopy >5 y previously	8.0	8.8	9.0	<.01
FOBT within 2 y	14.9	11.7	10.4	.04
Recent endoscopy	37.8	44.5	48.9	<.01

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Table 2.

Unadjusted Associations of Access to Health Care With Patterns of Colorectal Cancer Testing Among Medicare Enrollees: MCBS 2000 and 2005

	Unadjusted Odds Ratio (95% CI)^aStudy Year
	2000			2005
Study Parameters	Endoscopy >5 y	FOBT	Recent Endoscopy	Endoscopy >5 y	FOBT	Recent Endoscopy
CI=conficence interval; FOBT = home fecal occult blood test; MCBS = Medicare Current Beneficiary Survey; ref = reference.
^a Estimates derived from single-predictor multinomial logistic regression models.
Usual place of health care
Primary care	Ref	Ref	Ref	Ref	Ref	Ref
Non–primary care	1.08 (0.81–1.45)	0.91 (0.75–1.09)	0.83 (0.72–0.96)	0.88 (0.69–1.14)	1.12 (0.86–1.46)	0.83 (0.68–1.02)
No usual place of care	0.95 (0.69–1.30)	0.25 (0.18–0.36)	0.31 (0.24–0.41)	0.37 (0.25–0.56)	0.16 (0.10–0.26)	0.18 (0.14–0.24)
Insurance types
Medicare Part B only	0.52 (0.35–0.76)	0.42 (0.31–0.57)	0.38 (0.31–0.48)	0.66 (0.51–0.86)	0.71 (0.54–0.92)	0.42 (0.35–0.51)
Medicare-Medicaid	0.36 (0.26–0.51)	0.34 (0.27–0.43)	0.38 (0.32–0.46)	0.53 (0.41–0.68)	0.57 (0.42–0.77)	0.38 (0.31–0.46)
Supplemental Insurance	Ref	Ref	Ref	Ref	Ref	Ref
Delayed medical care due to cost	0.92 (0.63–1.34)	0.74 (0.56–0.98)	0.67 (0.53–0.84)	1.03 (0.74–1.43)	0.75 (0.52–1.06)	0.68 (0.55–0.84)

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Table 3.

Adjusted Associations of Access to Health Care With Patterns of Colorectal Cancer Testing Among Medicare Enrollees: MCBS 2000 and 2005

	Adjusted Odds Ratio (95% CI)^aStudy Year
	2000			2005
Study Parameters	Endoscopy >5 y	FOBT	Recent Endoscopy	Endoscopy >5 y	FOBT	Recent Endoscopy
CI=confidence interval; FOBT = home fecal occult blood test; MCBS = Medicare Current Beneficiary Survey; ref = reference.
^a Estimates derived from multinomial logistic regression models, which were simultaneously adjusted for each variable shown and demographic, geographic and socioeconomic factors, and health status.
^b These estimates were significantly different from each other based on the Wald test with the Bonferonni correction.
Usual place of health care
Primary care	Ref	Ref	Ref	Ref	Ref	Ref
Non–primary care	1.23 (0.92–1.65)	0.99 (0.80–1.22)	0.92 (0.79–1.08)	0.96 (0.74–1.23)	1.21 (0.92–1.60)	0.94 (0.76–1.16)
No usual source of care	1.05 (0.76–1.45)	0.27 (0.19–0.39)	0.35 (0.27–0.46)	0.39 (0.26–0.59)	0.18 (0.11–0.30)	0.22 (0.17–0.30)
Insurance stratified by education
Less than high school
Medicare Part B only	0.39 (0.25–0.62)	0.60 (0.36–0.98)	0.52 (0.39–0.70)	1.00 (0.63–1.59)	0.84 (0.49–1.43)	0.70 (0.48–1.01)
Medicare-Medicaid	0.37 (0.21–0.64)	0.43 (0.29–0.64)	0.80 (0.63–1.02)^b	0.72 (0.50–1.05)	0.91 (0.61–1.35)	0.81 (0.60–1.09)
Supplemental insurance	Ref	Ref	Ref	Ref	Ref	Ref
High school diploma or higher
Medicare Part B only	0.84 (0.48–1.46)	0.62 (0.44–0.89)	0.61 (0.46–0.80)	0.80 (0.56–1.16)	1.05 (0.78–1.41)	0.57 (0.44–0.73)
Medicare-Medicaid	0.65 (0.38–1.11)	0.55 (0.38–0.81)	0.41 (0.29–0.58)^b	0.70 (0.46–1.08)	0.86 (0.52–1.44)	0.53 (0.39–0.71)
Supplemental insurance	Ref	Ref	Ref	Ref	Ref	Ref
Delayed medical care due to cost	1.14 (0.78–1.67)	1.10 (0.81–1.49)	1.00 (0.79–1.27)	1.35 (0.95–1.92)	1.04 (0.71–1.52)	1.06 (0.85–1.33)

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The Article in Brief

Primary Care, Economic Barriers to Health Care, and Use of Colorectal Cancer Screening Tests Among Medicare Enrollees Over Time

Chyke A. Doubeni , and colleagues

Background In 2001, Medicare began providing reimbursement for screening colonoscopies for those at average risk of colorectal cancer, as defined by national guidelines. This study examines whether the expanded benefits reduced disparities associated with colorectal cancer screening.

What This Study Found Despite expanded coverage, Medicare enrollees who did not have supplemental insurance or a usual place of health care had disproportionally lower rates of colorectal cancer screening. During the 6-year study period, the gap in colorectal cancer testing grew between those without a usual source of health care and those who received usual care from a primary care physician.

Implications

Expanding health insurance benefits without additional targeted efforts to improve utilization of appropriate health care services will not eliminate disparities.
These findings reinforce the important role of primary care and the potential role of a patient-centered medical home in the delivery of colorectal cancer screening services.