Quantified trends in provider reimbursement and utilization volume in colorectal cancer screenings: analysis of Medicare claims from 2000 to 2019.

AIM: Colorectal cancer (CRC) screening rates in the United States remain persistently below guideline targets, partly due to suboptimal patient utilization and provider reimbursement. To guide long-term national utilization estimates and set reasonable screening adherence targets, this study aimed to quantify trends in utilization of and reimbursement for CRC screenings using Medicare claims. METHOD: Inflation-adjusted reimbursements and utilization volume associated with each CRC screening code were abstracted from Medicare claims between 2000 and 2019. Screenings, screenings/100 000 enrolees and reimbursement/screening were analysed with linear regression and compared with the equality of slopes tests. Average reimbursement per screening was compared using analysis of variance with Dunnett's T3 multiple comparisons test. RESULTS: The growth rate of multitarget stool DNA tests (mt-sDNA)/100 000 was the highest at 170.4 screenings/year (R2 = 0.99, p ≤ 0.001), while that of faecal occult blood tests/100 000 was the lowest at -446.4 screenings/year (R2 = 0.90, p ≤ 0.001) (p ≤ 0.001). Provider reimbursements averaged $546.95 (95% CI $520.12-$573.78) per mt-sDNA screening, significantly higher than reimbursements for all invasive screenings. Only FOBTs significantly increased in reimbursement per screening at $0.62/year (R2 = 0.91, p ≤ 0.001). CONCLUSION: We derived forecastable trend numbers for utilization and provider reimbursement. Faecal immunochemical tests/100 000 and mt-sDNA screenings/100 000 increased most rapidly during the entire study period. The number of nearly all invasive screenings/100 000 decreased rapidly; the number of colonoscopies/100 000 increased slightly, probably due to superior diagnostic strength. These trends indicate the that replacement of other invasive modalities with accessible noninvasive screenings will account for much of future screening behaviour and thus reductions in CRC incidence and mortality, especially given providers' reimbursement incentive to screen average-risk patients with stool-based tests.

On the Outskirts of National Health Reform: A Comparative Assessment of Health Insurance and Access to Care in Puerto Rico and the United States.

POLICY POINTS: Puerto Rico is the United States' largest territory, home to nearly 4 million American citizens, yet it has remained largely on the outskirts of US health policy, including the Affordable Care Act (ACA). We analyzed national survey data from 2011 to 2012 and found that despite its far poorer population, Puerto Rico outperforms the mainland United States on several measures of health care coverage and access to care. While the ACA significantly increases federal resources in Puerto Rico, ongoing federal restrictions on Medicaid funding and premium tax credits in Puerto Rico pose substantial health policy challenges in the territory. CONTEXT: Puerto Rico is the United States' largest territory, home to nearly 4 million American citizens. Yet it has remained largely on the outskirts of US health policy, including the Affordable Care Act (ACA). This article presents an overview of Puerto Rico's health care system and a comparative analysis of coverage and access to care in Puerto Rico and the mainland United States. METHODS: We analyzed 2011-2012 data from the Behavioral Risk Factor Surveillance System, and 2012 data from the American Community Survey and its counterpart, the Puerto Rico Community Survey. Among adults 18 and older, we examined health insurance coverage; access measures, such as having a usual source of care and cost-related delays in care; self-reported health; and the receipt of recommended preventive services, such as cancer screening and glucose testing. We used multivariate regression models to compare Puerto Rico and the mainland United States, adjusted for age, income, race/ethnicity, and other demographic variables. FINDINGS: Uninsured rates were significantly lower in Puerto Rico (unadjusted 7.4% versus 15.0%, adjusted difference: -12.0%, p < 0.001). Medicaid was far more common in Puerto Rico. Puerto Rican residents were more likely than those in the mainland United States to have a usual source of care and to have had a checkup within the past year, and fewer experienced cost-related delays in care. Screening rates for diabetes, mammograms, and Pap smears were comparable or better in Puerto Rico, while colonoscopy rates were lower. Self-reported health was slightly worse, but obesity and smoking rates were lower. CONCLUSIONS: Despite its far poorer population, Puerto Rico outperforms the mainland United States on several measures of coverage and access. Congressional policies capping federal Medicaid funds to the territory, however, have contributed to major budgetary challenges. While the ACA has significantly increased federal resources in Puerto Rico, ongoing restrictions on Medicaid funding and premium tax credits are posing substantial health policy challenges in the territory.