Grant Number:	5R01CA164023-04 Interpret this number
Primary Investigator:	Hsu, John
Organization:	Massachusetts General Hospital
Project Title:	Screening for Free: a Value-Based Insurance Design Natural Experiment
Fiscal Year:	2015

DESCRIPTION (provided by applicant): Aligning health insurance benefits with clinical goals, aka value-based insurance design (VBID), holds much promise for reducing financial barriers to recommended care, improving quality, and modulating spending growth. While studies have found that patient cost-sharing can reduce the use of necessary care and increase spending for downstream care such as hospitalizations, there have been few rigorous VBID studies, especially of the effects on overall clinical or spending outcomes. The Patient Protection and Affordable Care Act (ACA) requires that all Medicare beneficiaries have free access to preventive services starting in 2011, thus creating a VBID natural experiment. This elimination of cost-sharing has the potential to mitigate underuse of cancer screening tests recommended by the US Preventive Services Task Force (USPSF). Using information from large Medicare Advantage plans, this project will examine the clinical and economic effects of this ACA- mandated Medicare policy change. Our 2007-2014 data contain detailed, comprehensive information on insurance benefits, individual characteristics, testing, clinical events, and medical spending. The study sample includes beneficiaries with a range of pre-policy cost-sharing amounts with the staggered elimination of cost- sharing (free screening) over time. For example, 46% of the study population had free colorectal cancer screening in 2007, 74% in 2010, and 100% in 2011; all benefit changes occur on January 1st of the year. The three aims examine the cost-sharing changes' direct and overall effects: Aim 1) screening test rates; Aim 2) clinical event rates; and Aim 3) total medical spending. We will evaluate the outcomes in all subjects and illustrative subgroups, e.g., subjects for whom screening may be of high or low value as per the USPSTF recommendations. Our primary analyses will focus on within-person changes (fixed effects estimation), and will adjust for a rich set of demographic, clinical, physician, and system characteristics. We also will compare subjects with cost-sharing versus those without cost-sharing, using as concurrent controls subjects who consistently have free screening throughout the study period. With several million person-years of data, we will have adequate power to detect even small changes in our outcomes. This study provides an opportunity to evaluate the largest VBID natural experiment to date, to examine the early effects of a major ACA provision on access to preventive care, and to inform future Medicare policy decisions.




Prostate-Specific Antigen Screening and Prostate Cancer Mortality: An Emulation of Target Trials in US Medicare.
Authors: García-Albéniz X. , Hsu J. , Etzioni R. , Chan J.M. , Shi J. , Dickerman B. , Hernán M.A. .
Source: Jco Clinical Cancer Informatics, 2024 Aug; 8, p. e2400094.
PMID: 39159422
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Continuation of Annual Screening Mammography and Breast Cancer Mortality in Women Older Than 70 Years.
Authors: García-Albéniz X. , Hernán M.A. , Logan R.W. , Price M. , Armstrong K. , Hsu J. .
Source: Annals Of Internal Medicine, 2020-03-17 00:00:00.0; 172(6), p. 381-389.
EPub date: 2020-02-25 00:00:00.0.
PMID: 32092767
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Epilepsy Among Elderly Medicare Beneficiaries: A Validated Approach to Identify Prevalent and Incident Epilepsy.
Authors: Moura L.M.V.R. , Smith J.R. , Blacker D. , Vogeli C. , Schwamm L.H. , Cole A.J. , Hernandez-Diaz S. , Hsu J. .
Source: Medical Care, 2019 04; 57(4), p. 318-324.
PMID: 30762723
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Estimating the Effect of Preventive Services with Databases of Administrative Claims: Reasons to Be Concerned.
Authors: García-Albéniz X. , Hsu J. , Bretthauer M. , Hernán M.A. .
Source: American Journal Of Epidemiology, 2019-03-14 00:00:00.0; , .
EPub date: 2019-03-14 00:00:00.0.
PMID: 30869122
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Medicare claims can identify post-stroke epilepsy.
Authors: Moura L.M.V.R. , Smith J.R. , Blacker D. , Vogeli C. , Schwamm L.H. , Hsu J. .
Source: Epilepsy Research, 2019 03; 151, p. 40-47.
EPub date: 2019-02-08 00:00:00.0.
PMID: 30780120
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Adverse Selection into and within the Individual Health Insurance Market in California in 2014.
Authors: Fung V. , Peitzman C.G.K. , Shi J. , Liang C.Y. , Dow W.H. , Zaslavsky A.M. , Fireman B.H. , Derose S.F. , Chernew M.E. , Newhouse J.P. , et al. .
Source: Health Services Research, 2018 Oct; 53(5), p. 3750-3769.
EPub date: 2018-05-17 00:00:00.0.
PMID: 29774534
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Authors: Galbraith A.A. , Fung V. , Li L. , Butler M.G. , Nordin J.D. , Hsu J. , Smith D. , Vollmer W.M. , Lieu T.A. , Soumerai S.B. , et al. .
Source: Health Services Research, 2018 Feb; 53(1), p. 156-174.
EPub date: 2016-11-20 00:00:00.0.
PMID: 27868200
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The value of explicitly emulating a target trial when using real world evidence: an application to colorectal cancer screening.
Authors: García-Albéniz X. , Hsu J. , Hernán M.A. .
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Accuracy of claims-based algorithms for epilepsy research: Revealing the unseen performance of claims-based studies.
Authors: Moura L.M. , Price M. , Cole A.J. , Hoch D.B. , Hsu J. .
Source: Epilepsia, 2017 04; 58(4), p. 683-691.
EPub date: 2017-02-15 00:00:00.0.
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Screening Mammography For Free: Impact Of Eliminating Cost Sharing On Cancer Screening Rates
Authors: Jena A.B. , Huang J. , Fireman B. , Fung V. , Gazelle S. , Landrum M.B. , Chernew M. , Newhouse J.P. , Hsu J. .
Source: Health Services Research, 2017 Feb; 52(1), p. 191-206.
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Effectiveness of Screening Colonoscopy to Prevent Colorectal Cancer Among Medicare Beneficiaries Aged 70 to 79 Years: A Prospective Observational Study.
Authors: García-Albéniz X. , Hsu J. , Bretthauer M. , Hernán M.A. .
Source: Annals Of Internal Medicine, 2017-01-03 00:00:00.0; 166(1), p. 18-26.
EPub date: 2016-09-27 00:00:00.0.
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Causal inference as an emerging statistical approach in neurology: an example for epilepsy in the elderly.
Authors: Moura L.M. , Westover M.B. , Kwasnik D. , Cole A.J. , Hsu J. .
Source: Clinical Epidemiology, 2017; 9, p. 9-18.
EPub date: 2016-12-30 00:00:00.0.
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Feasibility of the collection of patient-reported outcomes in an ambulatory neurology clinic.
Authors: Moura L.M. , Schwamm E. , Moura Junior V. , Seitz M.P. , Hsu J. , Cole A.J. , Schwamm L.H. .
Source: Neurology, 2016-12-06 00:00:00.0; 87(23), p. 2435-2442.
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Source: Journal Of The American College Of Cardiology, 2016-08-02 00:00:00.0; 68(5), p. 570-1.
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Patient Population Loss At A Large Pioneer Accountable Care Organization And Implications For Refining The Program.
Authors: Hsu J. , Price M. , Spirt J. , Vogeli C. , Brand R. , Chernew M.E. , Chaguturu S.K. , Mohta N. , Weil E. , Ferris T. .
Source: Health Affairs (project Hope), 2016 Mar; 35(3), p. 422-30.
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Authors: García-Albéniz X. , Hsu J. , Lipsitch M. , Logan R.W. , Hernández-Díaz S. , Hernán M.A. .
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Association Between Addressing Antiseizure Drug Side Effects And Patient-reported Medication Adherence In Epilepsy
Authors: Moura L.M. , Carneiro T.S. , Cole A.J. , Hsu J. , Vickrey B.G. , Hoch D.B. .
Source: Patient Preference And Adherence, 2016; 10, p. 2197-2207.
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Patient-reported financial barriers to adherence to treatment in neurology.
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Source: Clinicoeconomics And Outcomes Research : Ceor, 2016; 8, p. 685-694.
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