Skip to main content
Grant Details

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.


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; 172(6), p. 381-389.
EPub date: 2020-02-25.
PMID: 32092767
Related Citations

Changes in screening colonoscopy following Medicare reimbursement and cost-sharing changes.
Authors: Song L.D. , Newhouse J.P. , Garcia-De-Albeniz X. , Hsu J. .
Source: Health services research, 2019 Aug; 54(4), p. 839-850.
EPub date: 2019-04-02.
PMID: 30941767
Related Citations

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 Apr; 57(4), p. 318-324.
PMID: 30762723
Related Citations

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 Mar; 151, p. 40-47.
EPub date: 2019-02-08.
PMID: 30780120
Related Citations

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.
PMID: 29774534
Related Citations

Impact of Copayment Changes on Children's Albuterol Inhaler Use and Costs after the Clean Air Act Chlorofluorocarbon Ban.
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.
PMID: 27868200
Related Citations

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. .
Source: European journal of epidemiology, 2017 Jun; 32(6), p. 495-500.
EPub date: 2017-07-26.
PMID: 28748498
Related Citations

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.
EPub date: 2016-03-17.
PMID: 26990550
Related Citations

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; 166(1), p. 18-26.
EPub date: 2016-09-27.
PMID: 27669524
Related Citations

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.
PMID: 28115873
Related Citations

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; 87(23), p. 2435-2442.
EPub date: 2016-11-04.
PMID: 27815405
Related Citations

Colonoscopy and Risk of Infective Endocarditis in the Elderly.
Authors: García-Albéniz X. , Hsu J. , Lipsitch M. , Bretthauer M. , Logan R.W. , Hernández-Díaz S. , Hernán M.A. .
Source: Journal of the American College of Cardiology, 2016-08-02; 68(5), p. 570-571.
PMID: 27470461
Related Citations

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.
PMID: 26953296
Related Citations

Patient-reported financial barriers to adherence to treatment in neurology.
Authors: Moura L.M. , Schwamm E.L. , Moura Junior V. , Seitz M.P. , Hoch D.B. , Hsu J. , Schwamm L.H. .
Source: ClinicoEconomics and outcomes research : CEOR, 2016; 8, p. 685-694.
EPub date: 2016-11-17.
PMID: 27895506
Related Citations

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.
EPub date: 2016-10-31.
PMID: 27826186
Related Citations

Infective endocarditis and cancer in the elderly.
Authors: García-Albéniz X. , Hsu J. , Lipsitch M. , Logan R.W. , Hernández-Díaz S. , Hernán M.A. .
Source: European journal of epidemiology, 2016 Jan; 31(1), p. 41-9.
EPub date: 2015-12-18.
PMID: 26683995
Related Citations

Systematic review of benefit designs with differential cost sharing for prescription drugs.
Authors: Ogbechie O.A. , Hsu J. .
Source: The American journal of managed care, 2015-05-01; 21(5), p. e338-48.
EPub date: 2015-05-01.
PMID: 26167782
Related Citations

Back to Top