Factors Influencing Mammography Use Among Women in Medicare Managed Care

Health Care Financing Review, Summer, 2001 by Judith K. Barr, Susan Reisine, Yun Wang, Eric F. Holmboe, Karin L. Cohen, Thomas J. Van Hoof, Thomas P. Meehan

Other factors, such as fears associated with mammography and fears associated with breast cancer, were less important for the women in this study than in some prior studies, especially of older women in HMOs (Lerman et al., 1990). It may be that women who have recently selected a Medicare HMO plan already have beliefs that are consistent with use of preventive services (Fox, Roetzhein, and Kingston, 1997). Prior studies have shown that non-elderly women in HMOs were more likely to have received a mammogram than women with fee-for-service coverage (Weinick and Beauregard, 1997; Tu, Kemper, and Wong, 1999-2000). The findings from this Medicare HMO survey are consistent with such comparisons and may reflect the interventional efforts of health plans to facilitate mammography screening, both by encouraging members to have regular mammograms and by encouraging physicians to refer women for mammograms when they are due (Thompson et al., 1995; Lerman et al., 1990; King et al., 1994; Stoddard et al., 1998).

Most of the findings from this study are consistent with those found for community studies, younger women and those in HMOs. These results indicate that age, strong beliefs in the importance of mammograms, and having a physician recommendation are critical factors for women in a Medicare managed plan, as well, and that interventions aimed at these beneficiaries can be modeled on those shown to be effective for other older women (Stoddard et al., 1998). Although overall rates of mammography are high in this sample, there is considerable room for improvement among the older age groups.

Limitations of this study should be noted. The data are based on self-report and were not independently validated by chart review for this sample. However, accuracy of self-report by women in the age group 50-74 of their most recent mammogram has been demonstrated (Zapka et al., 1996), and the agreement of patient self-reports with medical records has been found to be high (Montano and Phillips, 1995). Also, we do not know whether the absence of a mammogram represents an informed decision on the part of the woman, made perhaps in discussion with a physician, or the physician's considered judgment (Blustein and Weiss, 1998). Moreover, we did not assess mammography history prior to the most recent mammogram. Yet, prior use is a good predictor of current use, especially among Medicare HMO members (Taplin et al., 1994): and this factor may have differentiated those members who reported a timely mammogram from those who did not. Finally, because the sample was limited to those women who had the same physician for 2 years, there may be some bias toward including women who were satisfied with their physician.

CONCLUSIONS

The findings from this study of Medicare members of a network model HMO indicate that women generally are receiving mammography screening within the recommended time interval. Additional interventions to address patient satisfaction with the physician and physician-patient communication about mammography, as well as education for physicians and patients about breast cancer risk with age and the utility of regular mammography, should help to increase women's participation in this preventive service. Medicare managed care plans are a relatively new phenomenon and little is known about use of mammography among women who self-select into this type of health care coverage. This study adds to previous work by specifying facilitating beliefs, rather than fears, that are related to timely screening, as well as confirming the importance of a physician recommendation and the potential for enhanced physician-patient relationships in encouraging women to receive this important preventive service. Finally, the age differential confirmed in our study may reflect the continuing use of implicit age limits despite open-ended guidelines.