Cancer screening before and after switching to a high-deductible health plan

Ann Intern Med. 2008 May 6;148(9):647-55. doi: 10.7326/0003-4819-148-9-200805060-00004.


Background: Health plans with high deductibles could lead patients to avoid preventive care, such as cancer screening.

Objective: To determine the effect of membership in a high-deductible health plan on cervical, breast, and colorectal cancer screening.

Design: Before-after comparison between groups.

Setting: A high-deductible health plan and an HMO in Massachusetts. The high-deductible health plan fully covered mammography, Papanicolaou tests, and fecal occult blood testing (FOBT) but not colonoscopy, flexible sigmoidoscopy, or double-contrast barium enema (DCBE).

Participants: 3169 high-deductible health plan members and 27,022 HMO members (who served as controls).

Measurements: Change in the proportions of patients undergoing breast, cervical, and colorectal cancer screening.

Results: Cancer screening in the high-deductible health plan group was unchanged from baseline to follow-up (adjusted ratios of change, 1.04 [95% CI, 0.91 to 1.19] for breast cancer, 1.04 [CI, 0.92 to 1.17] for cervical cancer, and 1.02 [CI, 0.89 to 1.16] for colorectal cancer). High-deductible health plan members had colonoscopy, flexible sigmoidoscopy, and DCBE less often (ratio of change, 0.73 [CI, 0.56 to 0.95]) and FOBT more often (ratio of change, 1.16 [CI, 1.01 to 1.33]) than HMO members.

Limitations: Population screening frequency was probably underestimated because the study could not assess screening before the baseline year. The study may have included people ineligible for screening because of previous colectomy, mastectomy, or hysterectomy. The findings are limited to a population with relatively high socioeconomic status, which is typical of employed, commercially insured populations.

Conclusion: Members of a high-deductible health plan did not seem to change their use of breast, cervical, and colorectal cancer screening when tests were fully covered. However, members may have substituted a fully covered screening test (FOBT) for tests subject to the deductible (colonoscopy, flexible sigmoidoscopy, and DCBE).

Publication types

  • Comparative Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Aged
  • Breast Neoplasms / diagnosis*
  • Colonoscopy / economics
  • Colonoscopy / statistics & numerical data
  • Colorectal Neoplasms / diagnosis*
  • Deductibles and Coinsurance*
  • Enema / economics
  • Enema / statistics & numerical data
  • Female
  • Health Maintenance Organizations / economics
  • Humans
  • Insurance, Health / economics*
  • Male
  • Mass Screening / economics*
  • Mass Screening / methods
  • Mass Screening / statistics & numerical data
  • Middle Aged
  • Occult Blood
  • Papanicolaou Test
  • Sigmoidoscopy / economics
  • Sigmoidoscopy / statistics & numerical data
  • Uterine Cervical Neoplasms / diagnosis*
  • Vaginal Smears / economics
  • Vaginal Smears / statistics & numerical data