DOI

https://doi.org/10.25772/ASG6-G586

Defense Date

2023

Document Type

Dissertation

Degree Name

Doctor of Philosophy

Department

Health Related Sciences

First Advisor

Dr. Susan Parish

Second Advisor

Dr. Sarah Marrs

Third Advisor

Dr. Venassa Sheppard

Fourth Advisor

Dr. Sami Turner

Abstract

Breast cancer remains one of the leading causes of death among women. Roughly 2.4 million women are diagnosed annually with breast cancer throughout the world. Although breast cancer survival rates are favorable for the United States compared to other nations (90% 5-year survival for non-metastatic disease), it comes at a high cost. The United States spends an estimated $30 billion annually on breast cancer treatment. In addition, disparities in breast cancer survival rates also exist in the United States. Women Medicaid recipients, who are predominately minorities (60%), are more likely to die of breast cancer due to their high rates of late-stage breast cancer diagnoses.

Significant efforts to improve breast cancer survival while reducing identified disparities and treatment costs have been underway for more than forty years. Advances in healthcare policy have played a critical role in saving lives and increasing access to breast cancer screening in the United States. Breast cancer screening is universally supported among professional societies as a tool to diagnose breast cancer in its earliest stages when it is most treatable. However, breast cancer screening is underutilized among Medicaid recipients, correlating with their higher rates of breast cancer mortality.

The passage of the Affordable Care Act (2010) expanded access to health insurance for millions of Americans while allowing Medicaid organizations to compensate their recipients for participating in preventive health behaviors such as breast cancer screening. Financial incentives for preventive health behavior provided by Medicaid organizations have the potential to help cover out-of-pocket costs such as transportation, adult/childcare, or lost wages, as well as encourage Medicaid recipients to prioritize breast cancer screening and/or overcome apprehensions such as physical discomfort and fear of navigating the health care system.

Using the Gelberg-Anderson Behavioral Model for Vulnerable Populations, a retrospective quantitative study was conducted to assess the role of financial incentives in the utilization of breast cancer screening among Medicaid recipients (aged 50-64) residing in Baltimore, Maryland. The study aimed to answer the following research questions: One, do financial incentives increase the utilization of breast cancer screening among women with Medicaid aged between 50 and 74 compared to women who do not receive financial incentives? Two, are higher amounts of financial incentives associated with greater utilization of breast cancer screening? Three, what population characteristics are associated with higher utilization of breast cancer screenings among Medicaid recipients when financial incentives are provided?

The study included 2,578 unique Medicaid recipients who were not current with their breast cancer screening when applying the US Preventive Services Task Force recommendations (2016). Between 2019 and 2022, 738 breast screening exams were completed. Two cohorts were established in the study. One cohort did not receive a financial incentive (392) for breast cancer screening, and a second cohort did receive a financial incentive (2,186) for breast cancer screening. Logistic regression was the primary statistical tool for answering all three research questions. The dependent variable for all three questions was dichotomous, specifically, was a breast cancer screening claim identified (yes/no)? The predictor variable was the use of financial incentives which had three levels, $75, $100, and $150. Covariates such as age (years), race, geographic sub-region of Baltimore, Maryland for the primary residence, and the number of people reported as living with the Medicaid recipient (household count) were considered when assessing the role of population characteristics and breast cancer screening utilization when a financial incentive was provided.

The primary question considered by the study was asking if financial incentives provided to Medicaid recipients increased the utilization of breast cancer screening. The study findings were inconclusive. A secondary question considered if larger-sized financial incentives increased the likelihood of breast cancer screening compared to when a smaller incentive was provided. It was identified that the smaller financial incentive ($75) was statistically significant (p-value < 0.001) for increasing the likelihood of breast cancer screening utilization while the larger financial incentives ($100 or $150) were not found to be statistically significant. The covariates of the Baltimore sub-region and the household count were identified to be not statistically significant in either the financial incentive or no financial incentive cohorts. Alternatively, the age (OR=1.07, 95% CI 1.04, 1.11, p-value <0.05) and race covariates were identified as being statistically significant (p-value <0.05) when a financial incentive was provided to increase breast cancer screening among Medicaid recipients. It was noted that American Indian/Alaskan Native and Black participants who received a financial incentive had a statistically significant (p-value <0.05) increase in their likelihood of utilizing breast cancer screening.

Rights

© The Author

Is Part Of

VCU University Archives

Is Part Of

VCU Theses and Dissertations

Date of Submission

7-23-2023

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