Financial incentives do not increase breast cancer screening rates

Providing women with financial incentives to undergo breast cancer screening did not lead to significantly more of them receiving a mammogram, according to a randomized, controlled trial. The women all had private insurance through the Tufts health plan in Massachusetts.

“Study results indicate that, at least in this privately insured sample, very low-cost financial incentives may not be effective overall for health plan members overdue for mammograms,” wrote lead researcher Elizabeth Levy Merrick, PhD, MSW, of Brandeis University in Waltham, Mass., and colleagues. “However, exploratory analyses found that for a recently screened subgroup likely to be more amenable to screening, person-centered (choice-based) incentives did have an impact. Further research is indicated regarding higher-value incentives, testing modest incentives in a lower-income population, and further exploring person-centered incentives.”

Results were published in the November issue of the American Journal of Managed Care.

During the study, participants were divided into groups with some receiving incentives such as a $15 gift card or entrance into a lottery for a $250 gift card. Some got the choice of the $15 gift card or entrance into the lottery, and a fourth group received no incentive.

During the study, 11.9 percent of women in the control group had a mammogram compared with 11.7 percent of women who received the $15 gift card, 12.1 percent of women who entered the lottery for the $250 gift card and 13.4 percent of women who had a choice of the $15 gift card or entrance into the lottery.

The researchers mentioned that the U.S. Preventive Services Task Force recommends women between 50 and 74 years old undergo breast cancer screening every two years and suggests women between 40 and 49 make individual decisions on screening. Under the Patient Protection and Affordable Care Act, private health insurance plans are required to cover breast cancer screening mammography with no cost sharing for women who are 40 and older.

In this study, the researchers evaluated 4,427 members of the Tufts health plan, which includes health maintenance organization, preferred provider organization and point-of-service products. Tufts covers mammography annually with no copayment and no referral required.

The women were between 42 and 69 years old and did not have a mammogram claim with the plan between January 2010 and August 2012. The mean age was 53, the mean household income in their zip code of residence was $70,829 and 40.3 percent of women had a college education. The women had been enrolled in the health plan for a median of 83 months.

Tufts health plan sent a screening reminder letter to all of the women and encouraged them to contact their provider with any medical questions and reach out to the plan to find a mammography facility.

Women assigned to the gift card group were told they would receive a $15 American Express gift card if they obtained a mammogram within the following four months. Women in the lottery group were told they would be entered into a drawing for one of five $250 gift cards if they obtained a mammogram within the following four months. Women in the choice group were told they could receive the $15 gift card or enter the lottery if they obtained a mammogram within the following four months.

The researchers found that 14.3 percent of women from 40 to 49 had a mammogram compared with 10.3 percent of women from 60 to 69, which was a statistically significant difference. In addition, women in zip codes where the mean annual household income was at least $70,000 were significantly more likely to undergo mammograms compared with women who lived in less wealthy areas.

An exploratory analysis found that women who had the choice of incentives were more likely to undergo screening during the study if they had a mammogram in 2009, the most recent year before the study began. However, women who had screening in 2009 were not more likely to have future mammograms if they were in the gift card or lottery group.

The researchers cited a few limitations of the study. For instance, the mammography measure they used included some mammograms that were performed for diagnostic purposes, which could overstate the mammography rates. They also only had claims data on screening at the Tufts health plan, and they could not offer immediate incentives because they tracked the screening through claims.