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Changes in screening colonoscopy following Medicare reimbursement and costsharing changes

Objectives: To compare existing algorithms for classifying screening vs diagnostic colonoscopies and to quantify the increase in screening colonoscopy rates when Medicare began reimbursement in 2001 and when the Affordable Care Act (ACA) eliminated costsharing.

Data Sources: Twenty percent random sample of feeforservice (FFS) Medicare claims, 20002012.

Study Design: Using recent administrative codes as tarnished gold standards, we examined the sensitivity and specificity of five published algorithms for classifying colonoscopies and calculated annual screening colonoscopy rates. We estimated the change in rates after Medicare began reimbursement and used differenceindifferences analysis to estimate the effects of eliminating costsharing by comparing states with and without a mandate to cover screening colonoscopy prior to the ACA.

Findings: Modelbased algorithms have higher sensitivity (0.530.99) than expertbased algorithms (0.350.39), but lower specificity (0.430.65 vs 0.790.88). All algorithms detected increases in screening from both Medicare's reimbursement change (range: 2493/10 000) and the 2011 costsharing change (range: 1.134/10 000). Differenceindifference estimates of the ACA's effect varied from 51 to 155 tests per 10 000 depending on the algorithm.

Conclusions: Screening colonoscopy rates increased after eliminating costsharing in 2011, but the increase's size varied depending on the algorithm used to classify the indication. Improvements are needed in Medicare coding for screening.

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