The role of Federal legislation on breast cancer disparities

4.2.12。莱文摘要。联邦立法在乳腺癌差异方面的作用在联邦医疗保险计划开始向筛查乳房X光检查的提供者报销之后，美国老年人的乳腺癌死亡率开始下降。然而，白人的失业率下降得更快，种族差距扩大。有趣的是，美国各地的差距并没有统一扩大。我们假设，联邦医疗保险法律无意中支持白人获得筛查乳房X光检查服务，因为它将医疗援助定义为向提供者支付现金福利，无论现金在多大程度上是获得服务的主要障碍。我们建议使用观察到的死亡率差异的地理变异性来解决这一假设。我们将获得全国医疗保险数据和与SEER相关的医疗保险索赔数据的大样本，以检验下列子假设：H-L：在调整个别因素后，地区和州水平的特征将对乳房X光检查的利用率产生显著影响。H-2：对于非裔美国人和白人妇女来说，地区和州层面的特征对乳房X光检查使用的影响将是不同的。H-3：在筛查乳房X光检查使用率方面具有最大公平性的地区将更有可能制定旨在提高乳房X光检查使用率和减少差距的计划。H-4：与中等到高度成功的地方相比，失败的地方患乳腺癌的存活率更低，而且随着时间的推移，存活率的种族差异增加的比例更大。H-5：相对于不合格或有中到高筛查的乳房X光检查的地方 随着时间的推移，特别成功的地方将更有可能从乳腺癌中获得较高的存活率，并在存活率方面有更大百分比的减少。我们认为有令人信服的理由尽快使用替代方法解决拟议的假设：(A)数以千计的老年人死于乳腺癌 已经发生或即将发生的不良影响可追溯到联邦医疗保险对医疗援助的定义，即向提供者支付现金；(B)乳腺癌可能只是冰山一角，特别是随着作为联邦医疗保险一部分的为处方药提供现金的新计划的出现；以及(C)观察到美国在预期寿命和其他关键指标方面相对于其他工业化国家的地位下降，可能会产生更广泛的影响。该项目还提出了获得对政策制定者有用的初步答案的合理方法。

4.2.12. Levine Abstract. The role of federal legislation on breast cancer disparities After the Medicare program began to reimburse providers for screening mammography, mortality from breast cancer among US elderly began to fall. However, rates fell more rapidly among whites, and racial disparities widened. Interestingly, disparities did not widen uniformly across the US. We hypothesize that Medicare law inadvertently favors acquisition of screening mammography services by whites since it defines medical assistance as a cash benefit to pay providers regardless of the extent to which cash is the primary barrier to service acquisition. We propose to use the observed geographic variability in mortality disparities to address this hypothesis. We shall obtain large national samples of Medicare data and SEER-linked Medicare claims data to test the following sub-hypotheses: H-l: Regional and state level characteristics will have a significant effect on mammography utilization after adjusting for individual factors. H-2: The effect of regional and state level characteristics on mammography utilization will be different for African American and White women. H-3: The region having the greatest equitability for screening mammography utilization will be more likely to have programs in place aiming to increase mammography utilization and reduce disparities. H-4: Relative to places with moderate to high levels of success, failing places will be more likely to have low survival from breast cancer, and greater percentage increase in racial disparity in survival over time. H-5: Relative to places that are failing or have moderate to high screening mammography utilization, exceptionally successful places will be more likely to have high survival from breast cancer, and to have greater percentage reduction in racial disparity in survival over time. We believe there are compelling reasons to address the proposed hypotheses using alternative means as soon as possible: (a) thousands of deaths from breast cancer among the elderly may have already occurred or will occur because of unintended, adverse effects traceable to Medicare's definition of medical assistance as cash to pay providers; (b) breast cancer may be the tip of the iceberg, particularly with the advent of new programs to provide cash for prescription drugs as part of Medicare; and (c) there may be wider implications as regards the observed declines[2] in US position relative to other industrialized nations for life expectancy and other key measures. The project also proposes reasonable means for obtaining preliminary answers that will be useful for policy makers.