Encouraging People to Get Necessary Services

Research published in the Cancer Epidemiology, Biomarkers & Prevention Journal focused on how to increase mammography screening rates among low-income women.    This was a well-designed randomized trial which tested several levels of intervention.   (Mammography Study) The study included over 2300 women age 40 or older who had been noncompliant with recommended screenings and were covered by managed care organizations participating in TennCare.  Note that these women all were fully insured and the mammograms were free–no copays.  One group received usual care, a second group got a reminder letter from the managed care organization’s medical director and the third group had a stepwise intervention that included the letter from the medical director, then a letter from the personal primary care physician, then personal counseling by a peer who had been trained to be an outreach counselor. Each group had about 786 women in it.

It was expected that these women should have started with a screening rate similar to that of the general population since they had insurance and a primary care physician, but their rate was 24%, well below that of the overall population, which is around 70%.  Many of these women had also not had regular physical exams.  The usual care group received 105 screenings or a 13% rate in the year after the trial started, the MCO medical director letter only group had 126 or a 16% rate, and the stepwise group 213 or 27%.  While the stepwise intervention appears better than the usual care group or the single intervention group, the absolute rates are still abysmal, and did not improve the overall rate for this group significantly from what it was before.

While a number of reasons for these results are put forward by theoreticians, one that appears to be ignored is the general failure of many people in this group to take personal responsibility for their health, or for many other aspects of their lives.  These people have much better insurance coverage than the average middle-class American, but can’t manage to get even basic preventive screenings.  Probably a host of socio-cultural factors account for this, but changing behavior clearly won’t be accomplished by ever more intensive and expensive interventions.  The stepwise intervention described in this trial definitely couldn’t have paid for itself.  The best way to get people’s attention is to make it clear that either they get recommended care or they lose coverage.  Period.  The general public shouldn’t pay for the irresponsibility of a few citizens.