Abstract IA28: Rural disparities in uptake of well visits and access to cancer screening in Medicare under the Affordable Care Act
Authors: Anderson Roger T. , Camacho Fabian , Yao Aaron 
Published: February 2019

Abstract
Background: Under the Affordable Care Act (ACA), Medicare beneficiaries can receive annual wellness visits (AWV) to configure or update a personalized prevention plan. Previous data show the use of AWVs rose from about 7 percent overall (3.2 million visits) in 2011 to 20 percent (10.4 million visits) in 2016, but patterns of rural uptake of AWV have not been examined nor their potential to reduce rural disparities in cancer screening.
Methods: We examined physician and outpatient claims for rural and urban beneficiaries enrolled in Medicare 5% FFS (“Fee for Service”) from 2011-2014 among beneficiaries with &gt;1 year prior enrollment. Beneficiaries were classified into three groups based on previous care patterns: patients with annual health care visits but no AWV (controls); those without previous screening but who attended a subsequent AWV; and those with a previous screening episode with a subsequent AWV. Confounders considered included beneficiary race (white, black, other), gender, age category at reference, Charlson comorbidity score, reference date, National County Economic Distress from Appalachian Regional Commission, and NCHS rural urban status. Outcomes included receipt of colorectal (CRC) and breast (BC) cancer screenings, as well as a bundle of 7 recommended preventative services relating to cardiovascular disease, cancer, diabetes, and bone density.
Results: Per beneficiary, AWVs were more likely to occur in metropolitan regions and regions with higher socioeconomic indices, along with individual characteristics such as white ethnicity, female gender, and older age groups. By 2014, the AWV utilization rates in metropolitan residents were 60% higher than rural residents. For both urban and rural US populations, screening access for those without an AWV was significantly lower than with an AWV. For CRC and BC screening, having an AWV was associated with a greater than two-fold increase screening compared to controls (p &lt; .001). Only 20% of the control group had 1 of 7 possible preventive services examined compared to &gt; 80% of the other patient groups. We examine evidence of the impact of ACA on access to screening in rural Appalachia to identify policy and implementation research solutions for the well-documented higher late-stage cancer burden in this region.
Conclusions: Our findings strongly suggest that AWVs can be used to reduce disparities in preventive services, such as cancer screenings and vaccinations, especially in disadvantaged groups that tend to lack prior preventive services. However, rural beneficiaries have fewer opportunities to have an AWV. Policies to increase AWV penetration may involve increasing access through community health workers, practice-based supports, and increased financial incentives. Given the size of the screening effects found in this study together with the underutilization of AWV by rural populations, we believe policy seeking to expand the use of AWVs may help with early detection of cancer to improve survival.
Citation Format: Roger T. Anderson, Fabian Camacho, Aaron Yao. Rural disparities in uptake of well visits and access to cancer screening in Medicare under the Affordable Care Act [abstract]. In: Proceedings of the Tenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2017 Sep 25-28; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2018;27(7 Suppl):Abstract nr IA28.