title: Is cost a barrier to screening mammography for low-income women receiving Medicare benefits? A randomized trial.
abstract: BACKGROUND
  In 1991, Medicare began covering screening mammograms subject to copayment and deductible. This study evaluated the effectiveness of Medicare in removing financial barriers to screening mammography among low-income older women.
  
  
  METHODS
  In an inner-city public hospital's General Medicine Clinic, 119 consecutive, eligible, and consenting Medicare-enrolled women without known risk factors for breast cancer other than age, and no mammogram in the previous 2 years, were entered into a randomized controlled trial with follow-up after 2 months. The mean age was 71 years; 77% were black, 92% had an annual income below $10,000, and 52% had had a previous mammogram. All patients were counseled concerning indications for screening mammograms and Medicare coverage, and all were referred to a low-cost mammography facility. Sixty-one subjects were randomly assigned a voucher for a free screening mammogram at the referral facility. Obtaining a mammogram within 60 days of study entry was the main outcome measure.
  
  
  RESULTS
  Of the women given vouchers, 27 (44%) obtained screening mammograms, compared with six (10%) of those without vouchers (P < .001). Adjustment by multiple logistic regression confirmed this association, yielding an adjusted odds ratio of 7.4 (95% confidence interval, 2.5 to 21.4). Knowledge concerning mammography and breast cancer increased significantly overall (and within randomization groups) between initial interview and follow-up; fear did not change. For women without the voucher, the main reason for not obtaining a mammogram was financial; the main reason for women with the voucher was transportation.
  
  
  CONCLUSIONS
  In a low-income, inner-city population of older women, financial barriers to screening mammography persist despite Medicare coverage.
authors.affiliation: Department of Medicine, Baylor College of Medicine, Ben Taub General Hospital, Houston, Tex.
authors.forename: C I
authors.initials: CI
authors.lastname: Kiefe
authors.forename: S V
authors.initials: SV
authors.lastname: McKay
authors.forename: A
authors.initials: A
authors.lastname: Halevy
authors.forename: B A
authors.initials: BA
authors.lastname: Brody
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D003365:Costs and Cost Analysis; D035082:Federal Government; D005260:Female; D015438:Health Behavior; D007722:Health Knowledge, Attitudes, Practice; D006297:Health Services Accessibility; D006801:Humans; D008327:Mammography / Q000191:economics*; D006278:Medicare; D008875:Middle Aged; D010349:Patient Compliance; D018579:Patient Selection; D011203:Poverty; D012959:Socioeconomic Factors; D014481:United States; D014504:Urban Health