title: Modestly increased use of colonoscopy when copayments are waived.
abstract: OBJECTIVE
  Colorectal cancer (CRC) screening with colonoscopy often requires expensive copayments from patients. The 2010 Patient Protection and Affordable Care Act mandated elimination of copayments for CRC screening, including colonoscopy, but little is known about the effects of copayment elimination on use. The University of Texas employee, retiree, and dependent health plan instituted and promoted a waiver of copayments for screening colonoscopies in fiscal year (FY) 2009; we examined the effects of removing cost sharing on colonoscopy use.
  
  
  METHODS
  We conducted a retrospective cohort study of 59,855 beneficiaries of the University of Texas employee, retiree, and dependent health plan, associated with 16 University of Texas health and nonhealth campuses, ages 50-64 years at any point in FYs 2002-2009 (267,191 person-years of follow-up evaluation). The primary outcome was colonoscopy incidence among individuals with no prior colonoscopy. We compared the age- and sex-standardized incidence ratios for colonoscopy in FY 2009 (after the copayment waiver) with the expected incidence for FY 2009, based on secular trends from years before the waiver.
  
  
  RESULTS
  The annual incidence of colonoscopy increased to 9.5% after the copayment was waived, compared with an expected incidence of 8.0% (standardized incidence ratio, 1.18; 95% confidence interval, 1.14-1.23; P < .001). After adjusting for age, sex, and beneficiary status, the copayment waiver remained significantly associated with greater use of colonoscopy, with an adjusted hazard ratio of 1.19 (95% confidence interval, 1.12-1.26).
  
  
  CONCLUSIONS
  Waiving copayments for colonoscopy screening results in a statistically significant, but modest (1.5%), increase in use. Additional strategies beyond removing financial disincentives are needed to increase use of CRC screening.
authors.affiliation: Department of Internal Medicine, University of California San Diego, San Diego, California, USA.
authors.forename: Shabnam
authors.initials: S
authors.lastname: Khatami
authors.forename: Lei
authors.initials: L
authors.lastname: Xuan
authors.forename: Rolando
authors.initials: R
authors.lastname: Roman
authors.forename: Song
authors.initials: S
authors.lastname: Zhang
authors.forename: Charles
authors.initials: C
authors.lastname: McConnel
authors.forename: Ethan A
authors.initials: EA
authors.lastname: Halm
authors.forename: Samir
authors.initials: S
authors.lastname: Gupta
mesh_terms: D015331:Cohort Studies; D003113:Colonoscopy / Q000191:economics* / Q000639:trends*; D015179:Colorectal Neoplasms / Q000175:diagnosis*; D005249:Fees and Charges; D005260:Female; D006801:Humans; D008297:Male; D008403:Mass Screening / Q000191:economics* / Q000639:trends*; D008875:Middle Aged; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D013781:Texas; D014495:Universities