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This interaction allows the managed care spillover estimate to vary with state regulatory conditions.
The change in managed care spillover effects reflects the gradual acceptance of endoscopic CRC screening procedures, as they emerged as the gold standard during the period.
The statistical modeling estimates a national managed care spillover effect on both BC and CRC screening, which is modified by local state insurance regulations through a cross-level interaction effect.
As regards CRC screening, researchers examined 1999 data covering the traditional FFS Medicare population in the largest US counties and found evidence of a positive national managed care spillover associated with higher utilization of endoscopic CRC screening [21].
The data show that annual utilization rates of endoscopy among FFS Medicare enrollees did increase over time, and findings suggest that managed care spillover effects did increase over time (from retraining to non-restraining).
Recent papers have shown that ignoring spatial spillovers can yield highly inflated estimates of the marginal impact of living in rural poverty on preventive care service utilization by the elderly, misleading antitrust prescriptions, and inflated estimates of managed care spillover effects [5, 31, 32].
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The economic argument for managed care spillovers is as follows.
We found that managed care spillovers were significantly higher in the unregulated markets.
However, as suggested by other studies [17],[22], the magnitude of these managed care spillovers was expected to vary across states.
In addition to these direct effects, there is significant evidence of managed care spillovers onto other market constituents.
With particular relevance to this study, managed care spillovers can impact adherence to CRC screening guidelines by patients, irrespective of whether they are enrolled in managed care plans.
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