Startling Cost Barriers After Abnormal Screening Mammogram

Startling Cost Barriers After Abnormal Screening Mammogram


Despite federal legislation doing away with cost-sharing for initial breast cancer screening, out-of-pocket costs for needed follow-up tests remain significant financial barriers for many women.

An analysis of claims data found that women with higher cost-sharing undergo fewer subsequent breast diagnostic tests after an abnormal screening mammogram compared with peers with lower cost-sharing.

“The chief clinical implication is that women with abnormal mammograms — that is, potentially at risk for cancer — are deciding not to follow-up on diagnostic imaging because of high out-of-pocket costs,” Danny Hughes, PhD, professor, College of Health Solutions, Arizona State University in Phoenix, told Medscape Medical News.

One course of action for radiologists is to “strongly communicate the importance of adhering to recommended follow-on testing,” Hughes said.

Another is to “work to pass national and state legislation, such as recently passed [legislation] in Connecticut, that removes out-of-pocket costs for follow-on diagnostic breast imaging and biopsy in the same way that these patient costs are prohibited for screening mammography,” he suggested.

The study was published online March 27 in JAMA Network Open.

Worrisome Findings

The Affordable Care Act removed out-of-pocket costs for preventive healthcare, such as screening mammograms in women aged 40 and over.

However, lingering cost barriers remain for some individuals who have a positive initial screening mammogram and need follow-up tests. For instance, research shows that women in high-deductible plans, which often have higher out-of-pocket costs than other plans, may experience delays in follow-on care, including diagnostic breast imaging.

Hughes and colleagues examined the association between the degree of patient cost-sharing across different health plans — those dominated by copays, coinsurance, or deductibles as well as those classified as balanced across the three categories — and the use of diagnostic breast cancer imaging after a screening mammogram.

The data came from Optum’s database of administrative health claims for members of large commercial and Medicare Advantage health plans. The team used a machine learning algorithm to rank patient insurance plans by type of cost-sharing.

The sample included 230,845 mostly White (71%) women 40 years and older with no prior history of breast cancer who underwent screening mammography. These women were covered by 22,828 distinct insurance plans associated with roughly 6 million enrollees and nearly 45 million distinct medical claims.

Plans dominated by coinsurance had the lowest average out-of-pocket costs ($945), followed by plans balanced across the three cost-sharing categories ($1017), plans dominated by copays ($1020), and plans dominated by deductibles ($1186).

Compared with women with coinsurance plans, those with copay- and deductible-dominated plans underwent significantly fewer subsequent breast-imaging procedures — 24 and 16 fewer procedures per 1000 women, respectively.

Use of follow-on breast MRI was nearly 24% lower among women in plans with the highest cost-sharing versus those in plans with the lowest cost-sharing.

The team found no statistically significant difference in breast biopsy use between plan types.

Considering the risks posed by an unconfirmed positive mammogram result, these findings are “startling” and question the efficacy of legislation that eliminated cost-sharing from many preventive services, including screening mammograms, Hughes and colleagues write.  

“Additional policy changes, such as removing cost-sharing for subsequent tests after abnormal screening results or bundling all breast cancer diagnostic testing into a single reimbursement, may provide avenues to mitigate these financial barriers to care,” the authors add.

The authors of an accompanying editorial found the study’s main finding — that some women who have an abnormal result on a mammogram may not get appropriate follow-up because of cost — is “worrisome.” 

“From a population health perspective, failure to complete the screening process limits the program’s effectiveness and likely exacerbates health disparities,” write Ilana Richman, MD, with Yale School of Medicine, New Haven, Connecticut, and A. Mark Fendrick, MD, with the University of Michigan, Ann Arbor.

“On an individual level, high out-of-pocket costs may directly contribute to worse health outcomes or require individuals to use scarce financial resources that may otherwise be used for critical items such as food or rent,” Richman and Fendrick add. And “the removal of financial barriers for the entire breast cancer screening process has potential to improve total screening uptake and follow-up rates.”

Support for the study was provided by the Harvey L. Neiman Health Policy Institute. Hughes has reported no relevant financial relationships. Richman has reported receiving salary support from the Centers for Medicare & Medicaid Services (CMS) to develop healthcare quality measures outside the submitted work. Fendrick has reported serving as a consultant for AbbVie, Amgen, Bayer, CareFirst, BlueCross BlueShield, Centivo, Community Oncology Association, Covered California, EmblemHealth, Exact Sciences, GRAIL, Harvard University, HealthCorum, Hygieia, Johnson & Johnson, MedZed, Merck, Mercer, Montana Health Cooperative, Phathom Pharmaceuticals, Proton Intelligence, RA Capital, Teladoc Health, US Department of Defense, Virginia Center for Health Innovation, Washington Health Benefit Exchange, Wildflower Health, and Yale-New Haven Health System; and serving as a consultant for and holding equity in Health at Scale Technologies, Pair Team, Sempre Health, Silver Fern Health, and Wellth.

JAMA Netw Open. 2023;6:e234893, e234898. Article, Editorial

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