Out-of-pocket mammogram costs discourage follow-up screening

By Amerigo Allegretto, AuntMinnie.com staff writer

November 10, 2021 -- Despite the Affordable Care Act (ACA) eliminating cost sharing, about 5% of privately insured women receiving their first mammogram still faced out-of-pocket spending, according to research published November 5 in the Journal of the American College of Radiology.

A team led by Linh Tran from Penn State University attributed this to grandfathered insurance plans or mammograms coded as diagnostic and not covered by the policy. They also found that just under 14% of women experienced such spending due to follow-up testing.

"Worryingly, we found that women who experienced out-of-pocket spending as part of their first screening mammogram were significantly less likely to receive subsequent screening mammograms in the next 12 to 24 months. Although some of this dip was made up between months 24 to 36," Tran et al told AuntMinnie.com.

About one-third of U.S. women over the age of 40 have not received a mammogram within the past two years, despite the overall increase in mammography use over the past decade, the study authors said. Previous research suggests that cost is the most common barrier for women deciding whether to receive a mammogram. This includes concerns for uninsured women or women who are insured through health plans with high cost sharing.

The ACA requires Medicare and all private health insurance plans that weren't grandfathered under ACA to fully cover screening mammograms without any out-of-pocket expense for women 40 and older starting in late 2010. However, out-of-pocket costs can still come up if women are in grandfathered plans, need follow-up imaging, or get out-of-network preventive services.

Tran and colleagues wanted to find out whether out-of-pocket spending may influence subsequent screening decisions in the following 12 to 36 months among women first undergoing breast cancer screening in the period after ACA implementation.

They also wanted to study how the impact of out-of-pocket spending on subsequent screening may differ if such spending arises from the screening mammogram itself versus follow-up diagnostic testing.

The researchers looked at MarketScan claims data from 73,389 enrollees. Out of the total, 69,770 had no out-of-pocket expenditures for baseline screening mammograms and 3,619 women, or about 5%, had to pay out of pocket.

The team found that having any out-of-pocket payments for baseline screening mammograms significantly reduced the probability of screening in the subsequent 12 to 24 months by three percentage points.

Any out-of-pocket spending for follow-up tests resulting from baseline screening led to a lower probability of screening 12 to 24 months later by 2.7 percentage points. Higher out-of-pocket expenses were linked to significantly lower screening 24 to 36 months later.

For every $100 increase in out-of-pocket expenses for baseline mammograms, the women were found to be nearly two percentage points less likely to attend follow-up breast screening.

The study authors did not have data for patient race, ethnicity, or ZIP code information to adjust for disparities in mammography. However, Tran and colleagues wrote that reducing or eliminating cost sharing through policy and legislation may help with continued adherence to breast screening guidelines.

"Our results point to the importance of policies that also fully cover follow-up tests in order to ensure patients do not face unexpected cost-sharing which can impact decisions about subsequent screening," Tran et al told AuntMinnie.com.

They also said the team is working on related areas of research. These include continuing to study whether more recent data show similar results and how evolving health policies may impact out-of-pocket costs patients face for cancer screening. The researchers are also studying how dense breast notification laws may impact use of follow-up testing and how that impacts out-of-pocket costs.

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