High Out-of-Pocket Costs Mean Fewer Follow-Up Tests After Abnormal Mammogram
After an abnormal mammogram, women who have high out-of-pocket costs for follow-up tests are less likely to get those tests, according to two separate studies.
One study was published online on March 27, 2023, by the journal JAMA Network Open. Read “Patient Cost-Sharing and Utilization of Breast Cancer Diagnostic Imaging by Patients Undergoing Subsequent Testing After a Screening Mammogram.”
The other study was published on April 4, 2023, by the journal Radiology. Read the abstract of “Effect of a High-Deductible Health Plan on Patients’ Willingness to Undergo Indicated Breast Imaging.”
Getting called back after a screening mammogram
Getting called back for more imaging after a screening mammogram is fairly common. Although it can be scary and upsetting, it doesn’t mean you have breast cancer. According to statistics from the American Cancer Society, fewer than one in 10 women called back for more tests are diagnosed with breast cancer.
There are a number of reasons you might be called back, including:
The initial mammogram image isn’t clear and needs to be redone.
It’s your very first mammogram and the radiologist wants to take a closer look because there are no other images for comparison.
You have dense breasts, which can make it harder to see parts of your breast on a mammogram.
You have a cyst in your breast. Cysts are not cancer, but look like a mass on a mammogram.
You have calcifications in your breasts. Calcifications are tiny calcium deposits that may or may not be related to cancer.
At your follow-up appointment, the tests you have are based on your age, your personal breast cancer risk, and the radiologist’s recommendations. Follow-up tests may include a:
diagnostic mammogram, which includes more images of the breast than a screening mammogram
breast ultrasound
Based on the results of the follow-up imaging tests, your doctor or the radiologist may recommend a biopsy to definitively determine whether or not there is cancer in your breast.
About the studies
Although most women have no out-of-pocket costs for a screening mammogram, many women have to pay something for additional tests if they’re called back after a mammogram. In both studies, the researchers wanted to know if the amount a woman had to pay for follow-up testing affected how likely she was to have the follow-up testing.
The researchers looked at the records of 230,845 women ages 40 and older who were enrolled in the same commercial health insurance plan during the time of the study, from 2015 to 2017:
71.3% were white
7.3% were Black
7.1% were Hispanic
3.6% were Asian
10.7% were of an unknown race or ethnicity
The women were covered by 22,828 different health insurance plans.
The information came from the Optum Clinformatics Data Mart, which contains health insurance claims for members of large commercial healthcare plans and Medicare Advantage health plans.
The researchers classified the health insurance plans by the main type of out-of-pocket spending they required:
co-pays
co-insurance
deductibles
balanced between the three types of out-of-pocket spending
Overall:
58.3% were co-pays
20.7% were balanced
12.7% were deductibles
8.2% were co-insurance
Most of the people in the study were in deductible plans:
50.3% were in deductible plans
21.5% were in balanced plans
14.7% were in co-pay plans
13.4% were in co-insurance plans
The researchers found that average out-of-pocket costs for all medical services were lowest for co-insurance plans and highest for deductible plans. Average out-of-pocket costs for all medical services were:
$945.36 for co-insurance plans
$1,017.07 for balanced plans
$1,020.31 for co-pay plans
$1,186.02 for deductible plans
All the women had a screening mammogram in 2016; 25,073 (10.9%) had additional diagnostic imaging.
Women who had additional imaging paid an average of $75.24 in out-of-pocket costs for breast imaging and an average of $1,401.54 in annual out-of-pocket costs for all medical services.
Women who didn’t have additional imaging paid an average of $1.13 in out-of-pocket costs for breast imaging and an average of $1,055.42 in out-of-pocket costs for all medical services.
The researchers’ analysis showed that women who had higher out-of-pocket costs for follow-up testing had fewer follow-up tests:
Women in co-pay plans had an average of 24 fewer follow-up imaging tests per 1,000 people than women in co-insurance plans. This difference was statistically significant, which means that it was likely due to the difference in plans and not just because of chance.
Women in deductible plans had 16 fewer follow-up imaging tests per 1,000 people than women in co-insurance plans. This difference also was statistically significant.
Women in balanced plans had seven fewer follow-up imaging tests per 1,000 people than women in co-insurance plans.
This link between higher out-of-pocket costs and less follow-up testing was especially notable with breast MRI:
Women in co-pay and deductible plans had six fewer breast MRIs per 1,000 people than women in co-insurance plans.
Women in balanced plans had five fewer breast MRIs per 1,000 people than women in co-insurance plans.
All these differences were statistically significant.
“Considering the risk posed by an unconfirmed positive mammogram result, this is a startling finding that questions the efficacy of legislation such as PALS [the Protecting Access to Lifesaving Screenings Act] and ACA [the Affordable Care Act], which eliminated cost-sharing from many preventive services, such as screening mammograms, precisely to remove financial barriers that inhibit patients from receiving these important life-saving services,” the researchers wrote. “Additionally, because most abnormal results from screening mammograms are ultimately costly false positives, strictly adhering to physician recommendations financially penalizes patients with abnormal screening results.
“This may be important information for consumers when assessing the trade-off between different plans’ cost-sharing mechanisms and premiums when making insurance decisions.”
The researchers surveyed 844 women having a screening mammogram at Boston Medical Center between September 2021 and February 2022. The survey asked about the women’s:
age
race or ethnicity
education level
annual household income
insurance plan, including deductibles and co-pays
different scenarios about breast imaging
Not all the women answered all the survey questions.
Among the women in the study:
270 were Black
256 were white
91 were Hispanic
74 were of another race or ethnicity
155 had a high school education or less
369 had a college degree or attended college
143 had a graduate degree
185 had an annual household income of less than $35,000
180 had an annual household income of $35,000 to $80,000
158 had an annual household income of $80,000 or more
324 had employer-provided insurance
216 had Medicaid or no insurance
94 had Medicare insurance
45 had marketplace insurance
Of the 714 women who responded to the scenario, “If I knew I had to pay a deductible for the additional imaging [to make sure my screening mammogram is normal], I would skip this additional imaging”:
21.1% agreed with the statement
59.4% disagreed with the statement
19.5% were undecided
The groups with the highest percentage of women who would skip additional imaging were:
women who identified as Hispanic
women who had a high school education or less
women with an annual household income of less than $35,000
women with Medicaid or no insurance
Women with employer-provided insurance were the least likely to agree to skip additional imaging.
Of the 707 women who responded to the scenario, “If I knew that I had to pay a deductible for follow-up tests, such as imaging or biopsy, after screening mammogram, I would not undergo screening for breast cancer”:
18.2% agreed with the statement
65.8% disagreed with the statement
16% were undecided
The groups most likely to skip screening mammograms were:
women who identified as another race or ethnicity
women who had a high school education or less
women with an annual household income of $35,000 or less
women with Medicaid or no insurance
“The patients who were more likely to say they would skip diagnostic imaging tended to be racial/ethnic minorities, have a lower educational level, have a lower-income household, are on Medicaid or have no insurance at all,” lead author Michael Ngo, MD, radiology resident at Boston Medical Center and Boston University Chobanian & Avedisian School of Medicine, said in a statement.
“Prior research has shown that these groups tend to already have lower adherence to preventative services, including breast cancer screening, and tend to have worse breast cancer outcomes,” Dr. Ngo continued. “Based on these results, these out-of-pocket payments may account for at least a part of the delay in seeking care. This, in turn, leads to delays in breast cancer diagnosis and treatment, increases overall breast cancer mortality and exacerbates existing gaps in breast cancer care in women who already have financial barriers in care.”
What this means for you
All women — no matter their age, ethnicity, economic status, or insurance status — deserve the best healthcare possible.
The results of these studies are troubling and strongly suggest that even women with health insurance are often skipping follow-up imaging after an abnormal mammogram if they have to pay for the additional imaging.
If you are concerned about paying for follow-up screening and testing after a mammogram, it makes sense to talk to your doctor, a hospital social worker, or a staff member at a mammogram center. Ask about free or low-cost imaging programs and healthcare services in your area.
If your insurance company balks at covering follow-up screening or screening with MRI, talk to your care team and ask if there is a way they can help get the screening covered.
You also can negotiate with someone in the facility’s billing department to get the cost down to an amount you can afford. You also can ask if the facility accepts an interest-free payment plan.
It’s your health and your future, and you deserve the best care possible.
— Last updated on June 5, 2023 at 1:24 PM