• Posted March 31, 2023

Suspicious Mammogram? Out-of-Pocket Costs Keep Some Women From Follow-Up

Breast cancer screening may be free for women with health insurance, but high costs may still keep some from getting needed follow-up tests, a new study finds.

The study, of more than 230,000 U.S. women who underwent screening mammography, found that those in insurance plans with higher out-of-pocket costs were less likely to get follow-up testing after an abnormal screening result.

That testing is necessary to either diagnose breast cancer or rule it out.

Experts said the findings underscore a known and longstanding problem: "Cost-sharing" has been largely eliminated when it comes to breast cancer screening, but that still leaves many women unable to afford the next step.

"We know this is an issue, and we need to push for solutions," said Molly Guthrie, vice president of policy and advocacy for the breast cancer nonprofit Susan G. Komen.

Guthrie, who was not involved in the study, said Komen is advocating for policies to remove the financial barrier.

Some states, she noted, have passed laws to require insurers to cover follow-up tests at no cost. But that only covers women living in those states and in health plans that the states can regulate, Guthrie pointed out.

Federal lawmakers have introduced similar bills to address the issue at the national level. But so far, they have stalled out.

The Affordable Care Act, better known as "Obamacare," eliminated out-of-pocket costs for most U.S. women who are insured and undergo mammography screening. (It did the same for Americans having recommended screenings for colon, cervical and lung cancers.)

That was hailed as a step in the right direction, Guthrie said, but it did not address the costs that patients face after screening detects an abnormality.

In most cases, abnormalities seen on screening mammography turn out not to be cancer. But the only way to know is with diagnostic imaging -- often with another mammogram, or sometimes breast ultrasound or MRI.

Health insurance covers those tests, but plans vary in how much of the bill goes to patients. Some plans, for example, have high deductibles -- the amount of money a patient has to pay for medical services before the insurance kicks in.

"Some plans have a deductible of a few thousand dollars," said Dr. Geraldine McGinty, the senior researcher on the new study.

"When we talk about financial barriers to care, we often focus on people who are uninsured," noted McGinty, a professor of radiology at Weill Cornell Medicine in New York City.

But, she said, health insurance plans have been increasingly relying on cost-sharing in recent years. That can mean a hefty deductible, or having patients pay for a portion of each medical service -- through copayments (a flat fee) or coinsurance (a percentage of the total cost).

"There's a greater burden on patients now than there used to be," McGinty said.

For the current study, her team analyzed data on more than 230,000 U.S. women who had a screening mammogram in 2016. They belonged to nearly 23,000 different health plans, and the researchers grouped those plans according to how they approached cost-sharing.

They found that plans that mainly used deductibles to charge patients had the highest out-of-pocket costs, followed by plans that mainly charged copayments. Plans that relied on coinsurance had the lowest out-of-pocket costs.

Overall, women in the two types of plans with the highest out-of-pocket costs were less likely to have diagnostic imaging after a suspicious finding on screening. They had 16 to 24 fewer procedures for every 1,000 women, versus their counterparts in plans with lower out-of-pocket costs.

For women in plans that relied on deductibles, the average out-of-pocket charge for follow-up breast imaging was about $92 -- more than double the average for women in plans that relied on coinsurance.

Some women can manage that, but others can't. So those out-of-pocket costs, Guthrie said, could worsen existing disparities if they deter lower-income women from getting a diagnosis.

She noted that Black women have a somewhat higher rate of breast cancer screening than white women do, but are more likely to die of the disease.

A possible solution, both experts said, is to change how breast cancer screening is defined under Obamacare -- so that recommended follow-up tests carry no out-of-pocket costs. The precedent has been set with colon cancer: Starting this year, Medicare and private insurers must cover a follow-up colonoscopy at no cost for people with an abnormal finding on stool-based screening.

For now, there is financial help available for women who cannot afford follow-up imaging. Guthrie suggested calling Komen's Breast Care Helpline at 1-877 GO KOMEN. And McGinty said that medical centers, like hers, often have financial assistance programs for low-income patients.

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

More information

Susan G. Komen has more on follow-up after an abnormal screening mammogram.

SOURCES: Geraldine McGinty, MD, MBA, professor, clinical radiology, Weill Cornell Medicine, New York City; Molly Guthrie, vice president, policy and advocacy, Susan G. Komen, Dallas; JAMA Network Open, March 27, 2023, online