Patient Cost-Sharing and Utilization of Breast Cancer Diagnostic Imaging by Patients Undergoing Subsequent Testing After a Screening Mammogram

Abstract

ImportanceOut-of-pocket costs (OOPCs) have been largely eliminated for screening mammography. However, patients still face OOPCs when undergoing subsequent diagnostic tests after the initial screening, which represents a potential barrier to those who require follow-up testing after initial testing.ObjectiveTo examine the association between the degree of patient cost-sharing and the use of diagnostic breast cancer imaging after undergoing a screening mammogram.Design, Setting, and ParticipantsThis retrospective cohort study used medical claims from Optum’s deidentified Clinformatics Data Mart Database, a commercial claims database derived from a database of administrative health claims for members of large commercial and Medicare Advantage health plans. The large commercially insured cohort included female patients aged 40 years or older with no prior history of breast cancer undergoing a screening mammogram examination. Data were collected from January 1, 2015, to December 31, 2017, and analysis was conducted from January 2021 to September 2022.ExposuresA k-means clustering machine learning algorithm was used to classify patient insurance plans by dominant cost-sharing mechanism. Plan types were then ranked by OOPCs.Main Outcomes and MeasuresA multivariable 2-part hurdle regression model was used to examine the association between patient OOPCs and the number and type of diagnostic breast services undergone by patients observed to undergo subsequent testing.ResultsIn our sample, 230 845 women (220 023 [95.3%] aged 40 to 64 years; 16 810 [7.3%] Black, 16 398 [7.1%] Hispanic, and 164 702 [71.3%] White) underwent a screening mammogram in 2016. These patients were covered by 22 828 distinct insurance plans associated with 6 025 741 enrollees and 44 911 473 distinct medical claims. Plans dominated by coinsurance were found to have the lowest mean (SD) OOPCs ($945 [$1456]), followed by balanced plans ($1017 [$1386]), plans dominated by copays ($1020 [$1408]), and plans dominated by deductibles ($1186 [$1522]). Women underwent significantly fewer subsequent breast imaging procedures in dominantly copay (24 [95% CI, 11-37] procedures per 1000 women) and dominantly deductible (16 [95% CI, 5-28] procedures per 1000 women) plans compared with coinsurance plans. Patients from all plan types underwent fewer breast magnetic resonance imaging (MRI) scans than patients in the lowest OOPC plan (balanced, 5 [95% CI, 2-12] MRIs per 1000 women; copay, 6 [95% CI, 3-6] MRI per 100 women; deductible, 6 [95% CI, 3-9] MRIs per 1000 women.Conclusions and RelevanceDespite policies designed to remove financial barriers to access for breast cancer screening, significant financial barriers remain for women at risk of breast cancer.

American Cancer Society’s report on the status of cancer disparities in the United States, 2023

“…Differences in stage at diagnosis comprise a major contributing factor to disparities in cancer survival and mortality. 58 screening tests [60][61][62] and receipt of surveillance testing or screening for other cancers among cancer survivors. [63][64][65] Disparities in access to care for following suspicious symptoms can also result in disparities in stage at diagnosis of cancers for which routine screening is not recommended.…”

“…104,105 Without Health Savings Accounts, which allow pretax contributions to qualified health care expenses, they are also more likely to forgo subsequent diagnostic tests after abnormal cancer screening test results or to delay or forgo cancer care. 61,106 Disruptions in health insurance coverage have also been associated…”

Eliminating Financial Barriers to Breast Cancer Screening—When Free Is Not Really Free

“…Elsewhere in JAMA Network Open , Hughes and colleagues used a machine learning algorithm to identify patterns of cost-sharing in various health plan types. The authors then assessed how these predominant cost-sharing patterns were associated with the rate of follow-up testing after an abnormal result on a screening mammogram .…”

“…Elsewhere in JAMA Network Open , Hughes and colleagues used a machine learning algorithm to identify patterns of cost-sharing in various health plan types. The authors then assessed how these predominant cost-sharing patterns were associated with the rate of follow-up testing after an abnormal result on a screening mammogram . The study found a clear pattern: compared with individuals enrolled in plans with lower cost-sharing, patients in higher cost-sharing plans had lower rates of follow-up breast imaging after screening.…”

“…The study by Hughes and colleagues adds to a robust literature that demonstrates that cost-sharing strategies—such as copayments and deductibles—are frequently implemented as a blunt instrument and reduce use of both high- and low-value clinical services. Policy reforms could correct this shortcoming by eliminating cost-sharing for the entire screening process for those cancers for which the initial tests are fully covered.…”