Copayments discourage women from receiving screening mammography

January 29, 2008

Experienced mammographers are concerned that managed care insurers increasingly require copayments and coinsurance fees for screening mammography. The trend is discouraging women from receiving the potentially life-saving imaging procedure.

Experienced mammographers are concerned that managed care insurers increasingly require copayments and coinsurance fees for screening mammography. The trend is discouraging women from receiving the potentially life-saving imaging procedure.

Dr. Amal Trivedi and colleagues at Brown University uncovered the pattern as they reviewed coverage from 2001 to 2004 for 174 Medicare managed care plans and screening mammography utilization for their beneficiaries, more than 550,000 women aged 65 to 69. The study was published in the Jan. 24 New England Journal of Medicine (2008:358:375-383).

They found that the number of Medicare managed care plans that required a copayment of at least $12.50 (range: $12.50 to $35) or coinsurance of more than 10% for screening mammography rose steadily from year to year. Twenty-one plans enforced the requirements in 2004, up from three plans in 2001.

For those plans, the biennial breast cancer screening rates at the end of the period were 8.3 percentage points lower than for Medicare managed care plans that provided full coverage (77.5% for full coverage versus 69.2% for cost-shared plans). Biennial screening mammography increased 3.4% in the four-year study period for women who participated in the plans that did not require copayments or coinsurance.

The effect of cost sharing was magnified among women with incomes below the poverty line and for those who had not attended college.

"It's dramatic to think that a relatively small copayment - $10, $20 - would cause women to choose not to get a mammogram," Dr. Peter B. Bach, an epidemiologist with the Health Outcomes Research Group at Memorial Sloan-Kettering Cancer Center, told Diagnostic Imaging. "They are opting out of the service, even though it's one of the best we have."

In an editorial accompanying the study, Bach observed that a central premise of high-deductible managed care plans - in which third-party insurers increase cost sharing to reduce unnecessary or ineffective procedures - is that patients will take more responsibility for their own health and will seek high-quality and efficient providers, because they will save money by doing so. Results from Trivedi's study challenge that assumption.

"A knowledgeable consumer would opt for services that deliver value for a dollar. In the plans studied by Trivedi et al, mammography was a good value, with a meaningful gain in life expectancy available at a cost to patients of only $10 to $20 per mammogram," Bach said.

Oncology nurse Linnea Brown, breast health coordinator for the AtlantiCare Healthcare System in southern New Jersey, worries that breast cancer death rates could rise because copayments discourage poor and middle-class women from routine screening.

"Mammograms don't prevent breast cancer, but they can find it much earlier, and early detection is the key," she said. "We could see mortality rates increase, even though the incidence of breast cancer has gone down."

Dr. Carol H. Lee, chair of the American College of Radiology's breast imaging commission, noted that breast cancer mortality has dropped about 25% among women who undergo routine screening and that the ability of mammograms to detect breast cancer increases with the patient's age. These and other factors suggest to Lee that copayments could ultimately cost the managed care insurers and Medicare more money than they save.

"We are taking a segment of the population in whom the test works best and adding a disincentive to getting it. Given limited healthcare resources and limited dollars, perhaps this is not the best place to save money," she said.

Based on the study's results, Bach concluded the copayments encourage women to make poor healthcare decisions.

"There has been a pretty well-documented phenomenon that cost sharing decreases the utilization of services, so you don't do it with services you want people to have," Bach said. "That's the key metric, not to drive down premiums, but because it is an appropriate use of a healthcare resource."

For more information from the Diagnostic Imaging archives:

Demand skyrockets for digital mammography

Mammography waiting times reach crisis level in southern states

Study bolsters case for breast MRI screening

Internists' incendiary advice reopens old wounds