Medicare Mammography Study Shows Black Women Had Less Initial Access to Imaging Advances than White Women

In a large retrospective review of over four million Medicare claims, researchers found that Black women were 16 percent less likely to have access to digital breast tomosynthesis than White women.

Black women were significantly less likely than White women to have access to digital mammography and digital breast tomosynthesis (DBT) during the initial transitions to these imaging advances, according to a newly published study examining over 4 million Medicare claims from a 15-year period from 2005 to 2020.

For the study, recently published in Radiology, researchers reviewed data from 4,028,696 institutional mammography Medicare claims between 2005 and 2020. In comparison to White women, the study authors found that Black women were 20 percent less likely to have digital mammography as opposed to screen film mammography between 2005 and 2008. By 2009, there were no longer differences with access to digital mammography, according to the researchers.

Between 2015 to 2020, the researchers pointed out that Black women were 16 percent less likely than White women to have DBT. Noting an ongoing transition to DBT, the researchers said the differences with DBT access have started to subside in recent years.

“Organizations have a responsibility to be equitable in the provision of care. The ability for them to do so will be enhanced by reimbursement policies that facilitate investing in sites that serve disadvantaged individuals,” wrote lead study author Eric W. Christensen, Ph.D., the principal research scientist in Health Economics for the Harvey L. Neiman Health Policy Institute and adjunct professor of Health Services Management at the University of Minnesota, and colleagues. “The fact that the racial differences for digital mammography were transitory and subsided as new technology became universal supports the real potential for such policy changes to mitigate transitional disparities associated with technological advances.”

The study authors pointed out that costs, reimbursement, and insurance status play significant roles in the adoption of new imaging technologies. While the increased costs and Medicare reimbursement associated with DBT were relatively similar percentage-wise in contrast to full-field digital mammography (FFDM) in 2015, Christensen and colleagues pointed out that the increased interpretation time for DBT may lead to a lower reimbursement/cost ratio for DBT in comparison to FFDM. They also noted that a higher percentage of patients with private insurance at a given facility increases the facility’s ability to absorb the costs of adopting new technologies.

“Current incentives may drive the differences observed herein that result in racial disparities not because systems intentionally discriminate but because the economic incentives associated with private-public payer mix and Medicare reimbursement policy influence how technology diffuses,” noted Dr. Christensen and colleagues.

In an accompanying editorial, Christoph Lee, M.D., and Marissa Lawson, M.D., noted that while the majority of mammography centers now offer DBT, other institutions may not have DBT due to the high costs associated with replacing existing imaging modalities.

Pointing out that the mean age of the study’s Medicare population was 72, Drs. Lee and Lawson suggested that future research examine a younger population’s ability to access newer mammography technologies while balancing possible out-of-pocket costs and work-life priorities. Assessing the impact of social determinants of health may facilitate a well-rounded examination of health inequities as they relate to the use of new advances in mammography screening, according to Dr. Lee, a professor of radiology at the University of Washington School of Medicine, and Dr. Lawson, an acting instructor in the Department of Radiology at the University of Washington School of Medicine.

In regard to study limitations, Christensen and colleagues noted the use of organizational national provider identifications (NPIs) to determine where patients received a mammogram may not reflect site-specific differences in transitions with mammography screening within a multi-site health-care system. They acknowledged that the DBT findings are preliminary as not all radiology practices have transitioned from digital mammography to DBT.

The study’s focus on data from a Medicare fee-for-service database precluded any assessment of newer mammography modality use among women with private or Medicaid insurance, according to the study authors.