Patients with high out-of-pocket healthcare costs for breast cancer screening may miss important follow-up tests, leading to missed cancer diagnoses, according to research in JAMA Network Open. The Affordable Care Act requires preventive screening to be free for all types of health insurance plans, but coverage only extends to mammograms and not to follow-up tests like biopsies or diagnostic breast imaging. Patients are responsible for cost-sharing related to follow-up tests, and the study found that higher out-of-pocket costs correlated with lower rates of access to follow-up tests.
The cost-sharing and high out-of-pocket healthcare costs for breast cancer screening may deter patients from seeking the follow-up tests they require, resulting in missed cancer diagnoses, according to research published in JAMA Network Open. While preventive screening is an essential aspect of healthcare in the United States, it is only free for patients with all types of health insurance plans, and for breast cancer screening, this coverage only includes mammograms and excludes any follow-up testing, such as diagnostic breast imaging or biopsies. Patients are responsible for any cost-sharing that may be part of their health payer coverage for those tests.
Although cost-sharing is a common mechanism by which health insurance companies encourage healthy behavior and limit healthcare utilization among members, the current setup in which patients are responsible for some of the cost of follow-up cancer screening could have negative consequences. The researchers found that if patient concerns regarding out-of-pocket costs (OOPCs) are discouraging women from undergoing recommended follow-on testing, this has the potential to negatively affect outcomes for a significant number of those who require follow-up testing after the initial test.
The study examined over 200,000 women between the ages of 40 and 64 who underwent a mammogram to assess how their insurance type, as measured by the level of cost-sharing, affected their access to recommended follow-up tests. The researchers looked at insurance plans characterized by copays, coinsurance, or deductibles and patients with insurance plans that balance all three cost-sharing frameworks. The researchers found that having coinsurance resulted in lower out-of-pocket costs for follow-up tests than plans characterized by copays or deductibles. Health plans modeled by coinsurance had a mean of $945 for follow-up breast cancer testing, compared to $1017 in out-of-pocket costs for balanced plans, $1020 for plans dominated by copays, and $1186 for high-deductible health plans.
As predicted by the researchers, there was a correlation between higher out-of-pocket costs and the rate at which patients accessed follow-up testing. While patients typically did not defer care when they were referred to a breast biopsy, they did when they were referred to breast imaging. Patients with coinsurance plans were the most likely to access follow-up tests, whereas there were only 24 breast imaging procedures per 1,000 women in dominantly copay plans and only 16 procedures per 1,000 women in high-deductible health plans. These findings were more pronounced when looking at MRIs, the most expensive type of breast imaging available.
The researchers emphasized that these findings demonstrate how high out-of-pocket costs affect patient care access. Many patients may believe that preventive screenings, including every step of the screening, such as follow-up tests, are covered under their insurance. Upon learning otherwise, women often skip imaging follow-ups, which the researchers suggested could lead to negative outcomes for women who ultimately test positive for breast cancer.
These findings underscore the need for health policy change, according to the researchers. Lawmakers could first expand preventive screening coverage to include potential follow-up tests, such as biopsies and imaging. This has already been done for other types of cancer screening, such as colorectal cancer screening. Alternatively, policymakers could bundle screening mammograms with other follow-up procedures. The researchers suggested that these bundles produce negligible price increases but remove financial barriers for patients.
The researchers concluded that, despite policies aimed at removing financial barriers to access for breast cancer screening, significant financial barriers remain for women at risk of an abnormal screening test. Additional policy changes, such as removing cost-sharing for subsequent tests after abnormal screening results or bundling all breast cancer diagnostic testing into a single reimbursement, may provide avenues to mitigate these financial barriers to care.
