How Coverage Mandates May Impact DBT Breast Cancer Screenings

Insurance coverage mandates for a certain type of breast cancer screening may drive up utilization and lower costs, according to a study published in JAMA Network Open.

Digital breast tomosynthesis (DBT) creates an image of the breast that is practically three-dimensional and that may be more accurate than two-dimensional screenings. But because its benefits and drawbacks are not yet solidified, coverage for this type of screening is not mandatory among certain cancer and preventive care organizations.

The researchers used Blue Cross Blue Shield claims data from women ages 40 to 64 who received a mammogram between 2015 and mid-2019. Ultimately, the study included over 9.6 million screening claims for more than 5.75 million women.

“A central policy objective of coverage mandates is to ensure access to a particular medical technology or service by protecting patients from financial liability. Our results suggest that women in states with coverage mandates were more likely to begin to use DBT for breast cancer screening,” the researchers explained.

The de-identified claims were split into two categories: claims for women who lived in states that mandated coverage of DBT (mandate states) and claims for women living in states that do not mandate coverage (nonmandate states).

During the timeframe of the study, 15 states became mandate states. In mandate states, 16 percent of women who received a mammogram had a DBT screening, while in the 34 nonmandate states 11 percent of women who received a mammogram were screened with DBT.

Requiring coverage for DBT accompanied a boost in utilization. States that enacted a mandate saw DBT utilization jump 7.6 percentage points beyond nonmandate states’ utilization in a single year. Within two years, mandate states’ DBT utilization was 9.0 percentage points above nonmandate states’ utilization rates.

Requiring insurers to cover DBT also accompanied a drop in price for the screening. In mandate states, after two years of having the mandate in effect, the price of DBT screening was $38.70 lower than in nonmandate states.

Only seven percent of women in mandate states and in nonmandate states had any out-of-pocket healthcare spending for DBT screenings and this share did not change significantly across the study period.

“Our study also raises new questions about the mechanism by which mandates are associated with increased use of an emerging technology,” the researchers wrote. “These finding suggest that out-of-pocket payments were rare regardless of whether a mandate was in place and likely were not the primary barrier to DBT use for most women.”

Given that out-of-pocket healthcare spending may not have been the obstacle to receiving DBT screenings but that DBT screening utilization did seem to respond to the coverage mandate, the researchers contemplated an alternative. 

The researchers proposed that mandatory coverage for DBT screenings might reduce hesitancy among radiologists who are unsure about whether they will receive reimbursement for the service. This explanation could account for lower screening costs as well. For example, higher utilization might give insurers greater leverage to negotiate lower prices.

DBT screenings have not been confirmed as a high-value service, so the researchers warned that coverage mandates could proliferate low-value care services. But lower prices in mandate states might indicate that DBT screenings have cost-lowering value.

 “Our findings overall suggest that mandates may encourage DBT use but also may have more complex implications for the associations among technology adoption, price, and value,” the researchers concluded.

Certain preventable cancers—including breast cancer—have been shown to drive national healthcare spending upward. Preventive care services for these patient populations will be crucial to bringing healthcare costs under control.

Separate research investigated the benefits to covering precision medicine multicancer screenings that can identify multiple cancers with one test. However, there are still many obstacles to covering precision medicine multicancer screenings.

In the meantime, there are steps payers can take to improve cancer patient navigation and patient experience, including reforming network adequacy and streamlining appeals processes.