Does Cost-Sharing for Screening Result in Missed Cancer Diagnoses?

Patients who face cost-sharing and high out-of-pocket healthcare costs for breast cancer screening might not access any applicable follow-up tests they need, according to research published in JAMA Network Open.

Said otherwise, patients might not get the full scope of breast cancer screening they need, something the researchers posited could result in missed cancer diagnoses.

Preventive screening is a key part of healthcare in the United States, and under the Affordable Care Act, it is required to be free for patients with all types of health insurance plans. But for breast cancer screening, that coverage extends only to mammograms and does not include any follow-up testing like diagnostic breast imaging or biopsies. For those tests, patients are liable for any cost-sharing that might be spelled out as a part of their health payer coverage.

The researchers acknowledged that cost-sharing is a common mechanism by which health insurance companies encourage healthy behavior and only necessarily healthcare utilization among members. But under the current set-up in which patients are responsible for some of the cost of follow-up cancer screening, the researchers indicated cost-sharing could have deleterious effects.

“Although most of this subsequent care ultimately finds an initial abnormal screening mammogram to be a false positive, with additional diagnostic services recommended in more than 10% of screening mammograms, if patient concerns regarding OOPCs are deterring women from undergoing recommended follow-on testing, this has the potential to adversely affect outcomes for a substantial number of those who require follow-up testing after the initial test,” they wrote in the study’s introduction.

The researchers looked at more than 200,000 women ages 40 to 64 who received a mammogram to determine how their insurance type (level of cost-sharing) influenced whether they accessed recommended follow-up tests. Particularly, the researchers looked at insurance plans characterized by copays, coinsurance, or deductibles. The team also looked at patients with insurance plans that balance all three cost-sharing frameworks.

By and large, having coinsurance yielded 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.

And, as predicted by the researchers, there was a link between those higher out-of-pocket costs can the rate at which patients actually accessed follow-up testing. Although 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 most likely to access follow-up tests. Meanwhile, 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. Those findings were more salient when looking at MRIs, the most expensive type of breast imaging available.

These findings are notable, the researchers said, because they illustrate how high out-of-pocket patient costs influence patient care access. Many patients may operate under the assumption that preventive screenings—including every step of the screening, like follow-up tests—are covered under their insurance. Upon learning otherwise, women often forego imaging follow-ups, which the researchers asserted could result in negative outcomes for women who may ultimately test positive for breast cancer.

These findings signal a need for health policy change, the researchers said. First, lawmakers could expand preventive screening coverage to include potential follow-up tests, like the biopsies and imaging discussed in this study. 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 said these bundles produce negligible price increases but remove financial barriers for patients.

“Despite policies designed to remove financial barriers to access for breast cancer screening, significant financial barriers remain for women at risk of an abnormal screening test,” the researchers concluded. “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.”