Senior woman having a mammography scan at hospital
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If she faces a deductible, one in five women is likely to forgo additional testing after an abnormal finding on screening mammogram, according to a new study presented at this year’s annual meeting of the Radiological Society of North America (RSNA).

“The results show that a deductible payment for follow-up breast imaging after an abnormal finding on screening mammography discourages 21% of women from returning for additional evaluation and appears to lead 18% of women to skip the initial free screening altogether,” said the study’s lead author, Michael Ngo, M.D., radiology resident at Boston Medical Center and Boston University Chobanian & Avedisian School of Medicine.

High-deductible health plans (HDHPs) have become more prevalent as policy makers have sought more ways to reduce healthcare costs. They require patients to pay more upfront, i.e in copays and deductibles. However, there has been lots of debate over the years whether this is an appropriate way to cut costs. The plans, meanwhile, have proliferated.

“Policy makers pushed for HDHPs because they are more affordable since they typically have lower premiums. Therefore, more people will have health insurance. Unfortunately, the group of people who could not afford higher premiums are now unable to afford the high deductible that comes with essential health services such as diagnostic breast imaging,” Ngo told Inside Precision Medicine.

HDHPs are thought to lower overall health care costs by making individuals more aware of their medical expenses, i.e., that these patients have “more skin in the game.” The higher deductible also ostensibly lowers monthly insurance premiums by lowering overall costs, making these plans more attractive for people who typically need coverage only for preventative care or health emergencies.

But HDPS may come with high out-of-pocket cost—in excess of $1,400 for individuals and $2,800 for families—that may prevent people from seeking necessary care. Studies suggest that, for example (in BMJ): “High HDHP enrolment coupled with the high OOP [out of pocket] costs associated with HDHPs may be particularly detrimental to the financial well-being of people with diabetes and CVD, who have more healthcare needs than healthier populations.”

For this study, the researchers surveyed 932 patients presenting for breast imaging at Boston Medical Center between September 2021 and February 2022. The survey was comprised of demographic questions on race, education level, annual household income and insurance payor, as well as scenarios about utilization of breast imaging.

When asked whether they would skip indicated imaging if they knew they had to pay a deductible, of 714 respondents, 151 (21.2%) said they would skip imaging, 424 (59.4%) said they would not skip imaging, and 139 (19.5%) were undecided.

The groups with the highest percentage of responses indicating they would skip additional imaging were Hispanic (33.0%), high school educated or less (31.0%), household income less than $35,000 (27.0%), and Medicaid/uninsured (31.5%).

The survey also asked whether respondents would forgo the initial screening mammography exam if they knew they would have to pay a deductible for follow-up tests. Of 707 respondents, 129 (18.3%) said they would skip the screening mammography exam, 465 (65.8%) would not skip mammography, and 113 (16.0%) were undecided.

Ngo notes, “The screening mammogram is only the first step in detecting breast cancer. If the radiologist detects an abnormal finding on the screening image, then additional images and a biopsy are needed to determine if the patient has cancer. The ACA [Affordable Care Act]  does not mandate insurance to cover the costs of these additional services.” The act does cover certain preventative screening measures, including mammograms.

“Prior studies have shown that out-of-pocket costs deter patients from attending screening mammography,” Ngo said. “Other studies found that screening rates go down when there is an out-of-pocket cost for follow-up imaging after an abnormal finding on screening mammography.”

He tells Inside Precision Medicince, “It is important to advocate for legislation that would mandate coverage of diagnostic breast imaging in order to mitigate existing healthcare disparities and improve overall outcomes for all women, especially those in vulnerable groups.”

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