Price of Survival: Mammogram Costs Deter Many

Women who must pay more out of pocket for mammograms tend to skip screening.

February 9, 2009, 9:12 AM

Jan. 23, 2008— -- Arlene Brown learned exactly how expensive a mammogram can be in 2002.

Her health insurance was retroactively canceled due to the cost of her husband's hospitalization. Suddenly, what would have otherwise been a free test cost her hundreds of dollars.

"About three months after our health insurance was canceled, I called to make my yearly mammography appointment and realized that the screening would cost about $400," Brown explained.

Because Brown had a higher breast cancer risk than most other women, she required a more expensive, computer-assisted type of mammogram. Unable to pay such a high price, however, she deferred the screening test and began going in for her mammogram only as often as she could afford to -- about once every 18 months.

The story is an all too-common one, according to new research released Wednesday. But Brown is far from a stereotype when it comes to women who skip their mammograms because of out-of-pocket costs.

Brown is a family practice physician at Lincoln County Medical Center in Ruidoso, N.M.

"I think I have a relatively good understanding of the kinds of financial issues faced by a lot of patients because I go through them too," she said.

The American Cancer Society recommends that women over 40 receive a mammogram once every year. But a new study finds that, like Brown, many women skip their mammogram each year due to high out-of-pocket costs for the screening.

Researchers at Brown University in Providence, R.I., looked at 366,475 women covered by 174 different Medicare managed-care plans and found that even costs less than those Brown faced present a hurdle for many women.

They reported that those who have co-payments of more than $10 are less likely to get regular mammograms than those with more generous insurance coverage.

Mammogram screening rates were about 8 percent lower among women who had to pay more than $10 or 10 percent of a mammogram's cost, researchers found.

Researchers then examined health plans that once fully covered the costs of mammograms but later switched to only partial coverage.

From 2002 to 2004, mammography rates decreased by 5.5 percent in seven of these plans. However, in 14 other plans that continued to offer full coverage of mammograms, screening rates for breast cancer increased by 3.4 percent.

And the number of plans requiring women to make higher co-payments are on the rise. In 2004, one out of nine women was forced to pay for at least 10 percent of the cost of a mammogram out-of-pocket.

The worst impacts were seen among minorities and patients from communities with lower income and education levels, as these patients were mostly likely to enroll in cheaper health insurance plans that require co-payments for mammography.

Dr. Amal Trivedi, lead study investigator and assistant professor of community health at Brown, said that all health insurance plans should offer full coverage for mammography so that the greater good is served -- in this case, higher levels of mammography screening and fewer deaths from breast cancer.

"It's important for women to understand that mammograms are a very valuable preventive health service, and there's a lot of data that shows that women who get mammogram screenings are diagnosed at earlier stage of breast cancer and are therefore less likely to die from breast cancer," Trivedi explained.

"Our study supports the idea that eliminating co-pays for mammograms would be an important consideration for Medicare and health insurance programs in order to increase screening rates nationally."

But even in the group of women with full-coverage plans, the screening rate was still only 77.5 percent. While this is better in comparison to the 69.2 percent screening rate for women in cost-sharing plans, the statistic speaks to the fact that there are several other barriers to women getting regular breast cancer screenings in addition to the financial burden.

After mammography was shown to be an effective screening tool for breast cancer in the 1980s, the use of mammography in the United States increased rapidly. According to a study published last May in the journal Cancer, 70 percent of women reported having a recent mammogram in 2000. These mammography screening rates remained steady until about 2003, when screening rates started to decline among women aged 50 and older.

Although it may be impossible to pinpoint the exact cause of the decline in mammography screening rates, breast cancer and health policy experts believe there are a number of barriers.

"I suspect patients' fear, lack of knowledge of efficacy [of mammography screenings], physical discomfort during the procedure, denial, geographic barriers, lack of primary care doctor and inability to pay are all factors," said Dr. Alan Sager, professor of health policy and director of the health reform program at Boston University's School of Public Health.

Moreover, because only about 75 percent of women whose mammogram costs are fully covered actually go in for their mammogram, a number of experts believe the cause for the decline in screening rates is due more to lack of knowledge about the importance of mammography screening than the financial burden alone.

"The more important story is that some Americans remain so unconvinced about mammograms that they are deterred by a $10 co-payment," said David Dranove, distinguished professor of health industry management at Northwestern University in Chicago.

"We are not talking about putting people into bankruptcy here; that is less than 3 cents per day."

According to statistics from the American Cancer Society, an estimated 178,480 women are expected to be diagnosed with invasive breast cancer in the United States during 2007. An estimated 40,460 women will die from breast cancer. This means that breast cancer is the No. 2 killer of women in the United States, second only to heart disease.

A study published in the 2003 issue of the New England Journal of Medicine found that over a 10-year period, between two and six out of every 1,000 women will have their lives saved by mammography.

But despite the numerous studies showing that regular mammography screenings have decreased breast cancer mortality rates by finding the cancer at earlier, more treatable stages, many women remain unconvinced of the importance of getting regular mammograms.

"The big problem is not insurance, it is ignorance," Dranove explained.

But in Arlene Brown's case, ignorance had nothing to do with her decision to defer her yearly mammograms. Brown is well aware of the importance of regular mammography screenings, as she herself is at high risk for developing breast cancer. Her mother and both of her grandmothers had breast cancer.

Instead, Brown's choice to skip her yearly mammograms was one based solely on financial reasons.

Most experts contend that forcing all health insurance plans to offer full coverage for such screening tests would cause the mammography screening rates to go up once again.

"This is a very important finding that should lead to a major change in policy for both Medicare and non-Medicare patients for mammography as well as other preventive services," said Dr. Stephen Edge, chief of the breast division at Roswell Park Cancer Institute in Buffalo, N.Y. "This is not the only barrier to breast cancer screening, but one that should clearly be removed."

Since acquiring a new health insurance plan about two years ago, Brown has caught up with her mammography schedule and now manages to fit in her yearly screening. But she still believes this is an issue for far too many women.

"I see patients all the time who skip mammograms because of co-payments," Brown said. "It shows that our health care system has a lot of issues that need to be solved. Any preventive care ought to be first priority for any insurance company and for any patient."

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