Mammograms: Is It About Money?

Nov. 19, 2009 — -- The 16-member U.S. Preventive Services Task Force released its new recommendations on mammograms two days ago -- and the resulting firestorm has yet to die down. Doctors and patients are expressing outrage that a government panel would dare adjust the mammogram guidelines. The current standard recommends annual screenings for women 40 and older; the revised recommendations push that age out to 50 and recommended screenings every other year.

In a response that was typical of many in the medical profession, Dr. Daniel Kopans, head of breast imaging at Massachusetts General Hospital, said, "I think it is outrageous to reduce costs by taking away a test that is saving lives and saving a large number of lives."

But the recommendations aren't for taking away the test, only changing the guidelines for when testing should begin.

In addition, while there is no question that mammograms save lives, there is a very real debate about the cost incurred in screening all women every year between the ages of 40 and 50.

"Every medical care system in the world has a concern about not paying for things that shouldn't be done," said professor Theodore Marmor, a health care policy specialist at Yale University.

False Positives for Younger Women

Statistics from the National Cancer Institute show that the risk a woman of 40 will be diagnosed with breast cancer before she turns 50 is relatively low – less than 2 percent. But the false positive rate for those same women is relatively high – 50 percent higher than women in their 50s.

And those women are likely to undergo further, more expensive, procedures -- only to find out they are, in fact, healthy.

"Although screening every woman between the ages of 40 and 50 would turn up some breast cancer…the question is what is the cost per diagnosis per relevant harm," said Marmor.

If that calculus sounds cold, it shouldn't. That kind of cost-benefit analysis is, in fact, already routine in the health insurance industry.

"The question is going to be, between the ages of 40 and 50, what is the frequency with which you are going to find a true positive cancer finding, how many cases would we miss, how many of those cases would develop into cancer and what is it going to cost to treat them," said Ian Duncan, president of Solucia, a company that provides actuarial health care analysis for insurers.

But some have cited that the new research does not consider the impact of newer technologies in breast cancer screening. The authors themselves admit that the recommendations were limited because "studies of older women, digital mammography and magnetic resonance imaging are lacking."

Digital mammograms are 1.5 to 4 times more expensive than conventional film-based mammograms, according to the National Cancer Institute, which also reported in 2005 that only 8 percent of the country's breast imaging units provide the technique.

But digital mammograms are thought to be more effective at screening women in their 40s. The NCI points to a large clinical trial in 2001, which showed digital mammography was sensitive enough that it performed "significantly better in screening women ... under age 50."

Mammogram Debate: Is Money Behind It?

Duncan explained that mammograms are considered a value-based benefit because they are preventative in nature and relatively low cost – about $125 per exam.

He compared mammograms to diabetes drugs. Insurance companies pay for them, and thus increase the "utilization" -- the frequency that people use them – but they do this in the belief that, down the road, it will eventually reduce disease and, therefore, medical costs. Mammograms should reduce the need to pay for expensive cancer treatments later.

But talking about costs instead of clinical practices has taken on a new and ominous tone in light of the push for health care reform.

"I definitely think this is the beginning of rationed care and I am very upset that women are the first to get slammed with this," said Dr. Elizabeth Vliet, a women's health care specialist based in Tucson, Ariz., and an ardent opponent of health care reform. "I think that this change is designed to cut costs, not improve women's health."

Compromise Coming?

But that fear may be unwarranted. Duncan said many private insurers may take the political hornets' nest into consideration and "leave the coverage where it is." Or insurers might propose a compromise: "We will move the official standard to age 50 but we will be fairly liberal in allowing physicians to come in and argue for coverage on behalf of their patients."

In addition, Health and Human Services Secretary Kathleen Sebelius issued a written statement Wednesday that emphasized the members of the panel "…do not set federal policy and…don't determine what services are covered by the federal government."

Sebelius' statement continued: "My message to women is simple. Mammograms have always been an important life-saving tool in the fight against breast cancer and they still are today. Keep doing what you have been doing for years -- talk to your doctor about your individual history, ask questions, and make the decision that is right for you."

Still, despite the desire for damage control, many warn that mammograms have already become "the new death panels." And that is disheartening to people like Marmor, who say a discussion of care and cutting costs can take place together.

"People are holding up the standard of medical care that any medical treatment that does any good for anybody cannot be denied," he said. "That is a ridiculous standard."

And a costly one.