Eliminating extra fee for 3D mammography bolsters utilization, though disparities persist
Eliminating an added fee for digital breast tomosynthesis bolsters utilization, though healthcare disparities appear to persist, likely requiring further action, according to new research.
Following U.S. Food and Drug Administration clearance of 3D mammography in 2011, many commercial insurers were slow to adopt full coverage of this new technology without cost-sharing. This forced UCLA Health to implement a $45 out-of-pocket fee for DBT, refunded upon insurance payment, experts wrote Thursday in JACR.
The institution eventually removed the charge in January 2021 after most payers began covering 3D mammography. Nina M. Capiro, MD, and colleagues examined the impact of this decision, analyzing data spanning their multi-site institution between 2018 and 2022.
“Due to inconsistent reimbursement by insurance providers for newly adopted imaging technologies, facilities may resort to charging out-of-pocket fees for imaging examinations to assure payment and maintain revenue. As such, there may be decreased access to these new imaging technologies for patients unable to afford the added expense,” Capiro and co-authors wrote June 19. “Limited access to new imaging technologies, particularly those relating to breast cancer screening, can amplify healthcare disparities and perpetuate poor health outcomes for certain groups of patients,” they added later.
Among over 13,000 women, DBT utilization leapt from 83.7% before the intervention up to 91.5% afterward. Relative to white patients, the rise in digital breast tomosynthesis use was greater by 5 percentage points for Asian patients, 6.2 percentage points among black women, and 6.2 pp for Latinas. Non-English-speaking women also had a larger increase in DBT use (7.1 pp) when compared to those who speak the language. Same for patients on Medicaid (6.7 pp) and the commercially insured (5.1 pp) compared to those on Medicare. Finally, patients from more socioeconomically disadvantaged areas had a greater increase in 3D mammography use (5.2 pp) compared to those from more affluent areas.
“While our study identifies a potential strategy to promote health equity, it is important to note that disparities, although reduced, were not completely eliminated,” the authors cautioned. “Even following the removal of the fee for screening DBT, white patients, English-speaking patients, patients with Medicare and those from less socioeconomically vulnerable areas continued to have the highest rates of DBT utilization when compared to other groups. These persistent differences may result from other systemic factors, such as physician referral patterns, patient health literacy, or lingering concerns about healthcare costs. Addressing these remaining barriers should be a priority for future interventions to further advance equity in breast cancer screening.”
Capiro and colleagues believe their study offers important insights as radiology practices adopt artificial intelligence in breast imaging, often with an extra out-of-pocket fee. While doing so has the potential to improve outcomes, it also could deepen disparities for women who cannot afford to pay for AI.
“While prospective studies are ongoing, AI offers exciting potential to improve breast cancer screening for both patients and radiologists,” the authors added. “However, many breast imaging practices are charging patients an additional fee if they opt to have their screening mammogram interpreted by AI in addition to the radiologist. As AI is more widely implemented in clinical practice for interpretation of screening mammograms, it is essential to consider how out-of-pocket cost can lead to similar disparities as observed in our study in the use of this technology in the future.”
Read more, including potential study limitations, in the Journal of the American College of Radiology. JACR also on Friday published a related editorial on this topic.
Marty Stempniak has covered healthcare since 2012, with his byline appearing in the American Hospital Association's member magazine, Modern Healthcare and McKnight's. Prior to that, he wrote about village government and local business for his hometown newspaper in Oak Park, Illinois. He won a Peter Lisagor and Gold EXCEL awards in 2017 for his coverage of the opioid epidemic.