‘Innovative’ pay model eliminates cost uncertainty for breast and lung cancer screening patients

An “innovative” payment model could potentially eliminate cost uncertainty for breast and lung cancer screening patients, though it’s likely to pose other challenges. 

Experts have proposed “episode-based cost sharing” to address financial toxicity for healthcare consumers, according to new research published April 23 in JACR. The approach has patients trade a free initial screening mammogram—with subsequent out-of-pocket costs for follow-ups such as breast MRIs—for a single upfront payment that covers the entire care episode. 

Radiology researchers recently surveyed patients about the tradeoff and discovered a “strong” inclination toward this new, price transparency-focused model. 

“Our results demonstrate a general preference for episode-based cost-sharing (EBCS) over the status quo under which patients usually do not know their cost-sharing obligations until after care has been delivered,” Kevin Dao, MD, with the University of California, Irvine, Department of Radiological Sciences, and co-authors concluded. “Further, survey respondents placed significantly greater importance on the potential additional cost compared to the initial cost. EBCS models can further mitigate financial hardship by eliminating the negative consequences of unexpected [out-of-pocket] costs of additional services.” 

Dao et al. recruited their participants using Amazon Mechanical Turk, an online crowdsourcing platform, which has previously been used for similar research. They conducted three separate surveys based on individuals’ eligibility for breast and lung cancer screening, along with giving birth, with around 100 individuals participating in each. Respondents preferred episode-based cost sharing by 18.1 percentage points for BCS, 12 percentage points for LCS, and 44.5 for childbirth. Cost-sharing models with uncertainty around additional payments were the least preferred across all surveys, the authors noted. 

Lung cancer screening subjects with higher educational attainment and on government health plans were less likely to favor EBCS. The latter is likely because these additional services might be provided to them at a lower cost versus patients with private insurance, who can face higher prices and deductibles. Meanwhile, breast cancer screening patients who were previously imaged had a strong preference for EBCS, likely reflecting their own previous experiences with cost unpredictability.

“Our results suggest that participants who have been screened for cancer and have potentially experienced additional follow-up tests may view EBCS as an appropriate trade-off between comprehensive care and healthcare costs,” the authors wrote. 

Experts note that uncertainty around out-of-pocket costs often can lead to patients forgoing recommended follow-up exams or ceasing participation in screening programs. This adverse effect can be especially pronounced among individuals of lower socioeconomic status, from minority backgrounds or who are financially vulnerable, Dao and colleagues said. They believe episode-based cost sharing could be “especially beneficial” for screening episodes where patients receive initial low-intensity care but may subsequently require high-intensity, expensive follow-ups due to unexpected complications. 

While patients seemed to prefer EBCS, implementing it could pose challenges, and it could even be unnecessary in some states, the study authors cautioned. One previous study found that an initial out-of-pocket payment for screening mammograms “significantly” reduced the probability of undergoing subsequent exams. 

“There is a concern that requiring patients to pay even small amounts out-of-pocket for initial screening—which is currently provided at no cost to patients—may also prove to be a deterrent to screening,” the authors wrote. “Furthermore, several states have introduced legislation that would eliminate patient cost-sharing for diagnostic imaging after a screening episode, and these legislations have passed into law in some states,” they added later. “Such laws thus provide patients with superior financial protection against unexpected OOPC for screening episodes, thereby deeming implementation of the EBCS model unnecessary in those states.”

Dao and co-authors highlighted the survey’s finding patients’ preference to avoid cost uncertainty. Previous analyses have shown healthcare consumers tend to select imaging centers where prices are known upfront, with greater likelihood they’ll complete their exams. 

“Hence, EBCS may better address the issue of uncertain costs of additional services,” they advised. “As the focus of the U.S. healthcare system shifts toward patient-centered and patient-informed approaches, the general population’s preferences should be considered in future health policy reforms.”

You can read much more about the results in the Journal of the American College of Radiology. The study was limited by its focus on hypothetical scenarios that may not reflect the perspectives of patients experiencing these complex, real-life scenarios. It also had a sample that was overwhelmingly white (84%), and respondents skewed toward younger ages, with subjects potentially lacking previous lung or breast cancer screening experience, the authors cautioned. 

Experts also made their case for EBCS in a JAMA Internal Medicine viewpoint published last year.