A new Brown University study shows that even small copayments can keep women from getting mammograms – a concern because copays are increasingly common and rising in cost, and mammograms are crucial to detecting breast cancer early and saving lives.
The study, published last month in the New England Journal of Medicine, looked at data from 174 Medicare managed-care plans from 2001 to 2004 involving 366,475 women between the ages of 65 and 69 who lived in 38 states.
The researchers, based at Brown’s Alpert Medical School and at Harvard Medical School, found 8 to 11 percent fewer women got mammograms at least once every two years – as recommended for women over 40 – in plans with copays than in plans without them.
The required payments were relatively small, ranging from $12.50 to $35 and averaging about $20. But the number of plans requiring such co-pays grew rapidly over the period covered by the study: from three to 21, affecting 0.5 percent of women in 2001 and 11 percent by 2004.
And while among those with no cost sharing screening rates increased by 3 percent from 2002 to 2004, among those that introduced copays, they dropped by 6 percent.
“The message is simple and it’s startling – a small copayment for a mammogram can lead to a sharp decrease in breast cancer screening rates,” said Dr. Amal Trivedi, lead author of the study and assistant professor in the Department of Community Health at the Alpert Medical School, in a news release. “Because mammograms are critical in the fight against breast cancer – the most common cancer among American women – our findings have important health-policy implications.”
In an interview, Trivedi noted that co-pays “have been dramatically increasing in the past few years” in the health insurance industry as part of an effort to contain spending growth by reducing utilization of health services.
But previous research has shown that copays reduce appropriate, as well as inappropriate, utilization, Trivedi said. And while a person feeling chest pain, for example, might still go to an emergency room despite a sizeable copay, the impact of cost-sharing on preventive care – which you want people to seek even when they feel perfectly healthy – is a serious concern.
“Mammography is a highly valuable preventive health service,” he said. “And what we found is that copayments as low as $12 led to a very sharp decrease in the number of women who receive breast cancer screening.”
Asked whether such small sums should really make such a difference, Trivedi noted that patients in Medicare managed care are often living on fixed incomes and have other health problems that already cost them a great deal of money. “So for a person on a fixed income [that] can be a substantial financial deterrent, especially for someone who has no symptoms.”
The solution, as Trivedi and his colleagues see it, is quite simple: eliminate cost-sharing for mammograms.
“It doesn’t make a lot of clinical or economic sense to discourage women from getting mammograms,” he said. “I think it’s in the interest of public health but also in the interest of health plans to not charge for mammograms,” because breast cancer is expensive to treat.
The study focused on Medicare managed-care plans because of the volume of data available, but women covered by traditional fee-for-service Medicare Part B plans are also affected, Trivedi noted. They are required to pay 20 percent of the cost of a mammogram, which can range from $100 to $150 depending on where they live, Trivedi said.
As for women in commercial health plans, the study didn’t look at them, but the trend in the industry has been toward ever-higher copays and deductibles, Trivedi noted.
Locally, Blue Cross & Blue Shield of Rhode Island doesn’t require any cost-sharing for mammograms, spokeswoman Kim Keough said.
At UnitedHealthcare of New England, spokeswoman Debora M. Spano said mammograms are covered at 100 percent in “the majority” of plans the company offers, because United “believes the preventative services are an integral part of individual’s long-term health and wellness.”
The Brown study was funded by the federal Agency for Healthcare Research and Quality. •
