Patient Costs for Breast Exams

Non-invasive breast exams can reduce breast cancer mortality.

Breast cancer screens between the ages of 50-75 can reduce cancer deaths by 26%, and can-cer spread to other tissues by 29% (CDC 2022).

Several American medical societies recommend breast exams for the preventative detection of cancer by age 40, and exams every 1-2 years thereafter (Drukteinis 2014).

• The age and frequency of exams depends on risk factors, such as family history, genetics, and breast tissue density.
• 2D mammograms are the most common screening tool, primarily due to the relative availability of different equipment in healthcare facilities (Roganovic 2015; Hollingsworth 2019).

Secondary breast screens can cost thousands of dollars.

Primary Screening

The Affordable Care Act classifies primary breast cancer screens as a preventative service that insurance must cover at least once every two years (HRSA 2022).

Secondary Screening

Roughly 1 in 7 women may need a secondary cancer screen, which are often considered ‘diagnostic’ or ‘out-of-network' procedures that require out-of-pocket pay-ments (Roganovic 2015; Kunst 2020).

• Combined imaging techniques can increase the likelihood of correctly identifying cancerous tissue (Roganovic 2015).
• Around 20-25% of mammograms can be negative on the first screen and be positive in a second (Hollingsworth 2019).

The cost for secondary screens can depend on the type of insurance; plans can collect costs upfront (higher deductibles), distribute costs to consumers by usage (higher coinsurance or copays), or a combination of the above.

Table 1 lists the average out-of-pocket cost paid by a patient on private insurance in the U.S. for primary and secondary breast cancer screens (Hughes 2023; Roganovic 2015; Hollingsworth 2019).

Table 1. Average out-of-pocket costs for non-invasive breast cancer screens in the U.S.

Patients usually have one option for an employer-sponsored insurance plan, which determines their copay and deductible costs.

• Roughly 75% of employers who offer insur-ance in the U.S. (most under 200 employ-ees) offer one insurance plan (KFF 2019).

Roughly 16% of women on private insurance reported paying some out-of-pocket cost for a secondary mammogram, while 11% of uninsured women and 3% of Medicaid insured reported the same (KFF 2019).

• Roughly 3/4 of insured MO women obtain at least 1 breast cancer screen every two years, compared to 1/3 of uninsured women (KFF 2019).
• In a 2012-2016 study, the average cost to insurers for primary breast cancer screening in Missouri was between $100-400. Prices were most expensive in Southeast MO (Kunst 2020).
• Roughly 1 in 41 fewer breast exams are performed among patients in plans with high copays; for plans with high deductibles, roughly 1 in 62 fewer exams are performed (Hughes 2023).

Some states have eliminated breast screening copays.

16 states (including MO) and D.C. require insurance coverage for “any additional or imaging...deemed medically necessary” (RSMo 376.782), but allows insurers to charge copays, coinsurance, or deductibles for these services.

• 12 states prohibit out-of-pocket copays for screenings under their Medicaid plans (AR, ID, IN, LA, MA, NH, NV, OH, TX, VT, WA, WV; Sabik 2020).
• 7 states (AR, CO, IL, LA, NY, TX, and TN) prohibit out-of-pocket costs for all breast cancer screenings in both private and public insurance plans (Dense Breast-Info 2023).

Provider Impacts

It is not clear how state policies that prohibit out-of-pocket patient costs for breast cancer screens affect overall private insurance costs.

• In one estimate, hospitalizations resulting from high copays and low drug usage could save the medical system $1 billion/year (Goldman 2006).

Consumer Impacts

In the Medicare Advantage plan, eliminating copays for biennial mammography increased the screening rate by 6% (Trivedi 2018).

• Data is limited on the effect of eliminating copays for diagnostic screens on overall medical costs to the consumer since copays generally do not count toward patients' deductibles in health plans (GoodRx 2022).

References

2019 Employer Health Benefits Survey. (2019). Kaiser Family Foundation. Retrieved from https://www.kff.org/report-section/ehbs-2019-section-4-types-of-plans-offered/ 

Coverage of Breast Cancer Screening and Prevention Services. (2019). Kaiser Family Foundation. Retrieved from https://www.kff.org/womens-health-policy/fact-sheet/coverage-of-breast-cancer-screening-and-prevention-services/ 

Drukteinis, J. S., Mooney, B. P., Flowers, C. I., & Gatenby, R. A. (2013). Beyond mammography: new frontiers in breast cancer screening. American Journal of Medicine, 126(6), 472-479. doi:10.1016/j.amjmed.2012.11.025 

Goldman, D. P., Joyce, G. F., & Karaca-Mandic, P. (2006). Varying pharmacy benefits with clinical status: the case of cholesterol-lowering therapy. American Journal of Managed Care, 12(1), 21-28.  

Health and Economic Benefits of Breast Cancer Interventions. (2022). Centers for Disease Control and Prevention. Retrieved from https://www.cdc.gov/chronicdisease/programs-impact/pop/breast-cancer.htm 

Hollingsworth, A. B. (2019). Redefining the sensitivity of screening mammography: A review. American Journal of Surgery, 218(2), 411-418. doi:10.1016/j.amjsurg.2019.01.039 

Hughes, D. R., Espinoza, W., Fein, S., Rula, E. Y., & McGinty, G. (2023). Patient Cost-Sharing and Utilization of Breast Cancer Diagnostic Imaging by Patients Undergoing Subsequent Testing After a Screening Mammogram. JAMA network open, 6(3), e234893-e234893. doi:10.1001/jamanetworkopen.2023.4893 

Kunst, N., Long, J. B., Xu, X., Busch, S. H., Kyanko, K. A., Richman, I. B., & Gross, C. P. (2020). Use and Costs of Breast Cancer Screening for Women in Their 40s in a US Population With Private Insurance. JAMA Internal Medicine, 180(5), 799-801. doi:10.1001/jamainternmed.2020.0262 

Lee, B., Gerencher, K. (2022). Do Copays Count Toward Deductibles? Here’s How Health Plans Work. GoodRx Health. Retrieved from https://www.goodrx.com/insurance/health-insurance/health-insurance-premiums-deductibles-copays-co-insurance 

Roganovic, D., Djilas, D., Vujnovic, S., Pavic, D., & Stojanov, D. (2015). Breast MRI, digital mammography and breast tomosynthesis: comparison of three methods for early detection of breast cancer. Bosnian Journal of Basic Medical Sciences. Udruzenje Basicnih Mediciniskih Znanosti, 15(4), 64-68. doi:10.17305/bjbms.2015.616 

Sabik, L. M., Vichare, A. M., Dahman, B., & Bradley, C. J. (2020). Co-payment policies and breast and cervical cancer screening in Medicaid. American Journal of Managed Care, 26(2), 69-74. doi:10.37765/ajmc.2020.42395 

State Legislation Map. (2023). Dense Breast-Info. Retrieved from https://densebreast-info.org/legislative-information/state-legislation-map/ 

Trivedi, A. N., Leyva, B., Lee, Y., Panagiotou, O. A., & Dahabreh, I. J. (2018). Elimination of Cost Sharing for Screening Mammography in Medicare Advantage Plans. New England Journal of Medicine, 378(3), 262-269. doi:10.1056/NEJMsa1706808 

Women’s Preventive Services Guidelines. (2022). Health Resources and Services Administration. Retrieved from https://www.hrsa.gov/womens-guidelines#:~:text=Under%20the%20ACA%2C%20most%20private,services%20%E2%80%93with%20no%20cost%20sharing.