Physicians utilize a variety of tools and methods to screen for breast cancer, including mammography and magnetic resonance imaging (MRI). Unlike the commonly used mammogram, however, MRI screening for breast cancer, which is recommended for women who are considered high-risk, does not fall under the financial protection of the prevention provision of the Affordable Care Act (ACA). This ACA provision requires private insurance companies to waive out-of-pocket (OOP) costs for preventative services that were given either Grade A or Grade B recommendations by the United States Preventive Services Task Force (USPSTF).
“Unfortunately, MRI has been recommended for high-risk women, but the USPSTF has not published a guideline for these women,” said Ya-Chen Tina Shih, PhD, explaining why screening MRIs are not covered under the financial protection of the prevention provision of the ACA. “So, there is no [Grade A or B] recommendation to link to that [service].”
This means that, while MRIs for breast cancer screening are covered by public and private health insurances, OOP costs for private insurance plans go unregulated by the ACA. Women who have been determined as high-risk or in need of this screening method can become subject to high OOP costs, affecting their accessibility to screening MRIs that are better equipped to serve them than the common mammogram.
“It does have a higher sensitivity compared with screening mammography,” noted Shih, explaining why high-risk women are more likely to benefit from screening MRIs. “For example, some high-risk women have extremely dense breasts and some have other issues. Several professional societies, such as the American Cancer Society, have been recommending screening MRIs for high-risk women, but not for average-risk women, because of its added sensitivity.”
In an observational study, researchers at the University of Texas MD Anderson Cancer Center, including Shih who is Chief of the Section of Cancer Economics and Policy, examined the subsequent effects this lack of ACA protection can have on a patient, that patient's finances, and their willingness to continue with routine screenings. Researchers identified a group of 16,341 women who had undergone MRI screening for breast cancer and received a mammogram within 6 months of the MRI between 2009 and 2017.
After the group had been identified, researchers compared the trends of zero cost-shares for women who had undergone mammograms to those who had undergone MRIs for breast cancer screening and how those trends changed over this 8-year time frame. In this study, zero cost-share was defined as having no OOP costs, while OOP costs were quantified as being the sum of copayments, coinsurance, and deductibles. A multivariable logistic regression and a two-part model were used to examine the factors associated with zero cost-share and OOP costs from MRI breast cancer screenings.
The study found that the proportion of screening MRI claims with no OOP costs significantly declined during the study period. In 2009, approximately 43.1 percent of women did not have to pay OOP costs for their screening MRI. By 2017, the proportion of zero cost-share for MRIs had decreased to approximately 26.2 percent. The study also found that the adjusted mean of OOP costs for women with high-deductible insurance plans was more than twice as high as their counterparts ($549 vs. $251; 2-sided p<.001).
Other vulnerable women identified in the study were those who live in the South in the post-ACA era. These women were more likely to pay higher OOP costs for screening and less likely to receive zero cost-shares. Overall, the study concluded that many women who received preventative MRI screening for breast cancer have been subjected to a high financial burden.
“The problem is the financial consequences,” Shih said. “You might have a high-risk woman who receives an MRI recommendation from their doctor and then realizes: ‘Oh, I have to pay $300 or more for that.’ So, that might affect their decision the following year when they have to go back to get another screening done.”
Shih also expressed concerns that OOP costs for follow-up breast cancer screenings are not regulated under the financial protection of the current prevention provision of the ACA. This means that, if an average-risk woman receives a screening mammogram and is recommended for a follow-up diagnostic MRI, while her OOP cost may have been waived for the first mammogram, she will have to pay OOP for the follow-up MRI. The same can be said for colorectal cancer screening and lung cancer screening.
“Screening is more than just the initial screening test. It is a process,” Shih stated. “Waiving the out-of-pocket payment throughout the screening process could be a worthwhile approach to help patients complete the entire process.”
Elizabeth Rose Galamba is a contributing writer.