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While out-of-pocket costs (OOPCs) have largely been eliminated for screening mammography, they still serve as financial barriers to patients undergoing subsequent diagnostic tests, according to results from a retrospective cohort study.

The analysis of more than 200,000 commercially insured women who underwent screening mammography in 2016, detailed just how much more women enrolled in plans with higher cost-sharing (such as copay- and deductible-predominant plans) paid in OOPCs for subsequent imaging tests.

Plans dominated by coinsurance had the lowest mean OOPCs ($945), followed by balanced plans ($1,017), plans dominated by copays ($1,020), and plans dominated by deductibles ($1,186), reported Danny Hughes, PhD, of Arizona State University in Phoenix, and colleagues in .

In turn, women in plans with higher OOPCs had fewer subsequent diagnostic breast imaging procedures than patients enrolled in plans with lower OOPCs.

For example, women in predominant co-pay plans underwent on average 24 fewer subsequent breast imaging procedures per 1,000 patients than those in predominant coinsurance plans, while women in predominant deductible plans underwent 16 fewer per 1,000 patients (P<0.001 and P=0.01, respectively).

Moreover, this association between higher OOPC plans and lower utilization of subsequent diagnostic imaging was more pronounced with breast MRI, as patients from all plan types underwent significantly fewer breast MRI scans than patients in predominant coinsurance plans (five fewer per 1,000 women in balanced plans and six fewer per 1,000 women in copay- or deductible-dominant plans; all P<0.001).

"Considering the risk posed by an unconfirmed positive mammogram result, this is a startling finding that questions the efficacy of legislation such as PALS [Protecting Access to Lifesaving Screenings] and ACA [Affordable Care Act], which eliminated cost-sharing from many preventive services, such as screening mammograms, precisely to remove financial barriers that inhibit patients from receiving these important life-saving services," the researchers wrote.

"This may be important information for consumers when assessing the trade-off between different plans' cost-sharing mechanisms and premiums when making insurance decisions," they added.

In this study, the authors used data extracted from Optum's deidentified Clinformatics Data Mart, which contains health insurance claims for members of large commercial and Medicare Advantage health plans. They then used a machine learning algorithm, which classified four patterns of cost-sharing in various health plan types by whether the plan's mechanism design was dominated by patient copays, coinsurance, or a deductible, as well as plans that were relatively balanced across the three cost-share components.

The authors then assessed how these predominant cost-sharing patterns were associated with the rate of follow-up testing after an abnormal result on a screening mammogram.

The patient sample included 230,845 women (most ages 40-64 years), who were covered by 22,828 distinct insurance plans associated with more than 6 million enrollees and nearly 45 million distinct medical claims.

"The study by Hughes and colleagues adds to a robust literature that demonstrates that cost sharing strategies -- such as copayments and deductibles -- are frequently implemented as a blunt instrument and reduce use of both high- and low-value clinical services," wrote Ilana B. Richman, MD, MHS, of the Yale School of Medicine in New Haven, Connecticut, and A. Mark Fendrick, MD, of the University of Michigan in Ann Arbor, in .

They suggested that the problem could be corrected with the elimination of cost-sharing throughout the entire screening process for those cancers for which initial exams are fully covered.

"Removal of financial barriers for these essential follow-up tests will prevent the further exacerbation of existing health inequities and allow patients to reap the benefits of cancer prevention," Richman and Fendrick concluded.

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