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Figure  . Copays as low as $12.50 are enough to deter some women from getting mammograms, a recent study finds.

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Cost sharing, now a mainstay of most health care plans, may be discouraging patients from getting the preventive care they need. According to a recent study by Brown University and Harvard University researchers, a copayment of as little as $12.50 was enough to deter women from getting screening mammograms.

The study, published in The New England Journal of Medicine (2008;358:375–383), was based on data from the National Committee for Quality Assurance's Medicare Health Plan Employer Data and Information Set available through the Centers for Medicare and Medicaid Services. Researchers reviewed the biennial mammography rates of 366,475 women aged 65 to 69 years in 174 Medicare managed care plans during 2001 to 2004. They compared rates among women in plans with cost sharing for mammography (which required copayments of more than $10 or a coinsurance of more than 10%) with rates for women in plans offering full coverage of mammography. In addition to this cross-sectional analysis, they also performed a longitudinal analysis comparing plans offering full coverage from 2001 to 2004 with plans that instituted cost sharing during that period.

According to the study, the number of Medicare managed-care plans with mammography cost sharing increased from 3 to 21 during 2001 to 2004, with the proportion of women enrolled in these plans growing from 0.5% to 11.4%. Costs ranged from $12.50 to $35, with a median of $20.

During the study period, screening rates were 8.3 percentage points lower among women in cost-sharing plans compared with those who were fully covered (69.2% versus 77.5%, P <.001). Screening rates decreased by 5.5 percentage points among women whose plans implemented cost-sharing schemes during the study period (from 74.8% to 69.3%), while rates rose 3.4 percentage points among women in full-coverage plans (from 71.9% to 75.3%). Compared with women in plans with full coverage, women in cost-sharing plans were more likely to be African American and living in low-income areas with low education levels; however, researchers observed that copayments adversely affected screening rates for women across all groups.

“Recent surveys have shown a troubling drop in the use of mammography, but the reasons behind the drop have not been well understood. This study lends credibility to the idea that access to affordable health care is a very real factor. We already know many women are somewhat unwilling to receive regular mammography screening. Unfortunately, the added burden of a copayment may make some women even less likely to make screening a priority,” said Otis Webb Brawley, MD, Chief Medical Officer, ACS, when the report was released.

While $12.50 may not seem like much, it could be a significant barrier for the elderly, a population already beset with hefty health care costs, the researchers note. Adults over age 65 years are typically faced with mounting health care bills because of other illnesses, many of them chronic. Furthermore, several studies suggest that when faced with copays for preventive care, people are less likely to use those services because they seem less essential than care associated with symptomatic health conditions.

The authors of this study question the economic sense of requiring cost sharing for older Americans to receive underutilized, evidence-based preventive services. Cost-sharing plans, while designed to curb inappropriate health care spending, could inadvertently lead to higher costs associated with treatment of advanced breast cancer.

“We've isolated the effects of copayments on an important preventive health measure,” says Amal Trivedi, MD, lead author of the study and Assistant Professor in the Department of Community Health at Brown University's Alpert Medical School. “Mammograms are an essential service for older women, yet many women avoid that service when they are required to pay out of pocket. By eliminating copayments for mammograms, we could get more women tested. More testing would mean earlier breast cancer treatment and improved chances for breast cancer survival.”