What does a woman on Medicare have to pay for her yearly mammogram? At most, about $25. But a portion of women on Medicare and in private health plans think it will cost them far more, according to health services researcher Ann Scheck McAlearney, ScD—and this knowledge gap may cause women to avoid this important cancer screening test.
McAlearney and colleagues found great confusion about mammogram costs and insurance coverage in a recent study of 897 mainly low-income North Carolina women, aged 40 and older, who were overdue for an annual mammogram to detect early signs of breast cancer.
“When breast cancer is diagnosed early, the odds of survival are very, very good,” explained McAlearney. Research shows that more women survive breast cancer every year, thanks to wider use of mammography and improving treatments.
American women's use of mammograms is not, however, where it should be. The ACS recommends that women at average risk of breast cancer begin having annual mammograms at age 40. An estimated 25% of women who need the exam (aged 40 and older) have not had one in the past 2 years, and nearly 40% of poor women have never had a mammogram.
McAlearney's study looked for barriers that may prevent women from getting the exams on time. The group's racial composition was 32% African American, 41% Native American, and 25% White.
“Cost was far and above the biggest issue. It seemed to be more of a knee-jerk reaction, rather than knowing how much it would truly cost,” said McAlearney, Assistant Professor of Health Services Management and Policy at the Ohio State University School of Public Health in Columbus. Study findings were published in the journal Cancer (2005;103:2473–2480).
Interviewers asked about mammography in general and each woman's specific reasons for not getting the exam on time, as part of a larger study in rural Robeson County, NC (the ROSE Project). Afterward, women's beliefs about their coverage were compared with their actual insurance policies. Researchers found:
• More than half (53%) of the women identified cost as a barrier to getting a screening mammogram.
• Of that group, 40% did not fully understand how much their insurance companies would pay for the exam.
• Women aged 65 and older and those at the lowest incomes were more likely to misunderstand their insurance benefits.
A mammogram's total cost was about $60 in Robeson County in 1998 when the interviews took place, yet a number of women with health insurance stated (wrongly) that their out-of-pocket cost would be $50—nearly the full price.
In reality, the women with any kind of health insurance were not likely to pay more than $12 out-of-pocket; most often there would be no copayment at all. Medicaid and private insurance plans typically paid 100% of the bill for a mammogram, according to the study authors. Medicare paid 80% without requiring women to pay any deductible—so their 20% copayment was no more than $12.
The average cost for a mammogram nationwide is now $125, according a recent study.
Women who had Medicare alone, and especially those with private insurance, often underestimated how much their plans would pay for the exam. Women insured by Medicaid were better informed about their insurance, which covers the total cost of a mammogram.
The study findings suggest that doctors and insurance companies could play a critical role in increasing adherence to mammography guidelines, according to McAlearney, by making extra efforts to inform women of exactly what they'll pay out-of-pocket for a mammogram.
“The physician community could provide this information,” said McAlearney. “Doctors could say, ‘Go get a mammogram. And, by the way, you have Medicaid; they pay 100% of the cost.’ Or: ‘Medicare pays for 80% and other groups can help you with the 20%.’”
Most study participants had one or more physician office visits in the year or two before they were interviewed—and McAlearney sees those visits as missed opportunities to clear up any confusion about the cost of a mammogram. Specifically, nearly 70% of the women reported having a medical checkup in the 12 months before the study.
“Doctors generally blame the insurance companies, but this was a group in which close to half of the women were on Medicare or Medicaid or some combination. It should not be that hard to figure out what a mammogram will cost,” she said.
“Most private insurers cover it at 100%,” added McAlearney. “With a little leg work, medical practices could find out which insurers don't cover the cost of a [screening] mammogram. Unless you are uninsured, you should not be paying $100 today for a mammogram. At most, it should be $25.”
McAlearney also noted that women without insurance and at low incomes can turn to the National Breast and Cervical Cancer Early Detection Program for low-cost or free mammograms in most communities across the country. Information on the program is available online at http://www.cdc.gov/cancer/nbccedp/index.htm.