Mammography Use Increases When Copays Are Dropped

February 2012, Vol 3, No 1 - Breast Cancer

San Antonio, TX—When copayments were eliminated, annual screening mammography rates among insured rural women improved significantly, researchers from Duke University Comprehensive Cancer Center reported at the 2011 CTRC AACR San Antonio Breast Cancer Symposium.

“Cost-sharing for high-value healthcare services may have unintended negative consequences,” said Jeffrey M. Peppercorn, MD, MPH, Associate Professor, Duke University School of Medicine, Durham, NC.

Because of declining rates of screen­­ing mammography, the National Ru­­ral Electric Cooperative Association (NRECA), a national nonprofit health plan for rural electrical workers and their families, eliminated copayments for screening mammography in January 2006. The NRECA provides health insurance coverage to more than 100,000 members across the United States, more than 80% of whom live in rural areas.

Dr Peppercorn and colleagues evaluated the impact of eliminating co­payments on the utilization of annual screening mammography among wom­­en aged 40 to 64 years, based on claims data for screening mammography between 1999 and 2009. Changes in use over time were assessed before and after the policy change in 2006.

From 1999 to 2009, an average of 20,825 eligible women received health insurance each year through the NRECA. During that time, annual screening mammography increased from 38.1% in 1999 to 49.5% in 2009. In 2007, the year after the copayment was eliminated, screening rates jumped to 48%, from 43% in 2006. The rates increased in all age-groups by about ≥5%.

“We saw that in 2006, when we eliminated the copay, there was a significant bump in the screening rate, possibly in contrast to national trends. If you look at the age-group 45 to 49 in 2005, the screening rate was about 40% and now is close to 50%,” Dr Peppercorn said in an interview.

“We think that this is a striking finding in this rural population, but still only 40% to 60% of women, depending on the age-group, are having annual mammography. Yes, the drop in the copay eliminated one barrier, but there is still work to be done to determine why other women are not getting mammograms,” he added.

The incidence of advanced breast cancer—determined, as a surrogate, from the number of women receiving chemotherapy or mastectomy—seemed to decrease, dropping from 7.2% before the policy change to 3.7% afterward. The investigators attribute this to early detection, at least in some patients.

Dr Peppercorn noted that temporal trends unrelated to copayment elimination may explain the increase in the mammography rate and the increase in breast cancer treatment. In addition, some NRECA members may have obtained screening outside of the health plan.

Further research will evaluate biannual screening rates, sociodemographic associations with screening, the impact of recent controversies over screening guidelines, and additional barriers in this rural population.