By Steve May

According to the American Medical Association (AMA), an annual mammography is an annual preventive service every woman 40 or older should have.  We all know breast cancer, if detected is treatable to a successful outcome.   Preventive mammograms save lives.  Mammograms are uncomfortable, but the comparative discomfort and inconvenience is far outweighed by the peace of mind, or quick response to mitigate far worse health effects.

For many women, nearly 50%, that have mammograms there is an additional annual frustration.  These women are diagnosed with dense breast tissue.  Dense breast tissue can make standard mammograms difficult to read.  This requires a second mammogram, either a 3D image or an ultrasound.  In accordance with healthcare reform, preventive mammograms do not require any cost share from the member.   If there is a specific diagnosis that drives the need for a mammogram, or follow-up test the does incur cost.  For the women with dense breast tissue, the second test is necessary due to a “diagnosis” of dense breast tissue.  Not only do these women need to spend more time away from family or work responsibilities, they will also incur an expense for the 3D image or ultrasound test.  The national average cost for an additional ultrasound test is $360, and can be twice that amount depending in the region and facility.

The real frustration is the system does not adapt to the individual in these cases.  These women have been diagnosed with dense breast tissue every year.  They must endure the sterile, uncomfortable traditional mammogram only to be told what they already know; “You need to have an ultrasound due to dense breast tissue.”  This happens every year.  This action also leads to confusing members at the time of billing for the service.  Members understand that preventive mammograms are covered with no member cost share.  For no fault of their own, they are told the dense breast tissue requires a second test.  Members do not perceive dense breast tissue as a diagnosis, nor do they understand that the term diagnosis changes the procedure from preventive, no cost, to diagnostic, cost.  The stress of waiting for the results is compounded by the confusion of paying significant cost for  a required test.

Once the diagnosis of dense breast tissue is given, shouldn’t that person start with the ultrasound?  The additional test is inconvenient, stressful, and expensive.  These additional tests also drive-up cost for employers.  It is known that there will be 2 mammograms for nearly 50% of women that receive mammograms.  The traditional test is covered with no cost share for the member, but the employer pays the claims for that procedure.  The employer benefit plans provide coverage for the second test, but require the member cost share.  Employers pay the remaining claims cost after the benefit.  The employer also realizes the loss of productive time for the employee that endures a second visit.

Many states are beginning to address these inefficiencies through State mandated benefits. For fully-insured plans the Vermont state mandate reads:

• 4100a. Mammograms; coverage required

(a) Insurers shall provide coverage for screening by mammography for the presence of breast cancer. In addition, insurers shall provide coverage for screening by ultrasound for a patient for whom the results of a screening mammogram were inconclusive or who has dense breast tissue, or both. Benefits provided shall cover the full cost of the mammography service or ultrasound, as applicable, and shall not be subject to any co-payment, deductible, coinsurance, or other cost-sharing requirement or additional charge.

This language does not provide for the subtle change that would provide relief to members, nor the cost efficiency to the members.  This language still requires members to go through 2 tests.  Insurance carriers and plan administrators can change benefits, so if dense breast tissue has been a diagnosis, that member bypasses the traditional mammogram and starts with the ultrasound.

Review your summary plan descriptions and have a conversation with your insurance provider or plan administrator.  This could be a subtle change that provides value and relief to your employees.