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Mammograms contribute 62% of the cost and the remaining 38% is attributed to follow-on diagnostics.
A study of 1 million women who were screened for breast cancer with mammography showed the average cost per-episode, per-patient age 30 to 64 is $249.70. The cost reflects the 17% of episodes that
included follow-on testing.
While breast cancer screening rates have remained steady for more than a decade, according to HEDIS measures, the provision in the Affordable Care Act (ACA) to require mammography screening benefits with no member out-of-pocket costs has the potential to increase utilization. More than 70% of HMO members and 66% of PPO members adhered to the recommendations of biennial screenings in 2013.
According to the study, the mammogram itself contributes 62% of the cost, and the remaining 38% is attributed to follow-on diagnostics.
Milliman, which conducted the analysis from private-payer claims data, found variation in diagnostic utilization. With an overall 2.4% rate of biopsy, there was also a 19% breast
cancer surgery rate after biopsy, which researchers say suggests an 81% false positive rate resulting from breast biopsy procedures.
Among the recommendations, Milliman advises plans should review their claims experience for follow-on diagnostics and biopsies.
Additionally, guidelines for breast cancer screening can change with new evidence, so plans should review coverage policies periodically to be consistent with best practices.
The report was commissioned by Gamma Medica, which manufactures a molecular breast imaging diagnostic tool.