Throughout Women’s History Month, we’ve heard countless inspirational stories about female leaders – including those who have dedicated their careers to breast cancer research, prevention and detection, and those who have bravely fought the disease.
While heroic, the stories of women who have battled breast cancer are far too common. This year, 331,000 new cases of breast cancer will be diagnosed in the U.S. alone, and over 43,000 women are expected to die from the disease. Catching the disease early increases the odds of survival dramatically, and early detection often means a better quality of life for the patient. Personalized screening based on individual risk factors with an appropriate set of modalities maximizes every woman’s chances of finding early, curable breast cancer – and currently, diagnosis is the best defense.
While technologies like mammograms and breast MRIs have proven, long-standing track records of saving and improving lives, their accessibility can be a difficult labyrinth – or shot down altogether. Patient access to these testing technologies depends on many factors, including whether a physician decides to recommend a particular modality and whether an insurer (the government or a private payer) will pay for it. When these two factors are not aligned, medical claims are denied.
This can have a chilling effect – particularly for those who need more than mammography alone to screen for breast cancer. For women who are at a greater than 20% lifetime risk for breast cancer, a breast MRI can be an essential, life-saving part of their screenings for breast cancer.
Olive recently explored a convenience sample of over 73,000 claims for breast imaging and corresponding denial rates from February 2020 through February 2021. Based on care provided across health systems, the data is not representative and has limitations. However, it still allows an exploration of how care is provided, consumed and paid for in the real world.
Our data shined a light on the following about claims for breast imaging services:
- 3% denial rate for screening mammograms
- 7.5% denial rate for diagnostic mammograms
- 13.5% denial rate for breast MRI
Although the Affordable Care Act covers all screening mammograms, this provision is not in place for diagnostic mammograms, other screenings and diagnostic tests for breast cancer. This policy difference may help explain some of the variation in denials among screening mammograms and other essential modalities like MRIs.
|Total Mammography and Tomosynthesis Claims||Screening Mammography and Tomosynthesis Claims||Diagnostic Mammography and Tomosynthesis Claims||Breast MRI|
|Number of Claims||72,048||60,503||5,503||1,134|
Admittedly, MRIs are about eight times more expensive than mammograms, and they are not appropriate for everyone.
Like many things in medicine, the process is not one-size-fits-all. There are different approaches to screening and diagnosis. It is important to ensure adequate access to the right screening modality to catch breast cancer early, based on each patient’s individual breast cancer risk factors.
The number of women who may be adversely affected by these denials compels us to further study why and how claims for breast MRIs are denied. This exploration will shed light on how we can work with payers to be sure that they are covering and paying for these life-saving tests. As we apply this approach to other life-saving screenings we will close gaps in communication between different links throughout the entire healthcare system.
We hope that the data set from Olive can reveal differences in denial rates by imaging modality. This elucidation should encourage more studies of access at the point-of-care; enhanced coordination among health systems and payers; a reinvigorated effort to ensure that screening and early diagnosis are available; and a deeper exploration to understand if patients are getting care that is prescribed to them. Without this research, we cannot answer the question about how to mitigate the problems that arise when patients cannot get the care that their providers know they need reimbursed.
When we, as a healthcare community, are committed to improving and streamlining care, we can make rapid, critical and compassionate changes to ensure access to care for those who need it most. We should continue the coordination of care, communication and data-sharing that we saw between providers and payers this past year. Then we can apply that cohesiveness to other life-threatening diseases, like breast cancer, to save many more lives.
Additional Contributors: Andrea Wolf