Mammography and MRI Coverage for High-Risk Women - Case Study Example

 Mammography and MRI Coverage for High Risk Women Introduction Breast cancer is one of the commonest types of cancer in women. American Cancer Society statistics show that approximately 40,000 women die in the US of breast cancer each year (Elting et al, 2009). Annual statistics indicate that more than 200,00 new cases of breast cancer are diagnosed on a yearly basis. In about 10% of cases, the disease is hereditary resulting from mutations in the BRCA ½ genes (Elting, 2009). The remaining cases are sporadic in nature, occurring in women with no family history of the disease. . Epidemiological studies show that African American women have the highest incidence of breast cancer and are 30% more likely to die of the disease than caucasian women, at least in part due to later stage disease detection in this group of women (Schuler, 2009). Breast cancer screening tools such as mammography were introduced into widespread use based on the presumption that early detection afforded by routine screening would lead to more effective treatment and overall survival rates from this disease. Data collected from numerous clinical trials indicate that mammography screening done on an annual basis is associated with a significant reduction in mortality rates from breast cancer (Elting, 2009). According to the World health organization (WHO), a 35% decrease in mortality from breast cancer is associated with biannual mammography in women between the ages of 50-69 years (Elting et al, 2009). The statistics on actual use of mammography as a diagnostic tool for women over 40 reveal that this screening modality is significantly underused by women in this age group for whom the test is most highly recommended. For example, in 2002 approximately 25% of eligible women did not receive this diagnostic test (Schueler, 2008). Racial and ethnic differences in screening percentages mean that caucasian women are far more likely to receive annual mammography, which may account in part for the increased death rates in African American women from breast cancer in that it is not as likely to be detected in this group at an early stage (Schueler et al, 2008). In addition, women from lower socioeconomic groups (lower income, less education) are less likely to receive annual mammography screening. Moreover, the statistics indicate that women living in rural areas are less likely to receive diagnostic screening than women living in urban areas in the US (Schueler et al, 2008). Research suggests that the most important factor accounting for these demographic and racial differences in screening rates results from financial issues associated with the cost of annual mammography. Another factor concerns the level of knowledge and awareness of the importance of mammography that sometimes varies according to ethnicity and socioeconomic status. The HR 995 IH Mammogram and MRI Eligibility Act, proposed in 2009, was designed to address the fact that too few women avail themselves of mammography screening, to a large extent, because of the patient costs resulting from inadequate public and private insurance coverage for these essential screening tools. The purpose of this essay is to explore the provisions of this Act and the relative importance of cost coverage in determining compliance rates in women for whom breast cancer screening guidelines apply. Description of the Proposed Policy- HR 995 IH Mammogram and MRI Availability Act of 2009 Clinical research studies conducted over many years suggest that mammography represents the most important diagnostic tool available for the early detection of breast cancer. HR 995 IH Mammagram and MRI Availability Act was introduced by Rep. Jerrold Nadler in February 2009 to address some of the important barriers preventing women from receiving this diagnostic screening test on an annual basis. .HR 995 proposes an amendment to the Public Health Service Act and Employee Retirement Income Security Act of 1974 requiring group and individual health insurance coverage for annual screening mammography for women 40 years of age or older. The bill also requires group and individual health insurance coverage for screening and annual MRI for women 40 year of age or older at high risk for breast cancer if their coverage or plan includes coverage for diagnostic mammography. The bill would prohibit insurers from denying coverage based on the coverage not being deemed medically necessary for annual screening mammography or annual MRI or that the screening is not pursuant to a referral, consent, or recommendation by any health care provider. The bill would prohibit insurers from denying women eligibility or continued eligibility for the purpose of avoiding the requirements of the bill. The bill would prohibit insurers from providing incentives to women to accept less than the minimum protections available and prohibit incentives to providers to provide care inconsistent with the bill. The bill was sent to committee in October, 2009 and has not proceeded further since that time. Cost Issues For over a decade, the actual costs of mammography screening have far exceeded the insurance coverage rates for this procedure. In 2001, the average cost of a mammography test was $105.57; however, Medicare reimbursement rate was only $50 (Feig, 2005). This problem has yet to be addressed by Medicare or other insurance programs. Inadequate reimbursement has led to a decline in mammography services in many hospitals and clinics (Miller et al, 2005). This means that older equipment is in use, long waiting times for procedures and a climate of indifference among health professionals whose budgets are increasingly strained by the inadequate coverage available for this procedure. More recently, reimbursement levels by major insurance funding such as Medicare has increased to $90+ per mammogram. Compliance rates among women for mammography screening remain at only 59% (Feig, 2005). This situation, thus, is inadequate to provide for the screening needs of this segment of the population (Feig, 2005). Current estimates are that breast cancer kills almost 4% of American women each year. Based on this significant mortality index, health professionals argue that the allocation of 0.43% of national healthcare costs to this screening procedure represent a large cost-effectiveness ratio (Feig, 2005). The cost effectiveness for bypass surgery, dialysis or even seat-belt use is comparatively much lower. Discussion Two key questions must be addressed in considering the proposed bill: 1-Does the bill provide for sufficient insurance coverage benefits for mammography and MRI screening? 2 If cost is not an issue, will compliance rates for these procedures by women increase significantly? Regarding the first issue, the main deficit is that it provides only coverage for high -risk patients at age 40. Clinical research indicates that high-risk women with a family history of breast cancer should be screened annually starting at age 25 (Artmann et al, 2006; Warner et al, 2008). Given that 90% of these high-risk women will develop breast cancer by age 50, it is imperative that the bill provide for screening coverage for both mammography and MRI beginning at age 25 (Lalonde et al, 2005). For women with an inherited predisposition to develop breast cancer, clinical recommendations are screening from age 25 years annually (Artmann et al, 2006). Controversy over the efficacy of mammography in women 40-50 years has continued as insufficient clinical data exist to provide definitive data for this age group (Crowe et al, 2009). Current estimate are that a 15% reduction in breast cancer mortality is associated with mammogram screening in this younger age group (Richardson et al, 2010). The situation is vastly different for young women who carry the BRCA-1/2 mutations, in that 50-90% of women in this high-risk group will be expected to develop breast cancer before 50 years Warner et al, 2008). Mammagraphy screening in this group of women is far less successful in reducing mortality rates from breast cancer than in the general population (Lalonde et al, 2005). In part, this appears to be due to the lower sensitivity of this procedure in women with dense breasts, a common occurrence in younger women. The calcified breast cancer histology detected by mammograms is infrequently present in breast tumors in this high-risk group, which may be a very basic and important reason for decreased sensitivity of this screening procedure in BRCA-1/2 carriers (Lalonde et al, 2005). Recent clinical data suggest, however, that breast mammography and ultrasound in women under 40 is associated with low screening sensitivity, detecting only 30-40% of breast tumors due to high breast density in women of younger ages (Crow et al, 2009). Research has shown that combining magnetic resonance imaging (MRI) with mammography enhances the diagnostic sensitivity to 90% in women of this younger age group (Richardson et al, 2010). Contrast enhanced MRI may be the most sensitive screening tool (Artmann et al, 2006). Contrast enhanced magnetic resonance imaging (MRI) has been suggested to provide a much-need screening tool for high- risk individuals (Miller et al, 2005). Clinical studies suggest that it may be a useful screening device for this high-risk population. The Dutch National Prospective Research Study compared the efficacy of conventional mammography to MRI in patients with a history of familial breast cancer (Lalonde, 2005). The relative efficacy of breast examination, mammography and MRI in detecting malignant tumors in this group of women was 17.9%, 33.3% and 79%, respectively. This study suggests that there may be an enormous clinical benefit to the addition of MRI screening to the diagnostic tools offered to high-risk women. Another clinical trial, the UK MARIBS showed a 77% detection rate for MRI as compared to 40% using mammography. Based on these clinical trial data, it is essential that the proposed bill cover MRI screening in high-risk women beginning at age 25 (Artmann et al, 2006). In regard to the second question, the significance of cost as a critical determinant of compliance rates, an important study by Scheck-McAlearney et al (2005) indicated that mammography cost was a crucial factor in the decision among women in the underserved communities of non-caucasian women of lower socioeconomic status and among rural women. It is important to note that the perception of cost in this group of underserved women was shown to be disproportionately high compared to actual cost. Based on the importance of this and similar research findings, strategies to remove the cost barrier would appear to represent a primary goal to ensure a higher level of compliance with mammography recommendations in these groups of underrepresented women. Some researchers suggest that cost documentation efforts to educate women about the actual costs of mammography might be as useful as better insurance coverage policies related to the procedure. (Scheck-McAlearney et al, 2005). Approximately 20% of Americans between the ages of 18-64 are not insured. Many private insurers do provide coverage for breast cancer screening. However, the coverage is often incomplete and patient co-pays are required. A study by Makuc (2007) showed that patient co-pays in women between 40-64 years were twice as common as in women 65+ covered by Medicare and that these co-payments often served as a financial barrier for insured women to rtake advantage of mammography screening. (Makuc, 2007). Surprisingly, the authors of this study found that women 65+ were less likely to receive mammograms than women 50-64, despite the fact that the younger age group was far more likely to incur co-payment costs for the procedure (Makuc, 2007). The results of this study suggested that financial issues are not the only relevant factors determining compliance rates for breast screening procedures. Alternative factors may be fewer physician referrals of older women for mammography screening, Moreover, the statistics indicate that, within the 40-64 year age group, women with public insurance fully covering the procedure were less likely to receive mammograms than women with private coverage in this age group. Not surprising is the fact that uninsured women were less likely to receive mammograms than either group of insured women (Farley et al, 2010). The BCCEDP is the largest cancer screening program for uninsured low-income women in the US. Study data show that 60+% of women qualifying for this program do not enroll and not receive mammograms (Farley et al, 2010). Despite the fact that the program services only about 15% of eligible women, this program has provided breast and cervical screening for several million eligible women in the US. Of these, only 1% of American women receive breast screening via BCCEDP, since many uninsured women not poor enough to be eligible for this program, nevertheless, cannot afford to pay for mammography out-of-pocket (Makuc, 2005). Conclusions and Recommendations Evaluation of clinical research studies strongly suggests that minimizing the financial burden of mammography and MRI is key to increase the number of women receiving proper breast cancer screenings. Screening mammography and MRI will lead to an increase in early stage diagnosis of breast carcinomas. Early diagnosis and treatment will lead to a reduction in breast cancer mortality and possibly breast conservation. Moreover, based on clinical trial data on women with a family history of BRCA-1/2 mutations, it is essential that the proposed bill cover MRI screening in high-risk women beginning at age 25, rather than commencing at age 40, as the current bill proposes. Based on the importance of the above-cited research findings, strategies to remove the cost barrier would appear to represent a primary goal to ensure a higher level of compliance with mammography recommendations in ethically and socio-economically underrepresented and underinsured women. Additional research suggests that cost documentation efforts to educate women about the actual costs of mammography might be as useful as better insurance coverage policies related to the procedure. The overall consensus of numerous clinical health studies is that removing the cost barrier to facilitate access to these breast cancer diagnostic screening tools will produce greater compliance rates, particularly among currently underserved groups. It is also probable that increased compliance will produce a lower death rate from this disease. However, these studies also make clear that cost issues are not the sole determinants of compliance with health guidelines and recommendations. Educational approaches to explain the importance of breast cancer screening also need to be made widely available to increase public awareness of the importance of mammography and MRI in early stage breast cancer detection References Artmann, A., Hellerhoff, K., & Heywang-Kobrunner, S. H. (2006). Screening in women with increased breast cancer risk. Breast Care, 1, 22-25. Crowe, J. P., Patrick, R. J., & Rim, A. (2009). The importance of preoperative breast MRI for patients newly diagnosed with breast cancer. The Breast Journal, 15(1), 52-60. Elting, L.S., Cooksley, C.D., Bekele, B.N., et al. (2009) Mammography capacity impact on screening rates and breast cancer stage at diagnosis. Am J Prev Med , 37:102–8. Farley, T.A., Dalal, M.A., Mostashari, F., and Frieden, T.R. (2010) Deaths preventable in the U.S. by improvements in use of clinical preventive services. Am J Prev Med , 38:600–9. Feig, S. (2005).The economics of breast imaging: Challenges and strategies for Survival. 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