Even in the face of rising premiums and insurers pulling out of state marketplaces, the Affordable Care Act (ACA) did a few things right: The number of uninsured Americans is the lowest in history, the growth in healthcare spending slowed, and the number of patients undergoing USPTF-recommended screening grew dramatically through the removal of financial barriers and expansion of Medicaid eligibility.
Medicaid patients are historically up to 2.5 times more likely to be diagnosed with late-stage cancer compared to privately-insured women, chiefly due to low screening rates. While their mammography utilization has improved with the implementation of the ACA, DBT was given a CMS Current Procedural Terminology (CPT) code in 2015, opening the door for large-scale implementation of the more precise breast modality.
The clinical benefits of adding DBT to the standard mammography workup are well documented, but is it cost-effective? Researchers from a variety of New England institutions built an economic model using data from 31 million Medicaid patients to determine the efficacy of mammography plus DBT, publishing their results in the Journal of the American College of Radiology.
“The primary driver of DBT economic value comes from the capacity for DBT to reduce the number of women recalled for additional follow-up imaging and diagnostic testing services and the corresponding reduction in the costs of health care resource utilization,” the authors wrote. “A secondary driver of DBT economic value is the capacity of DBT to facilitate earlier diagnosis of cancer, particularly diagnosis of cancers at earlier stages, when treatment costs are less. Together, these value drivers offset additional reimbursement costs of DBT and produce a potential net cost savings for Medicaid plans.”
The model assumes a base follow-up rate of 14.38% with regular mammography, decreasing to about 10 percent for mammography with DBT—a figure supported by the American College of Radiology (ACR) and the Agency for Healthcare Research and Quality (AHRQ). That four-and-a-half percent difference represents the clinical value of DBT.
Researchers used a hypothetical average-sized state Medicaid program to estimate costs, comprising 1.4 million enrollees. They found in an average state-wide program, DBT could prevent nearly 1,200 women per year from having unnecessary follow-up appointments, saving an average of $8.14 per patient. For a large state Medicaid program, this translates to over $200,000 a year.
Money isn’t the only motive for implementing DBT: Previous studies suggests that the added sensitivity can improve patient throughput. Radiologists using DBT were more confident in their decisions, measured by the increase in patients classified as “Normal” in the BI-RADS system as opposed to “Probably Benign." DBT also reduces the need for additional imaging after a suspicious finding: 57 percent of cases using standard mammography needed additional imaging, but only 43 percent of women who underwent DBT needed the same.
Reducing follow-up exams has social benefits as well. Follow-up exams can create stress and anxiety for women, even though most do not have breast cancer. According to the authors, cutting out unnecessary exams can reduce emotional distress, in addition to indirect costs such as transportation or childcare.
“As Medicaid programs continue to evolve, and as DBT becomes more widely adopted for routine breast cancer screening, results from this study will assist policymakers and financial stakeholders in examining ways to address disparities and barriers to accessing value-based preventive care by some of the nation’s most vulnerable citizens,” the authors wrote.