insurance Gaps Leave High-Risk Women Facing Steep Bills for breast Cancer Screenings

Millions of American women at high risk for breast cancer are facing a significant financial hurdle: the uncovered costs of crucial follow-on screenings needed for early detection. These screenings, including ultrasounds, MRIs, and tomosynthesis, are often necessary because breast cancer can be missed on mammograms, especially for women with dense breast tissue. Molly Smith, a 46-year-old mother of two from Myrtle Beach, South Carolina, experienced this firsthand in 2021 when an initial mammogram revealed abnormal tissue, leading to over $1,000 in out-of-pocket expenses despite a clean report after further testing.

Smith’s experience underscores a growing concern for women with a family history of breast cancer or other risk factors.With her grandmother, mother, sister, and another family member all diagnosed with the disease, regular screenings are a vital part of her healthcare.

The Importance of Additional Screenings

While annual mammograms are typically covered by insurance,additional screenings often are not fully reimbursed,leaving women to bear the financial burden. this is particularly problematic for women with dense breast tissue, a condition affecting approximately half of women over 40. The Food and Drug Governance (FDA) now requires mammogram providers to inform women with dense breast tissue that they may need further evaluation.

Dr. Madhavi Raghu, a radiation oncologist in western Connecticut, emphasizes the importance of these additional screenings, stating, With ultrasounds you find cancers that are not evident on mammograms. She further explains, If tomosynthesis is normal and the ultrasound is normal, the likelihood a patient has underlying cancer is quite low.

Medicare Coverage Changes and Their Impact

Adding to the financial strain, doctors in Connecticut, New York, North Carolina, and Texas report that Medicare stopped reimbursing for breast cancer ultrasound screenings in 2024, despite having covered them in 2023. Dr. Raghu provided records showing Medicare declining reimbursements for ultrasound breast screenings it previously covered.

A spokeswoman for the Centers for Medicare and Medicaid Services (CMS) clarified that ultrasound or MRI scans are only covered by Medicare as diagnostic tests, not as screening tests for asymptomatic patients. If the scans were provided as a screening test, then Medicare is unable to cover those by law, she said.The CMS maintains that its “coverage policy” has not changed.

However, physicians argue that there is only one reimbursement code for breast ultrasounds, irrespective of whether they are for screening or diagnostic purposes. They fear that Medicare’s recent denials effectively categorize all breast ultrasounds as non-covered screenings.

The Ripple Effect on Private Insurance

The concern extends beyond Medicare recipients, as private insurers often follow CMS’s lead on reimbursement decisions. This creates a difficult situation for women like Molly Smith,who have private insurance but still face significant out-of-pocket costs.

You know you need to go back, Smith said, and there’s always that looming question: Am I a ticking time bomb, and what is it going to cost me?

The Impact of Cost on Screening Decisions

Research published in the journal *Radiology* highlights the growing financial burden on women seeking cancer screenings, particularly those enrolled in high-deductible insurance plans. The study reveals that approximately 21% of women would decline additional screenings if they had to pay out of pocket.

Doris Cardwell, a survivor of inflammatory breast cancer in Spearfish, South Dakota, emphasizes the need for awareness, stating, the fact that mammograms are not always a good standard or indicator is a problem we have to raise awareness on. Cardwell, who requires annual MRIs because inflammatory breast cancer does not typically show up on mammograms, anticipates paying $1,200 out of pocket this year.

It feels like you shouldn’t have to struggle to get the extra screening you need for early detection, Cardwell added. The earlier you catch cancer, the cheaper it is to treat. This shoudl be easy.

Rising Diagnoses in Younger women

The American Cancer Society’s recent statistics indicate a concerning trend: between 2012 and 2021, breast cancer diagnoses rose faster among women under 50 than among those over 50.

Lisa Lacasse, president of the American Cancer Society Cancer Action Network, stresses the importance of accessible early detection services. Out-of-pocket cost sharing is a significant barrier for those individuals who need access to multiple early detection services in order to find cancer at an earlier stage when treatment is more effective, Lacasse

The Crushing Cost of Early Breast Cancer detection: A National Crisis?

Millions of women face crippling financial barriers to vital breast cancer screenings, leaving them vulnerable to delayed diagnoses and possibly worse outcomes. Is this a systemic failure, or simply the unfortunate reality of healthcare in America?

Interviewer: Dr. Evelyn reed, a leading oncologist specializing in breast cancer and healthcare policy, welcome to World Today News. This issue of high-risk women facing exorbitant bills for crucial follow-up screenings after initial mammograms hits close to home for many. Can you shed light on why this is happening?

Dr. Reed: Absolutely. The problem of women facing significant out-of-pocket expenses for subsequent breast cancer screenings, like ultrasounds and MRIs, following an initial mammogram, boils down to a complex interplay of factors. This encompasses issues related to insurance coverage policies, particularly Medicare’s evolving stance, and the inherent ambiguities in medical coding regarding diagnostic versus screening procedures. Ultimately, the cost of these vital tests can be a significant barrier to early detection and treatment for many women, disproportionately impacting those with limited financial resources.

Interviewer: The article highlights the experience of Molly Smith,who despite having insurance,still faced significant out-of-pocket costs. Is this a common experience?

Dr. Reed: Unluckily, yes. Molly Smith’s situation reflects a widespread problem. Many women, even those with private insurance, find themselves with high deductibles and co-pays for follow-up screenings. High-deductible health plans are becoming increasingly prevalent,placing a greater financial burden on patients. Even with “good” insurance,the cost of these supplementary screenings can pose significant financial hardship. The reality is that many women could delay or forgo necesary secondary screenings due to these costs—potentially impacting their long-term health outcomes.

Interviewer: The article mentions Medicare’s coverage changes impacting reimbursements for breast ultrasound screenings. What’s the significance of this shift?

Dr. Reed: Medicare’s decision to restrict reimbursements for ultrasounds performed as screening tests—rather than solely as diagnostic tools— represents a crucial turning point. This change has created confusion and inconsistencies across the healthcare system. While the Centers for Medicare & Medicaid Services (CMS) maintains that its coverage policy remains unchanged, the practical consequence is that many physicians are no longer reimbursed for these crucial preventive screenings. This, in turn, influences how private insurers make coverage determinations, making it harder for women to access essential preventive measures. This means that many facilities may be less likely to offer these screenings, making early detection more challenging.

interviewer: This leads to the critical question of access. How does the cost of additional screenings influence a woman’s decision to pursue them?

Dr. Reed: Studies consistently demonstrate a direct correlation between the cost of healthcare services and a patient’s willingness to access said services. This is particularly true for non-emergency procedures and preventive screenings.Research shows that a substantial percentage of women would delay or forego necessary breast cancer screenings, ultrasound imaging being a key example, if faced with significant out-of-pocket expenses. This delay can have life-altering consequences. Consequently,the financial burden imposed by these costs poses a direct threat to timely diagnoses and effective breast cancer management. The situation is particularly dire for women in lower socioeconomic brackets who may lack the resources to cover these costs.

Interviewer: What are the long-term implications of this financial barrier to early detection?

Dr. Reed: It’s crucial to remember that early detection is pivotal for accomplished breast cancer treatment.The later the diagnosis, the more extensive and aggressive the treatment, which is frequently enough also more expensive. Delaying or avoiding crucial screenings due to financial constraints can directly result in more advanced-stage cancers, with poorer prognoses, and substantial increases in the long-term cost of cancer treatment. This cascades into challenges in patient quality of life and potentially extends to increased mortality rates.

Interviewer: What solutions are available to address this concerning issue?

Dr. Reed: Addressing this multifaceted problem requires a comprehensive strategy involving multiple stakeholders.

Advocating for clearer, consistent insurance coverage guidelines: This includes lobbying for legislation to ensure coverage for screenings tailored to individual risk factors, including denser breast tissues.

Improving medical coding and billing practices: This aims to resolve ambiguities between screening and diagnostic procedures to avoid reimbursement issues.

Expanding access to financial assistance programs: These programs could help bridge the financial gap for medically necessary screenings, allowing cost-effective early detection.

Increased public awareness through educational campaigns: Many women are unaware of their increased risk factors or the importance of follow-up screenings after mammograms.

* Promoting price transparency and cost-efficiency in the healthcare industry: This includes pushing healthcare providers to communicate testing costs upfront.

Interviewer: dr. Reed, thank you for your insightful commentary. This is a critical issue that impacts millions of women. What’s the single most significant message to our readers?

Dr. reed: The message is clear: Early detection saves lives — and it shouldn’t bankrupt you. We need a collaborative effort involving policymakers,insurers,healthcare providers,and patients to dismantle financial barriers to critical breast cancer screenings. This is a matter of equitable access to life-saving care. Share this interview and encourage others to speak up. Let’s work together to make a difference.