Paying For Mammograms: We’re Thinking About It All Wrong
(A version of this Health Alert was published by Forbes.)
The third rail of American health policy is women’s health care. The U.S. Department of Labor states that women make 80 percent of health care decisions for their families, although this appears to be derived from folklore rather than scholarly research. Nevertheless, any politician knows that the way to drive up polling numbers among women is to dial up the rhetoric on health care.
Back in 1996, Hillary Clinton, bitter after the defeat of HillaryCare, campaigned against “drive-by deliveries,” demanding that a federal law should be passed mandating that health insurers pay for mothers to stay in hospital for at least 48 hours after delivery. The campaign succeeded quickly: The Newborns’ and Mothers’ Health Protection Act passed that year, and took effect in 1998. It mandated a 48-hour stay (or 96 hours for Caesarian section). Although, doctors are free to discharge their patients earlier.
More recently, controversy arose when the Affordable Care Act was being debated, because it was being jammed through Congress just as women were struggling with a 2009 decision by the US Preventive Services Task Force to change its guidelines recommending annual mammograms. The new guidelines recommended screening starting at 50 years, not 40 (as previously recommended).
Needless to say, this upset many people. The American Cancer Society maintained its recommendation that preventive screening start at 40, as did the Mayo Clinic. Politicians took note, and made an exception in Obamacare for mammograms, such that the 2009 USPSTF revision was ignored when it came to Obamacare’s “free” preventive care.
The USPSTF looks ready to re-issue its guideline, which means “free” mammograms for women in their 40s will not be mandated by Obamacare. Avalere Health has published a study estimating that this could “eliminate guaranteed coverage” for 17 million women.
I understand that everyone’s personal experience will color their response to these guidelines. Nevertheless, I think we can deal with the issue much more satisfactorily if we look at it in a different way – by recognizing that “free” mammograms are not “free” at all. Although I am a man, this concerns me directly as the sole breadwinner in my family. If my wife loses any “free” preventive coverage, we’ll pay for it out of my wages if she chooses to undergo the procedure.
My employer-based health plan covers mammograms fully as preventive care. Never having paid for a one cirectly, I went to trusty NerdWallet, which informed me that they are offered for a median price of $250 in San Francisco and $294 in Washington, DC – two of America’s most expensive cities. In Atlanta, the median cost is $130 and in Denver it is $160.
Most mammograms performed are paid by insurers. (A study using data from 2007-2008 reported that only 5.5 percent of women getting mammograms were uninsured.) So, these prices are artificially increased by the administrative load of health insurance. If almost all mammograms were paid directly, the price would drop by a significant percentage.
How much? Let’s look a little deeper at the study citing 2007-2008 data. Overall, the mean (average) price of a mammogram was $266.49, of which the patient payed $32.90 directly. Almost 95 percent of the women were insured (by private insurance, Medicare, or Medicaid) and they paid $31.32 directly out of a total price of $272.09.
So, did the small number of uninsured women pay the total price? No: They paid $60.03 directly, of a total “price” of $170.47. What is the meaning of the so-called “price” of $170.47? Obviously, it has no meaning other than to justify the byzantine billing bureaucracy maintained between government, health insurers, and providers. The actual price of a mammogram in 2007-2008 was about sixty bucks.
So, the question is: Would women rather pay for mammograms directly, and make their own informed decision about when it is clinically indicated; or pay indirectly through higher insurance premiums, and worry about whether the preventive guidelines are influenced by politicians’ and insurers’ self-interest?
It’s interesting how these recommendations work. The claim is that mammograms starting at age 40 do not really save that many lives, and cause stress and cost due to call-backs and biopsies (not in small part due to our litigious society).
Yet, now the USPTFS is recommending CT scans for smokers. Are more lives going to be saved? Do you think when the radiologists see all kinds of artifacts and “possible cancers” they are not going to recommend further follow-up and biopsies?
I agree we need to come up with some reasonable strategies for screening, but tying these recommendations to insurance payment is dangerous.
And I totally agree John, they are not “free”.
John,
This is a nice article, but the ending seems to imply that the various associations that prefer screening starting at 40 are not issuing guidelines influenced by their self-interest. It would be nice to see you engage with the research rather than one-sidely identifying groups that act in their own self-interest.
Thank you but I am not a mind reader. And self-interest is not hostile to public interest in many cases. It would be entirely irresponsible for me to engage in commenting on the medical research.
I know from experience that mammograms starting at 40 save lives. However, the point about the cost is well taken. I would pay for it myself if my insurance did not cover it. You rightly point out that they are not really that expensive, and 3rd-party payers are driving up the cost of healthcare. The test is worth the expense. We need to return to a true insurance model.
The concern is, will doctors stop ordering this test, and radiologists stop providing it, if it is no longer covered by insurance for women under 50? The arguments about undue stress and unnecessary biopsies are most likely being made by people who have fortunately not been found with cancer. Or, perhaps more cynically, they are an effort to reduce utilization of lifesaving technology by whispering in women’s ears, do they really want this ‘nasty’ test? That will conveniently allow Obamacare proponents to tout that they are lowering costs but result in more dead or disfigured women.
Thank you very much. While the cost of false positives are significant, those with true positive results are certainly glad they are tested.
Excellent piece. Better to pay for small claims and let the insurance cover the large, unexpected ones. Better to make your own decisions on preventive care with your doctor, rather than paying more in insurance premiums for “free services” that you may or may not use or need or you may want to use more often than permitted.
Women shouldn’t be getting mammograms IN THE FIRST PLACE. They CAUSE or TRIGGER breast cancer. They inflict radiation on the tissues, and they cause breast trauma. They are very inaccurate. Women should be getting THERMOGRAMS instead. Of course, the medical Establishment supports mammograms because they make money with them. They make money from selling the machines, and they make money from followup tests and “care”, which consists of the same cut, poison, burn strategies that end so many cancer victims’ lives far too early. And all the so-called cancer “charities” push mammograms. Susan G Komen, which is as bogus as a three dollar bill, pushes them. It has ties to the pharmaceutical industry, and it refuses to warn women of the abortion-breast-cancer link. It donates to Planned Parenthood, which CAUSES breast cancer by doing abortions on women. When will the American people wake up? Probably not until they get some accurate information. I am NOT IN THE LEAST concerned about whether women get mammograms or not, but I sure wish they wouldn’t. This article totally misses the point. Let the author seek to have THERMOGRAMS provided and paid for. They catch cancer much earlier, and they’re much more accurate, and they don’t do any harm whatsoever to breast tissue; all they do is detect the temperature of the tissues and show an image that identifies potential trouble spots.
I know someone who got a thermogram, for the reasons you cite. The provider, suspecting she must be a health-conscious “new age health nut,” tried to convince her the red areas of the scanned image were probably caused by toxins. They told her she probably needed to have them perform expensive tests and pay them to administer a detox regimen.
My acquaintance realized that what is holding back thermograms from becoming mainstream is the nuts administering them who try to sell snake oil along with the results.
Thank you for this response on thermal imaging. We have some tolerance for idiosyncratic notions in this blog. We’re reaching the limit for this article!
There are a lot of medical procedures that are available for meager sums that cost an arm and a leg at the hospital. If more of these were not covered, patients might get into the habit of asking questions about price. The spillover effects may lower costs at the hospital.
Graham’s notion is still a totally wrong way of thinking about mammography: it’s thinking WITHIN (and projecting out from) the confines of the mainstream medical business.
The rarely broadcast fact is that there has never been much, if any, good evidence that mammography does anything of great significance in terms of breast cancer mortality reduction at any age bracket but (practically only medical industry-sponsored biased flawed “studies” claim that), but plenty of sound data shows the test dose much more serious harm than serious good (read “Mammography Screening: Truth, Lies and Controversy” by Peter Gotzsche and “The Mammogram Myth” by Rolf Hefti – more at TheMammogramMyth dot com).
Other things point to the fact that Graham doesn’t understand the real issue. Somewhere else he stated that cancer survival statistics are not fallacious but only limited. Yet cancer survival rates can go up and mortality rates can go down or stay the same, or cancer survival rates can go up and cancer mortality rates can stay the same or go up too – clearly, these are fallacious statistics.
But Graham is just like most members of the general public: because of the one-sided promotion and marketing of the test by the medical business (and their allies such as the cancer charities and the mass media), they have a skewed highly inaccurate picture of the real truth about mammography (and other screening tests and medical interventions). Because of this one-sides propaganda information by corporate medicine, favoring their business interests, it is also why women have been obstructed from making an informed choice about the benefits and risks of mammography.
As usual, in a propaganda nation, the real truth is carefully suppressed and censored from the larger populace.
My finger hovered over the delete button on this comment, because it has little to do with the article.
However, suppose you are a person who believes that mammograms are harmful (not because of responding inappropriately to false positives but for some clinical reason). Or you believe that vaccines cause autism. Or you don’t want flouride on your teeth.
Should your taxes or mandatory health insurance have to pay for it? There is a question.