To our knowledge, this is the first study using a nationally representative survey sample to estimate women's average out-of-pocket mammography expenditures and total mammography expenditures and how these expenditures vary by insurance status and type, poverty status, facility where mammogram was received, and region of the United States where a woman resided at the time of the mammogram. Our study findings suggest that women without available resources that enable access to care, such as health insurance, had higher out-of-pocket mammography expenditures, which may pose a high financial burden. Such a financial burden is a potential barrier for receipt of mammograms in the future. Previous research by Trivedi et al.16
showed that a copayment as much as $10 may deter eligible women from receiving a mammogram, and our study suggests that nationwide average out-of-pocket mammography expenditures are at least twice as high. Our findings also have implications for future screening decisions.16
High out-of-pocket mammography expenditures may negatively influence a woman's decision to receive future mammography screening. Study findings by McAlearney et al.6,10
highlighted how perceived cost or overestimation of cost of a mammogram can act as a barrier to receiving a mammogram.
Our study findings also confirm that even among women who received mammograms, the out-of-pocket mammography expenditures as a proportion of the total mammography expenditures varied by presence of insurance. These findings are consistent with those of another study, in which the authors reported that uninsured women were more likely to report paying some or all of the cost of their most recent mammogram compared to women who were insured.7
Further efforts are needed to identify available resources for these women in order to deflect their out-of-pocket mammography expenditures.
Additional variations in mammography expenditures were observed among women residing in different regions of the United States. Women in the Midwest bear nearly twice the out-of-pocket mammography expenditures as those who reside in the West. Women who reside in the Northeast have the lowest out-of-pocket mammography expenditures yet the highest total mammography expenditures of all regions. This may be explained by different reimbursement rates that are calculated based on the area's various labor market factors.
Other variations in mammography expenditures were observed between the types of facility where a mammogram was received. Compared to women who received mammograms at an office-based facility, women who received mammograms at a hospital outpatient facility had lower out-of-pocket mammography expenditures but greater total mammography expenditures. Because of a shortage of specialists, many rural areas may not have an office-based facility that provides mammography services. Therefore, women may receive their mammogram at a hospital outpatient facility in either their area or some distance away.
Although adherence to recommended mammography screening guidelines was not the purpose of the present study, our sample (largely white, of high income, with private insurance) suggests that women for whom cost is not a barrier and out-of-pocket mammography expenditures do not present a high financial burden may be more likely to receive a mammogram. A descriptive comparison of women who did and who did not receive a mammogram in 2007 or 2008 is shown in the Appendix
Major strengths of our study include large nationally representative data, comprehensive information on many variables that can be controlled for, and the availability of payments rather than charges for mammograms. However, some limitations need to be noted. A major limitation is that the study did not examine mammography expenditures associated with guideline-consistent mammography screening; the purpose of this study, however, was not to determine guideline-consistent mammography screening but how much the women were paying. Another limitation may arise from recall bias. To limit recall bias, the survey was conducted in five panels that occur in shorter intervals than if it was administered at one time. In addition, our sample may suffer from selection bias; for example, women classified as poor represented almost 15% of our sample, whereas they represented almost 36% of women 40–64 years of age who did not receive a mammogram during the calendar year. Furthermore, almost four times as many women (20.8%) who were uninsured did not receive a mammogram during the calendar year compared to those who did (5.5%). Finally, although this study only examined possible financial barriers to receiving a mammogram, nonfinancial barriers have been demonstrated to be equally effective at discouraging women from receiving a mammogram. Study findings from Schueler et al.43
found that women who did not have a usual source of care, did not see a obstetrician/gynecologist, and did not have a physician recommend a mammogram were less likely to receive a mammogram. In addition, a lack of screening knowledge and particular mammography beliefs, as well as concerns about safety and pain, prevented receipt of mammography.43
Despite these limitations, our study estimated women's average out-of-pocket mammography expenditures. The average out-of-pocket mammography expenditure was found to be $33. Although public insurance coverage reduced the average out-of-pocket mammography expenditures, the proportions of out-of-pocket mammography expenditures to total mammography expenditures were larger among some subgroups of women, suggesting that higher financial burden and higher cost sharing may influence women's decision to seek health services, especially those that are preventive, such as a mammogram. Further disparities in out-of-pocket mammography expenditures were seen among women who were uninsured and living in different geographic regions of United States and also in the type of facility where the mammogram was received.
Considering that the largest variations in out-of-pocket mammography expenditures were observed among uninsured women, the recently passed healthcare reform bill that includes provisions of the Patient Protection and Affordable Care Act may be a step in the right direction to eliminate these disparities. (www.healthcare.gov/center/regulations/prevention/regs.html
This law prohibits the imposition of cost-sharing requirements with respect to evidence-based recommendations with a rating of A or B by the United States Preventive Services Task Force. Strict enforcement of this provision across regions and type of facilities that offer mammography screening will go a long way toward eliminating financial barriers to mammography screening.