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Understanding Regional Variation in the Cost of Breast Cancer Screening Among Privately Insured Women in the United States

Kunst, Natalia; Long, Jessica B; Xu, Xiao; Busch, Susan H; Kyanko, Kelly A; Lindau, Stacy T; Richman, Ilana B; Gross, Cary P
BACKGROUND:Breast cancer screening for women aged 40-49 years is prevalent and costly, with costs varying substantially across US regions. Newer approaches to mammography may improve cancer detection but also increase screening costs. We assessed factors associated with regional variation in screening costs. METHODS:We used Blue Cross Blue Shield Axis, a large US commercial claims database accessed through secure portal, to assess regional variation in screening utilization and costs. We included screening mammography±digital breast tomosynthesis (DBT), screening ultrasound, diagnostic mammography±DBT, diagnostic ultrasound, magnetic resonance imaging and biopsy, and evaluated their utilization and costs. We assessed regional variation in annual per-screened-beneficiary costs and examined potential savings from reducing regional variation. RESULTS:Of the 2,257,393 privately insured women, 41.2% received screening mammography in 2017 (range: 26.6%-54.2% across regions). Wide regional variation was found in the DBT proportion (0.7%-91.1%) and mean costs of DBT ($299; range: $113-714) and 2-dimensional (D) mammograms ($213; range: $107-471). In one-fourth of the regions, the mean DBT cost was lower than the mean 2D mammography cost in the full sample. Regional variation in the per-screened-beneficiary cost (mean: $353; range: $151-751) was mainly attributable to variation in the cost of DBT (accounting for 23.4% of regional variation) and 2D mammography (23.0%). Reducing regional variation by decreasing the highest values to the national mean was projected to save $79-335 million annually. CONCLUSIONS:The mean mammogram cost for privately insured women ages 40-49 varies 7-fold across regions, driving substantial variation in breast cancer screening costs. Reducing this regional variation would substantially decrease the screening costs.
PMID: 33560712
ISSN: 1537-1948
CID: 4814792

Surprise Bills from Outpatient Providers: a National Survey [Letter]

Kyanko, Kelly A; Busch, Susan H
PMID: 32671720
ISSN: 1525-1497
CID: 4529122

Breast cancer supplemental screening: Women's knowledge and utilization in the era of dense breast legislation

Aminawung, Jenerius A; Hoag, Jessica R; Kyanko, Kelly A; Xu, Xiao; Richman, Ilana B; Busch, Susan H; Gross, Cary P
BACKGROUND:Given the growth in dense breast notification (DBN) legislation in the United States, we examined the association between different types of DBN laws and supplemental screening behaviors among women. METHODS:We surveyed in March-April 2018 a nationally representative sample of women aged 40-59 years who received a routine screening mammogram in the past 18 months. Survey items included the following topics regarding supplemental screening: discussing risks or benefits with a provider, knowledge about the risk of false positives, and utilization. We grouped women by state DBN into non-DBN, generic DBN (mentions breast density but not supplemental screening), DBN that mentions supplemental screening (DBN-SS), and DBN with mandated insurance coverage for supplemental screening (DBN-coverage), and estimated adjusted predicted probabilities for supplemental screening behaviors. RESULTS:Of 1641 women surveyed, 21.3% resided in non-DBN, 41.2% in generic DBN, 25.8% in DBN-SS, and 12.5% in DBN-coverage states. Overall, 23.0% of respondents had discussed supplemental screening with a provider, 11.3% of whom discussed the risks, and 49.5% discussed the benefits. In adjusted analysis, women living in DBN-coverage states were more likely to discuss supplemental screening (27.5%) than women in non-DBN states (13.6%); pairwise contrast 13.8% (95% CI, 2.1% to 25.6%; P = .01). They were also more likely to have received supplemental screening for increased breast density (19.3%) compared to women living in non-DBN (9.9%); contrast 9.4% (95% CI, 1.6% to 17.3%; P = .01), Generic DBN (7.3%); difference 12.0% (95% CI, 4.6% to 19.4%; P =< .001), and DBN-SS (8.8%); contrast 10.5% (95% CI, 2.6% to 18.5%; P < .01) states. CONCLUSIONS:Women in DBN-coverage states were more likely to discuss supplemental screening with their providers, and to undergo supplemental screening, compared to women in states with other types of DBN laws, or without DBN laws.
PMID: 32537899
ISSN: 2045-7634
CID: 4489862

Dense Breast Notification Laws, Education, and Women's Awareness and Knowledge of Breast Density: a Nationally Representative Survey

Kyanko, Kelly A; Hoag, Jessica; Busch, Susan H; Aminawung, Jenerius A; Xu, Xiao; Richman, Ilana B; Gross, Cary P
BACKGROUND:To date, 38 states have enacted dense breast notification (DBN) laws mandating that mammogram reports include language informing women of risks related to dense breast tissue. OBJECTIVE:Nationally representative survey to assess the association between residing in a state with a DBN law and women's awareness and knowledge about breast density, and breast cancer anxiety. DESIGN/METHODS:Internet survey conducted in 2018 with participants in KnowledgePanel®, an online research panel. PARTICIPANTS/METHODS:English-speaking US women ages 40-59 years without a personal history of breast cancer who had received at least one screening mammogram (N = 1928; survey completion rate 68.2%). MAIN MEASURES/METHODS:(1) Reported history of increased breast density, (2) knowledge of the increased risk of breast cancer with dense breasts, (3) knowledge of the masking effect of dense breasts on mammography, and (4) breast cancer anxiety. KEY RESULTS/RESULTS:Women residing in DBN states were more likely to report increased breast density (43.6%) compared with women residing in non-DBN states (32.7%, p < 0.01, adjusted odds ratio, 1.70, 95% CI,1.34-2.17). Interaction effect between DBN states and education status showed that the impact of DBN on women's reporting of dense breasts was significant for women with greater than high school education, but not among women with a high school education or less (p value = 0.01 for interaction). Only 23.0% of women overall knew that increased breast density was associated with a higher risk of breast cancer, and 68.0% of women understood that dense breasts decreased the sensitivity of mammography. There were no significant differences between women in DBN states and non-DBN states for these outcomes, or for breast cancer-related anxiety. CONCLUSIONS:State DBN laws were not associated with increased understanding of the clinical implications of breast density. DBN laws were associated with a higher likelihood of women reporting increased breast density, though not among women with lower education.
PMID: 31916210
ISSN: 1525-1497
CID: 4257502

Changes in breast cancer screening costs after the introduction of digital breast tomosynthesis [Meeting Abstract]

Richman, I B; Long, J; Kunst, N; Hoag, J; Xu, X; Kyanko, K A; Aminawung, J; Busch, S; Gross, C
BACKGROUND: Previous studies have estimated that breast cancer screening costs more than 7 billion dollars annually in the US. However, in recent years, screening technology has changed considerably with the introduction of digital breast tomosynthesis (
ISSN: 1525-1497
CID: 4803442

Comparative effectiveness of digital breast tomosynthesis for breast cancer screening among olderwomen [Meeting Abstract]

Upneja, A; Long, J; Aminawung, J; Kyanko, K A; Kunst, N; Xu, X; Busch, S; Gross, C; Richman, I B
BACKGROUND: Digital breast tomosynthesis (
ISSN: 1525-1497
CID: 4803472

Incorrect Provider Directories Associated With Out-Of-Network Mental Health Care And Outpatient Surprise Bills

Busch, Susan H; Kyanko, Kelly A
Mental health services are up to six times more likely than general medical services to be delivered by an out-of-network provider, in part because many psychiatrists do not accept commercial insurance. Provider directories help patients identify in-network providers, although directory information is often not accurate. We conducted a national survey of privately insured patients who received specialty mental health treatment. We found that 44 percent had used a mental health provider directory and that 53 percent of these patients had encountered directory inaccuracies. Those who encountered inaccuracies were more likely (40 percent versus 20 percent) to be treated by an out-of-network provider and four times more likely (16 percent versus 4 percent) to receive a surprise outpatient out-of-network bill (that is, they did not initially know that a provider was out of network). A federal standard for directory accuracy, stronger enforcement of existing laws with insurers liable for directory errors, and additional monitoring by regulators may be needed.
PMID: 32479225
ISSN: 1544-5208
CID: 4480892

Use and Costs of Breast Cancer Screening for Women in Their 40s in a US Population With Private Insurance

Kunst, Natalia; Long, Jessica B; Xu, Xiao; Busch, Susan H; Kyanko, Kelly A; Richman, Ilana B; Gross, Cary P
PMID: 32202606
ISSN: 2168-6114
CID: 4358382

Effect of mandated breast density reporting legislation on women's awareness and knowledge of breast density [Meeting Abstract]

Kyanko, K A; Hoag, J R; Busch, S; Aminawung, J; Xu, X; Richman, I B; Gross, C
Background: To date, 35 states have enacted dense breast notification (
ISSN: 1525-1497
CID: 4052802

Consumer experiences with private health insur-ance provider networks [Meeting Abstract]

Kyanko, K A; Busch, S
Background: Provider networks are an important tool for private health insurers to control costs and ensure quality care for their enrollees. However, provider networks have been criticized for inaccurate directories, limited or narrow choice of providers that omit highly rated " star" hospitals and may lead to undesired or surprise out-of-network care, and disruption of continuity of care if a provider leaves the network or a patient changes plans. We conducted a nationally representative survey to examine consumer experiences and preferences with provider networks in private health insurance plans.
Method(s): Internet survey conducted in 2018 with participants in the GfK KnowledgePanel, a probability-based online research panel designed to be representative of the U.S. population. The sample included 2,059 English-speaking US adults aged 18 to 64 years enrolled in private health insurance with a provider network and used an outpatient health care provider in the last year.
Result(s): 74% agreed that their insurer had made enough in-network providers available. A significantly greater proportion of respondents rated protection from inpatient surprise bills as extremely important or very important from their plan as compared to inclusion of top rated " star" hospitals in the plan network (77% versus 59%, p< 0.01). Among those with a choice of plan, 60% of respondents tried to determine if a specific provider was in-network before choosing a plan, and just over half (57%) reported that the result of the search affected their choice of plan. Of the 46% who used the provider directory once enrolled in the plan, 36% reported a problem either with inaccurate provider contact information or with a listed provider not actually taking their insurance or not taking new patients. Among the 16% who had a provider leave their network, 62-66% had their relationship with the provider disrupted and switched to new provider. Another 10-12% simply stopped treatment.
Conclusion(s): Consumers in private insurance plans report satisfaction with the breadth of their provider networks, however problems remain in the accuracy of provider directories and disruption in care from provider turnover. More respondents rated protection from surprise inpatient out-of-network bills as an important plan attribute compared to inclusion of top rated hospitals in the network. Insurers may consider in their product design strong consumer preferences for protections from surprise out-of-network bills and the inclusion of a specific provider in the network in their choice of a plan. In addition to monitoring network adequacy and accuracy of provider directories, additional policy efforts may be needed to ensure and continuity of care due to providers leaving a network. Addressing these provider network issues can preserve their function as a cost saving tool without compromising access and the consumer experience
ISSN: 1525-1497
CID: 4053022