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Co-Pays Contribute to Drop in Preventive Care

Even small co-pays made some women opt out of screening mammographies, study finds,,,,

WEDNESDAY, Jan. 23 (HealthDay News) -- A co-pay as small as $10 can stand in the way of a woman getting a potentially lifesaving mammography, new research suggests.

When women in Medicare managed-care plans were asked to contribute a small co-pay, in some cases around $10 to $20, 8 percent of the women decided to forgo mammograms altogether, according to a study published in the Jan. 24 issue of the New England Journal of Medicine.

"A small co-pay can lead to a sharp decrease in the breast cancer screening rate," said study author Dr. Amal Trivedi, an assistant professor of community health at the Warren Alpert School of Medicine at Brown University in Providence, R.I.

Trivedi said more and more, insurance plans are instituting cost-sharing in the form of co-pays, and the idea behind it is to get consumers to consider cost before getting health-care services. The hope is that people will reconsider potentially unnecessary procedures or medicines but not forgo essential health-care services. However, it doesn't always work out that way, as this study illustrates.

"This is an example where a co-pay had an adverse effect on health," Trivedi said. "For highly valuable services, such as mammography, insurers should eliminate co-pays. It could save lives. And, a small co-pay doesn't make a lot of economic sense if it deters women from getting timely screenings. The costs of untreated early disease are much higher."

Trivedi and his colleagues reviewed mammography data from 174 Medicare managed-care insurance programs. They reviewed data on 366,475 women between the ages of 65 and 69 from 2001 through 2004.

The researchers compared plans with cost-sharing to those that didn't. They also compared rates of mammography in plans with recently instituted co-pays to those that retained full coverage.

The number of insurance plans that required a $10 co-pay or more, or a 10 percent or higher co-insurance payment per mammography, increased dramatically during the study period, according to Trivedi.

"In 2001, one woman in 200 was required to pay a co-pay. In 2004, the number required to pay a co-pay had increased to one in nine. That's a twenty=fold increase," he said.

Those co-pays made a difference in care. Screening rates were 8.3 percent lower in the cost-sharing plans versus plans with full coverage. Cost-sharing appeared to hit the poorest and least educated women the hardest.

Screening rates dropped 5.5 percent in insurance plans that introduced cost-sharing during the study period, yet increased by 3.4 percentage points in plans that maintained full coverage.

"A proportion of the population is very price-sensitive, and they tend to be the ones with fewer dollars to start. Apparently, we haven't been able to make our case to this group of women that $10 spent on mammography is money well-spent," said Dr. Peter Bach, a pulmonologist and epidemiologist at Memorial Sloan-Kettering Cancer Center in New York City.

Bach, who wrote an accompanying editorial in the same issue of the journal and was a senior advisor for Medicaid and Medicare Services, said this study shouldn't be interpreted to mean that all co-pays should be waived for preventive services. "We have to ask, what's the health gain? It doesn't matter the cost per test. Some preventive services really work, and some don't. We want people to use services that are of value."

Because "the value of breast cancer screening has been demonstrated in many studies," Trivedi said he does recommend waiving co-pays for mammograms. "Co-pays can deter women from getting mammograms. I would urge health plans to eliminate co-pays."

More information

To learn more about screening mammography, visit the National Women's Health Information Center.

SOURCES: Amal Trivedi, M.D., assistant professor, community health, Warren Alpert School of Medicine, Brown University, Providence, R.I.; Peter Bach, M.D., pulmonologist and epidemiologist, Memorial Sloan-Kettering Cancer Center, New York City; Jan. 24, 2008, New England Journal of Medicine

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