In the Garden State, a breast density law is costing plenty and raising concerns about returns

A study in New Jersey, one of a growing number of states to mandate that insurers pay for sonograms of breasts deemed dense in screening mammography exams, may provide additional ammo to detractors who warn that such legislation is misplaced and unproductive.

Looking at mammography patients of the 111-bed Hackettstown Regional Medical Center, authors Clay Hinrichs, MD, of the medical center, and John Sobotka, of St George’s University in Grenada, found a hefty increase in patient utilization after enactment of the law. Specifically, their review of the data turned up a minimum relative increase of 176.90 percent and a maximum relative increase of 335.56 percent in patient utilization of screening breast sonography.

From this and other data they estimated an increased direct cost for insurers of $4.9 million to $9.8 million for a given month.

The authors don’t cite concomitant rates of cancer detection or abnormal interpretations at Hackettstown Regional but point to an earlier study by the American College of Radiology Imaging Network (ACRIN) concluding that adding screening ultrasound to mammography will identify an additional 4.3 cancers per 1,000 women screened.

“Although the ACRIN trial has shown that increased numbers of cancers are found, this benefit must be weighed with the risk of subjecting patients to unnecessary studies and stress from false-positive results,” Sobotka and Hinrichs wrote in their study report, posted online July 9 in the Journal of the American College of Radiology. “A state must also weigh the financial repercussions we believe to be inherent to legislation endorsing further screening with this debatable possibility of beneficence for prospective patients.”

Patients whose records informed the study visited the facility for mammography during five months in 2014. Patients who opted for follow-up breast ultrasound during the study period, excluding those who had previously presented abnormalities, represented an “affirmative response.” The authors compared the mean number of patients seen during three months prior to the May 2014 enactment of the law with a mean of patients seen three months after enactment.

The authors then followed up approximately six months after enactment to avoid under- or overestimating sonogram participation. “The difference in breast ultrasound volume is then combined with the average reimbursements of these examinations,” they wrote, “to provide an aggregate reimbursement amount of these measures and thus a direct financial impact.”

Sobotka and Hinrichs noted that the dramatic increase in ultrasound use they observed required “retooling” of Hackettstown Regional’s ultrasound department to deal with various “downstream” provider costs. For example, the increased volume forced the department to purchase an additional ultrasound unit and to dedicate a technologist to performing breast sonography during the day.  

While this latest study is limited to a particular region in a particular state, it adds some additional perspective to the debate over how to address breast density in the course of breast cancer screening. It comes on the heels of commentary published in JAMA Internal Medicine arguing that breast density reporting laws, now on the books in two dozen states, are well-intentioned but ineffective.

Among the experts opposing that opinion was the influential David L. Katz, MD, who took his views to the pages of US News & World Report.

“With all due respect to my colleagues, they are wrong,” wrote Katz. “They are making a common mistake—conflating absence of evidence for evidence of absence. They are also failing to allow for the population of gaps left by science with the obvious ingredient: sense.”