Payers and employers must evaluate breast cancer screening follow-on diagnostic pattern quality, value

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Higher follow-on diagnostic rates, variation in patterns of follow-on diagnostics, higher breast biopsy rates, and higher false positive biopsy rates due to Affordable Care Act (ACA) provisions demonstrate the need for payer and employer evaluation of the quality and value of breast cancer screening follow-on diagnostic patterns, according to an actuarial analysis published by Milliman on Feb. 20.

Provisions of the ACA are expected to increase breast cancer screening utilization and affiliated follow-on diagnostic testing in the future. However, the broad variation in screening use and testing indicates that better methods are needed to examine suspicious lesions.

Milliman’s analysis reviewed claims from 2009-2011 from MarketScan and identified a study population of about one million women between the ages of 30 and 64 who had undergone mammography screening. Seventeen percent of the studies had follow-on testing, revealing a higher recall rate than that of previous research.

The average screening episode was calculated to be $249.70 for each woman; 62 percent of the cost was from the mammogram and the remaining 38 percent was from follow-on diagnostics. Of the follow-on diagnostics, almost 18 percent were from biopsy, 7.2 percent from follow-up diagnostic mammogram and 4.2 percent from MRI. Less than one percent of the cost was attributed to molecular breast imaging and other procedures.

Additionally, a wide variation in utilization and follow-on diagnostic sequencing was observed. A breast biopsy rate of 2.4 percent was twice that of rates published by the Breast Cancer Surveillance Consortium and a false positive rate of 81 percent was higher than rates reported by the organization as well.

The Milliman report suggests payers and employers review their population’s breast cancer screening recall rates, biopsy rates and evidence of subsequent cancer detection to assess their quality and value of follow-on diagnostic testing.

The report was sponsored by Gamma Medica.