Effect of Fee Removal on the Use of Digital Breast Tomosynthesis to Minimize Health Care Disparities.

Background: After FDA clearance of digital breast tomosynthesis (DBT) in 2011, many insurers were slow to adopt full coverage without cost sharing. Our institution implemented a $45 out-of-pocket fee for DBT, refunded upon insurance payment. This fee was eliminated in January 2021 after most insurers began covering DBT. We evaluated the effect of out-of-pocket fee removal on DBT versus digital mammography use across patient groups.

Methods: We conducted a retrospective analysis of screening mammograms scheduled at a multisite academic institution between March 2018 and August 2022. A difference-in-difference analysis was performed for women with screening mammography both before and after fee removal to assess the effect of fee removal across patient groups.

Results: Among 13,284 women (mean age, 61.5 ± 11.2 years), DBT utilization increased from 83.7% (11,123 of 13,284) pre-intervention to 91.5% (12,256 of 13,284) postintervention. Relative to White patients, the rise in DBT utilization was greater by 5.0 percentage points (pp) for Asian patients (95% confidence interval [CI] = 3.7-6.2), 6.2 pp for Black patients (95% CI = 5.0-7.3), and 6.2 pp for Hispanic patients (95% CI = 4.9-7.5). Non-English-speaking patients had a larger increase in DBT usage than English-speaking patients (7.1 pp; 95% CI = 6.1-8.1). Medicaid (6.7 pp; 95% CI = 4.8-8.5) and commercially insured (5.1 pp; 95% CI = 3.8-6.4) patients showed a greater rise in DBT usage than patients with Medicare. Patients from more socio-economically disadvantaged areas had a greater increase in DBT utilization compared with those from less disadvantaged areas (5.2 pp; 95% CI = 4.1-6.8).

Conclusion: Eliminating out-of-pocket cost for DBT improved overall utilization and narrowed disparities. However, persistent inequities suggest additional strategies are needed to ensure equitable access to DBT for all women undergoing screening mammography.