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

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.

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.

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).

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.