4
Understanding Cost & Coverage Issues with Diagnostic Breast Imaging
V. Patient Perspective
In-depth interviews with women from five targeted states (TX, CA, IL, FL, OH and MA) shed light on the issue.
Four reoccurring themes were uncovered throughout Martec’s phone interviews:
1. With diagnostic imaging costs varying so much across the board, women are unsure of what to expect—
leading to frustration, confusion, and sometimes avoidance.
- Elayne from Columbus, OH [Medicaid] “It’s not fair to people when they have to make the choice between getting
mammograms and ultrasounds vs something else…like paying rent or for their kids’ lunch.”
- Krista from Wellesley, MA [Tufts] “I just found out my scheduled breast MRI is not covered by my insurance. So it
seems like I have three choices right now—cancel my MRI, private pay, or appeal the decision…which takes I don’t know
how long. I’d consider the private pay option, but no one can give me an estimate…doctors have no idea. Everyone
throughout this whole process seems to be in the dark—as if they haven’t done this a million times before.”
- Stephanie from Cyprus, TX [Cigna] “He wants me to do a Diagnostic Mammogram...I asked them about out-of-pocket
charges…I would have to pay $430 and that doesn’t include radiologist charges and other separate charges. This really
pisses me o because they want us to do screening each year but then the cost is getting higher which makes it pretty
hard to aord. I know I paid half that price last year.”
2. The process of getting tested is already stressful—women view the unexpected costs as a “cherry on top”
and yet another aspect of the experience to dread. Some even believe the cost is getting worse over time.
- Raechael from Chino, CA [Blue Cross Blue Shield] “It’s already a really scary process—finding a lump, getting tested, waiting
for results…wondering if I’ll be paying o my bills for the next few years is just the icing on the cake. It’s a lot to handle.”
- Jan from Palo Alto, CA [Health Net & Cigna] “I was referred for a mammogram and ultrasound for a lump that my primary
doctor found. Because I’m about a year too young, by insurance covers nothing. I struggled to pay $1,200 combined.”
- Ebonie from Chicago, IL [Humana HMO] “I used to have Blue Cross Blue Shield and we didn’t have a copay for
normal mammograms but even then, I still paid $1700 because the no-cost mammogram lead to ultrasound, another
mammogram, and an MRI. But Humana, which I have now, is even worse because I have a $50 copay just for screening.”
3. Many women decide to cancel or delay their doctor recommended diagnostic tests when they find out the
cost—either waiting for better coverage or until they can save up enough money. Others are jaded by past
prices paid and will only return for testing if they feel it is necessary (i.e. finding a lump on their own).
- Kristen from Lagrange, IL [Blue Cross] “Since I just got checked out, I probably won’t go back for at least 3 or 4 years.
The copay is so high for specialists, and even for my primary care doctor, so I’ll only go if I think I feel something again.”
- Theresa from San Francisco, CA [Anthem Blue Cross] “I have extremely dense breasts and every time I have a
mammogram or a breast exam, the technician or medical personnel comments that I would be better o having a 3D
mammogram. Since my insurance won’t cover a 3D until the regular mammogram comes back in question, the cost-
prohibitive 3D exams will not be covered, so I haven’t had one. Recently, I had genetic testing as part of a mammogram/
breast study, and the results came back as my having a gene (not the BRACs) that are indicating a very increased risk
for breast cancer. I was scheduled for a breast MRI in October, but when I found out that I would first have to meet my
$500 deductible and then still have to pay even more (insurance will only cover 80% until I meet the $2500 max out of
pocket), I ended up cancelling that procedure. I still haven’t gotten it because I can’t aord it right now.”
- Annie from Wylie, TX [Medicaid] “I’m a 14-year breast cancer survivor, so you think I’d be able to aord at least a yearly
mammogram. But Obamacare is terrible. It doesn’t cover hardly anything. I’ve been waiting a few years to get checked
again because in March I qualify for Medicare and I’ve heard that’s better.”
- Nancy from Chicago, IL [No insurance] “Prior to beginning my job in June, I was a contractor and responsible for
covering my own medical costs. Hence, I put o having an MRI (breast mammogram) until approximately two years ago
when I turned 48, as I did not want to pay out-of-pocket.”
- Brittany from Chicago, IL [Aetna PPO] “I had to pay $549 out of pocket for my ultrasound, but they let me pay it o
monthly. I’m still making payments. It makes me hesitant to go in the future…. knowing how much it will cost me makes
me think, maybe I can put it o a little longer until I get my finances together... Some of my friends are even hesitant to
go to the gyno because they think everything will cost too much. They want to wait until they feel something.”