Screening Mammography: Leveling the Playing Field
Requiring access to screening mammography means an equal opportunity for insured women to receive a potentially life-saving health service regardless of ability to pay.
Leaving aside disagreements about when to begin screening, how often to screen, how to approach lead-time bias, and how to minimize overdiagnosis, etc. (enough material for a slew of other blog posts), let's get to the real heart of the matter: access to mammography.
The concept of access does not mean having an accredited facility with board-certified radiologists and convenient office hours within short travel time of every woman's home. Certainly, the word access connotes a door, portal, or (with respect to getting a mammogram) physical locale. But by access, we actually mean the ability to pay for a mammogram. Insurance coverage for screening services provides access for those who are insured. Eliminating the cost of a mammogram, the biggest hurdle for women of the least means, levels the playing field. Denying access would prevent economically vulnerable high-risk women from receiving the right care at the right time.
When we profess support for mammography access, we are saying screening mammograms are worth it, the lives benefitted by mammography are worth it. We are telling patients and policy-makers we value screening mammography, and we believe resources should be allocated accordingly. A large segment of society (many individuals, many medical professionals, and many legislators) believe that requiring insurers to cover screening mammography, whether or not patients can afford to pay, is both sound medicine and good public policy. If you really and truly believe that radiologists save women's lives using screening mammography, that women should have access to this service regardless of ability to pay, and that coverage should be blind to disagreements among medical societies, then you have an obligation to do your part to help secure that access.
Already people are speaking out after the American Cancer Society's new breast cancer screening recommendations. Six days after the announcement, the editorial board of the New York Times succinctly described the confusion-inducing advisories from medical professional societies and government agencies regarding starting age and frequency. The column concludes with its own bottom line: "When there is still such a dizzying array of expert opinion, it would be wiser to require insurers to continue covering all women starting at 40."
In other words: let's not upset the mammography insurance coverage apple cart quite yet. In the absence of clear consensus, it is preferable to maintain the status quo. This level-headed sentiment is echoed in a recent email from ACR CEO William T. Thorwarth Jr., MD, FACR, urging members to contact their states' U.S. senators and representatives. "We need your help to ensure that patients retain access to screening mammography," said Thorwarth.
The ACR's plea for insurance coverage for women between the ages of 40 and 49 does not directly address the merits or flaws of the scientific underpinnings of the USPSTF recommendations. Rather, it is the potential for denial of coverage by insurers (even for high-risk women) that is at stake. USPSTF grade A and B recommendations are covered by insurance. Grade C (and below) recommendations are not. Insurance coverage of screening mammography for women less than age 50 is in jeopardy, even if a woman and her personal physician decide it is appropriate for her to start undergoing screening mammograms at age 40 (the starting age recommended by the ACR and others) or 45 (the starting age in the new American Cancer Society recommendation). The grade C may as well be D or F: D for "Denied coverage" or F for "Forget about getting that mammogram."
So do your part and let Congress know that current coverage requirements should stand. And if your appeals to level the playing field fall on deaf ears with your legislators, consider sending Congress an additional message, paraphrased here: D can also mean "Don't think you'll get my vote" and F can also stand for "Forget about campaign donations." Make your voice heard in Congress by contacting your representatives.
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