Understanding Regional Variation in the Cost of Breast Cancer Screening Among Privately Insured Women in the United States.

Background: Breast cancer screening for women aged 40-49 years is prevalent and costly, with costs varying substantially across US regions. Newer approaches to mammography may improve cancer detection but also increase screening costs. We assessed factors associated with regional variation in screening costs.
Methods: We used Blue Cross Blue Shield Axis, a large US commercial claims database accessed through secure portal, to assess regional variation in screening utilization and costs. We included screening mammography±digital breast tomosynthesis (DBT), screening ultrasound, diagnostic mammography±DBT, diagnostic ultrasound, magnetic resonance imaging and biopsy, and evaluated their utilization and costs. We assessed regional variation in annual per-screened-beneficiary costs and examined potential savings from reducing regional variation.
Results: Of the 2,257,393 privately insured women, 41.2% received screening mammography in 2017 (range: 26.6%-54.2% across regions). Wide regional variation was found in the DBT proportion (0.7%-91.1%) and mean costs of DBT ($299; range: $113-714) and 2-dimensional (D) mammograms ($213; range: $107-471). In one-fourth of the regions, the mean DBT cost was lower than the mean 2D mammography cost in the full sample. Regional variation in the per-screened-beneficiary cost (mean: $353; range: $151-751) was mainly attributable to variation in the cost of DBT (accounting for 23.4% of regional variation) and 2D mammography (23.0%). Reducing regional variation by decreasing the highest values to the national mean was projected to save $79-335 million annually.
Conclusions: The mean mammogram cost for privately insured women ages 40-49 varies 7-fold across regions, driving substantial variation in breast cancer screening costs. Reducing this regional variation would substantially decrease the screening costs.
Competing Interests: N.K. reported funding from the Research Council of Norway and LINK Medical Research (grant numbers 276146 and 304034) during the conduct of the study, and personal fees for speaking from Thermo Fisher Scientific. X.X. reported receiving research support through Yale University from the Centers for Medicare & Medicaid Services to develop and maintain performance measures, and grants from the American Cancer Society during the conduct of the study. S.H.B. reported receiving research grants from the National Institute of Health, the Robert Wood Johnson Foundation, the Donaghue Foundation and the American Cancer Society during the conduct of this study. K.A.K. reported receiving research support through Yale University from the Centers for Medicare and Medicaid Services to develop and maintain hospital performance measures during the conduct of the study. S.T.L. is the founder and co-owner of NowPow, LLC and reports receiving royalty payments from UpToDate. I.B.R. reported receiving grants from the National Institutes of Health/National Center for Advancing Translational Sciences during the conduct of the study and personal fees from the Centers for Medicare and Medicaid, outside the submitted work. C.P.G. reported receiving research grants from the National Comprehensive Cancer Network-(funded by Pfizer/Astra-Zeneca), funding from Johnson & Johnson to assist with developing new approaches to sharing clinical trial data (through the Yale Open Data Access Project), and funding from Flatiron Inc. for travel/speaking, outside the submitted work. J.B.L. declares no conflict of interest.
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