Patricia Quinn knows she really should go to the doctor.
The 51-year-old Philadelphia resident has dense breast tissue and a history of benign cysts, both of which can make it harder to scan for breast cancer.
But after an unexpected $800 bill for a diagnostic mammogram last year, Quinn has been putting off a return visit.
Most insurance plans are required to cover routine mammograms to screen for cancer in full. But diagnostic mammograms, commonly ordered to get a better look at possible abnormalities that may have been obscured by dense tissue and cysts, can lead to bills for patients — especially those who, like Quinn, have a high-deductible health plan.
“I am concerned about the health implications. I know I need to go to the doctor to get another mammogram, but I keep putting it off,” said Quinn, who is the founder of Final Farewell, a Jenkintown nonprofit that provides financial assistance to help families pay for children’s funerals.
Delaying preventive services such as mammograms can be dangerous, potentially allowing an illness to advance to a point where it could be more difficult to treat.
But rising health-care costs are straining people’s budgets to the point where they are rationing medications, skipping doses entirely, and delaying procedures because they fear they can’t afford them. Research has found that patients with high-deductible health plans, who face greater out-of-pocket costs in exchange for low monthly premiums, are especially susceptible to delayed care.
A new Harvard study has found that the trend extends beyond mammograms to breast cancer treatment. Women with high-deductible health plans waited up to eight months longer to get treatment for breast cancer compared with women with low deductibles, according to findings published in the March issue of the journal Health Affairs. Low-income women had the longest delays, but the time lag to first biopsy, surgery, and chemotherapy treatment existed for women across income levels, the study found.
Cancer treatment can cost tens of thousands of dollars, and comes with other financial losses even for those with good insurance. The study’s findings reinforce concern among patient advocates that the incredible cost — a phenomenon widely known as “financial toxicity” — is further damaging women’s health.
“Diagnosis of breast cancer, is of course, devastating for patients. But they don’t realize until later that it’s also financially devastating — even when they have insurance,” said Pat Halpin-Murphy, president of the Pa. Breast Cancer Coalition, a patient advocacy organization.
‘Delays every step of the way’
Researchers analyzed health-plan claims data for about 131,000 women with high deductibles and varying incomes to find out how long it took for the women to reach key benchmarks in cancer treatment: diagnostic imaging, biopsy, surgery, and chemotherapy.
Low-income women with a high deductible of more than $1,000 got their first diagnostic breast imaging 1.6 months later than peers with low-deductible health plans. Their breast biopsy was delayed 2.7 months and their first surgery was 6.6 months behind women with health plan deductibles below $500. Chemotherapy came 8.7 months later for this group, compared with peers with low-deductible plans.
High-income women with high deductibles experienced shorter, but still sizable, delays — for example, their chemotherapy came 5.7 months later than women with similar incomes and lower deductibles.
“High-deductible health plans are a type of insurance that substantially increases the level of out-of-pocket cost people pay for their care, in this case women with breast cancer. We have been trying to see how much those out-of-pocket costs affect access to breast cancer care,” said J. Frank Wharam, an associate professor at Harvard Medical School and the study’s lead author. “We found delays every step of the way.”
‘In a bind’
The findings point to the need for greater research into two questions a study based on claims data can’t answer, Wharam said: Why are the delays happening and how do they affect women’s health?
An earlier study by researchers at Fox Chase Cancer Center at Temple University found a 3 percent to 4 percent decline in survival rate among women who had surgery three to four months after diagnosis, compared with having the procedure within a month.
“Delays in breast cancer do matter, but what we found is they matter to a magnitude that is much smaller than we were always concerned,” said Richard Bleicher, a surgical oncologist and professor in the Department of Surgical Oncology at Fox Chase Cancer Center.
Cancer doctors try to minimize delays, but Bleicher said it is important to develop a treatment plan that is appropriate for the patient, even if it delays surgery by a few weeks.
Researchers are still learning about how delays to treatment affect outcomes, which could vary depending on the cancer’s aggressiveness. In the meantime, there’s no “hard and fast rule for when you need to have surgery by,” Bleicher said.
The Harvard study did not investigate exactly why women with high-deductible plans delayed care, but Wharam said he suspects that out-of-pocket costs are a major factor.
Doctors often are not trained to discuss cost of care with their patients. But for women facing a breast cancer diagnosis, cost is top of mind, said Halpin-Murphy. Women worried that their diagnosis could bankrupt their families commonly base their treatment decisions on what they can afford, she said.
For example, intravenous chemotherapy administered at a hospital is typically covered by insurance, but until recently, chemotherapy pills that can be taken at home were not covered the same way, putting that approach out of reach for many women. Pennsylvania passed legislation three years ago to require that oral chemotherapy be covered the same way as the infused medication.
“People are just in a bind. They think they’re doing the right thing, they have insurance. Then they find out they’re not covered for basic things,” Halpin-Murphy said.
When Quinn got her $800 diagnostic mammogram bill, she turned to the Pa. Breast Cancer Coalition for help challenging it with the provider.
For 2019 she switched back to a low-deductible plan.
She said she plans to call her insurer to check how much a diagnostic mammogram will cost, but faces yet another typical problem: whether the price she is quoted will be what she really is charged.
“You sit on the phone, you’re on hold, it seems like people don’t even know the right answers. No one can give you a straight answer,” Quinn said.