Starting next month, all health insurers in Missouri will be required to cover 3D mammograms, as well as the traditional flat images.
So do you need one?
The medical community isn’t in total agreement, but a consensus is growing among specialists that 3D is the way to go for spotting breast cancer.
“(For) the majority of specialized breast radiologists who read a ton of mammograms day in and day out, really the evidence is building that digital breast tomosynthesis (3D mammogram) increases cancer detection and decreases false positives,” said Ruby Meierotto, a radiologist at the St. Luke’s East Breast Center. “At some point, the 3D mammogram will be the standard of care.”
But it’s not there yet, which is why some private insurers haven’t covered it for routine breast exams in the past.
In the medical community at large, there’s some disagreement about whether researchers know enough to say definitively that the 3D mammograms are better.
But the National Cancer Institute, a federal consortium of cancer researchers, says that’s getting ahead of the evidence.
“Although many women are offered DBT (digital breast tomosynthesis), it has not yet been determined conclusively whether it is superior to 2-D mammography at identifying early cancers and avoiding false-positive results,” the institute says on its website.
NCI is funding a large-scale clinical trial to get a more definitive answer. It began last year and is expected to take five years.
“I think NCI is always kind of a cautious organization,” said Tiffany Lewis, a radiologist at Truman Medical Centers. “I do think there’s long-term data and studies that prove the benefits (of 3D mammograms).”
Lewis said she spots cancers almost every day on 3D scans that she might have missed on 2D.
Meanwhile, although 3D mammograms are covered under the federal health insurance program Medicare, a separate federal advisory group, the U.S. Preventative Services Task Force, has so far declined to make it one of the preventive services that insurers are required to cover under the Affordable Care Act.
In the absence of a federal coverage mandate, some states have passed their own.
Arkansas, Connecticut, Illinois, Maryland, New Jersey, Pennsylvania and Texas all had one on the books by the end of 2017, according to the American College of Radiology, while Missouri was one of at least seven other states that considered bills in 2018. Kansas has not taken up legislation.
The Missouri bill, HB 1252, was introduced by Rep. Dean Plocher, a Republican attorney from St. Louis.
Plocher said it seemed like a “no-brainer” given the prevalence of breast cancer. He said he wasn’t aware there’s still some disagreement about whether the 3D scans are better, but said that discussion should be between doctors and patients.
“I think the doctor should have a greater input, along with the patient, as to the course and scope of medical care and not just the insurance company that’s trying to make a bottom line,” Plocher said.
The bill proved non-controversial, passing the House 145-2 and the Senate 32-1.
America’s Health Insurance Plans, a trade group for health insurers, didn’t oppose it.
The bill also lowers the patient age at which insurers must cover annual mammograms from 50 to 40. Medical guidelines for that are all over the map.
The American College of Radiology recommends annual mammograms starting at age 40.
The American Cancer Society’s guidelines call for annual scans starting at 45 and then one every two years after age 55, but the group also says women 40 to 44 should be given the option of a mammogram.
The U.S. Preventive Services Task Force recommends mammograms every other year, starting at age 50, but also says younger patients should be offered them at their discretion.
While all the groups say mammograms are indispensable for detecting cancer, they disagree on when the risks of false positives and unnecessary medical procedures like biopsies outweigh the benefits of early detection.
The Missouri bill goes into effect Aug. 28, but for the first few months insurers will only be required to pay for 3D mammograms at the 2D rate. Depending on their plan, patients may have to pay the difference, which is between $50 and $100.
Insurers will have to cover it at the full 3D rate starting Jan. 1, 2019, when new insurance plans with new premiums go into effect.
Plocher said he expects the effect on premiums to be minimal.
Blue Cross and Blue Shield of Kansas City, the area’s largest private insurer, started covering the 3D mammograms on July 1.
Lewis said it’s an important step. She said about half of her patients now who have to pay out of pocket for the 3D scan choose the 2D instead. Truman Medical Center already serves a vulnerable population or patients, and Lewis said having to choose the older technology makes some more vulnerable.
“I think it would be fantastic in the future if all mammograms were 3D mammograms,” Lewis said.