Depending on the insurance company, Connecticut consumers may be paying for the legislature and Gov. Dannel P. Malloy’s decision to expand required coverage of breast cancer imaging to include 3D mammography.
Earlier this month during public hearings on proposed increases in their health insurance rates, one insurance company said it was going to have to raise its rates partly due to tomosynthesis, which is also known as 3D mammography.
ConnectiCare told Insurance Department regulators that it would have to increase its rates by $1.38 per member, per month, in order to accommodate coverage of the new technology.
In consultation with its chief medical director, ConnectiCare officials said it “came up with, looking at that data, an average utilization of 5,869 services per year, with an average unit cost of $110 per service. If you multiply those two numbers and divide by approximately 500,000 member months, you get to the $1.38.”
However, Anthem officials told Insurance Department regulators that they weren’t going to increase rates for this particular new coverage requirement.
Guidance issued by the Insurance Department in July stated that tomosynthesis was not considered mammography, according to the United States Preventive Services Task Force, and does not have to be considered a preventive service. If it were considered a preventative service, it would mean that there would be no cost-sharing by patients.
As a result, if insurers proceeded based on Insurance Department guidelines, women could face fees or deductibles for 3D Mammography.
“Breast tomosynthesis is not subject to the ACA requirement for no cost sharing and may be covered with a cost-sharing requirement for women of all ages,” the Insurance Department guidance reads.
A spokeswoman for the Insurance Department said they issue bulletins routinely “as a way of giving instruction to the industry, including guidance around new laws.”
Dr. Michael Crain, head of the Radiology Department at Middlesex Hospital, said there’s “no doubt that tomosynthesis is mammography.”
He said instead of looking directly at the breast with a 2D image, tomosynthesis looks inside the breast. That inside look catches cancers about 15 months before they would have been spotted with a 2D mammogram, Crain said.
“I would never recommend a 2D mammogram alone to anybody,” Crain said.
Crain, who has a practice in Guilford, said he was going to be put out of business by Yale Medical Group, if he didn’t purchase the $400,000 tomosynthesis machine.
While he hasn’t charged anything extra for the technology, he’s aware there’s a question about who pays for it. He said if insurance companies make it part of a deductible and require patients to pay out-of-pocket, then women are not going to get screened.
“Insurance companies understand this is an important technology. The question is who pays?” Crain said.
Crain said the number of patients who have to be called back for a second mammogram has been cut in half through use of the technology and those call-back mammograms are more costly than the initial one.
Under the Affordable Care Act, the state would be responsible for paying benefits beyond those included in the required essential health benefits, according to the Insurance Department. But proponents of the legislation weren’t convinced that’s the case since mammography is already a covered benefit and this is just a different type of mammography.
The state’s Insurance Department estimated tomosynthesis coverage for exchange participants would cost the state $9.2 million in fiscal year 2017 and $10 million for fiscal year 2018. Malloy included those costs in the state budget.
House Minority Leader Themis Klarides and other supporters of the bill disputed those figures. Advocates said while the cost of purchasing new equipment would be more expensive initially, the money would be made up because the 3D tests are more accurate, meaning thousands of 2D tests that are currently being done would no longer be needed.
“This service is priced differently because it’s not a standard offering,” Malloy has said. “As it becomes a standard offering, I hope the price will actually come down . . . because it’s no longer the exception, but the rule.”
Klarides said it’s only an option for patients and their doctors, rather than a mandate.
The 3D technology is better at preventing false positives, and would prevent repeat mammograms, according to medical professionals.
Editor’s note: An earlier version of this story mistakenly spelled Dr. Crain’s name incorrectly.