Abstract P1-02-03: Defining a breast screening “bundle”: Provider reimbursement and patient cost-share
Authors: Omotoso K , Fredrick M , Dalton V , Bell S , Charkhchi P , Kamdar N , Carlos R 
Published: May 2019

Introduction: Alternative payment models encourage “bundling” of imaging services, where a bundle aggregates all services used by a population of patients for a clinical indication and estimating the per patient cost. We assess provider cost and patient cost-share for screening mammography as a bundle, or episode of care.

Methods: We used patient-level analytic files between 2004 and 2014 from Optum™ Clinformatics™ Data Mart including women 40-64 years without a history of breast cancer or mastectomy and at least one year of continuous enrollment in a given plan, examining standardized costs as a proxy for provider cost and patient cost-share, summing copayments, coinsurance and deductibles. In the episode of care, we included screening mammography (SM) and all downstream diagnostic tests up to but not including biopsy. Definition of the diagnostic pathway or episode of care aggregated any subsequent testing after the initial SM independent of test order. Bureau of Labor Statistics Medical Consumer Price Index (CPI) adjusted costs to 2014 dollars.

Results: We identified an average of 530,844 commercially insured women ages 40-64 years with at least 12 months of continuous enrollment in a given plan per year. We identified 8 order-independent diagnostic pathways that women can experience during the episode: 1) SM only; 2) SM+ diagnostic mammography (DM); 3) SM + DM + MRI 4) SM + DM + ultrasound (US); 5) SM+DM+US+MRI; 6) SM+MRI; 7) SM+US; 8) SM+US+MRI. Across the whole population, patient cost-share fell from $9.83 (CI of $9.68-9.98) in 2004 to $7.31 (CI of $7.18-7.45) in 2014, largely due to cost-share elimination for screening mammography after the ACA. However, evaluating the individual diagnostic pathways, patient cost-share increased over time for all pathways except for those who had a negative screening mammogram and required no further diagnostic work-up prior. Among those requiring diagnostic work-up, rate of cost-share increase was steeper for any diagnostic pathway that included breast MRI. In contrast, provider cost held steady or declined, particularly for those pathways that included MRI. Across the whole population, provider cost for the breast screening episode fell from $176.54 (CI $175.92-177.16) in 2004 to $141.16 (CI $140.83-141.49) in 2014.

Implications for Practice: Although provider cost and patient cost-share for the breast cancer screening bundle declined over time, patients experience an uneven burden of cost-sharing dependent on the diagnostic pathway. Patient cost-share bundles need to be created in conjunction with provider cost bundles for the breast cancer screening episode of care.

Key Words: Affordable Care Act (ACA), alternative payment models, radiology, mammography, bundled payments, cancer screening, breast cancer

Citation Format: Omotoso K, Fredrick M, Dalton V, Bell S, Charkhchi P, Kamdar N, Carlos R. Defining a breast screening “bundle”: Provider reimbursement and patient cost-share [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-02-03.