Mammogram cover changing?

Health insurers last week said they will continue to provide coverage for routine mammograms for women in their 40s despite a government task force's recommendation against the screenings.

Health insurers last week said they will continue to provide coverage for routine mammograms for women in their 40s despite a government task force's recommendation against the screenings.

And self-funded employers, which often rely on their health plan administrators for such coverage guidelines, are unlikely to start denying such benefits to their female employees due to the backlash that likely would ensue, experts say.

But if more evidence is published and consensus builds in support of the new recommendations, health plans and self-funded employers might reconsider their coverage provisions, they say.

Most fully insured plans provide mammography coverage for women in their 40s as a result of state mandates, so unless state legislatures take up the issue, coverage will remain in place.

After advising women in 2002 to have breast cancer screenings every one to two years beginning at age 40, the U.S. Preventive Services Task Force last week said it now recommends biennial mammograms for women starting at age 50.

The independent panel of doctors and scientists concluded that because any additional benefit gained by starting screening at age 40 rather than age 50 is “small” and potential harm from the screenings—including false positives, unnecessary procedures and radiation exposure—remains, decisions to start regular biennial mammograms after age 40 should depend on individuals rather than be routine.

Health care experts say that while the recommendations have generated controversy, women in their 40s will continue to receive coverage for mammograms, at least in the near term.

“I think a lot of people have been looking at the part of the guideline that relates to women 40-49 and there are two pieces to that,” said a spokeswoman for the Washington-based America's Health Insurance Plans.

“The first piece says that the task force is recommending against routine screening for all women 40-49 and in that context "routine' basically means "automatic.' But the second part says the decision to start screening earlier than age 50 should be an individual patient decision. So if you're following the guideline, what that means is, if a physician and a patient have a discussion about mammography and decide to go ahead with it and the physician writes the order, than it typically is going to be covered,” she said.

In terms of coverage provisions, Randall Abbott, a senior consultant for Watson Wyatt Worldwide in Boston, said, “We don't see anyone rushing to make changes.”

As more guidance comes out, there is a possibility that health plans and employers will revisit this, he said. But from an employee-relations point of view, any employer contemplating a reduction in benefits likely will be met with a very adverse reaction from workers. It's not a costly benefit and there are many testimonials from women in their 40s who have survived breast cancer because of early detection from a mammogram, he said.

Coverage changes are not likely to happen immediately, agreed Susan Margolis, a New York-based director in the health care practice of PricewaterhouseCoopers Human Resource Services.

Other professional organizations, such as the American Cancer Society, continue to recommend annual mammography screening for women in their 40s. Until there is more uniform advice, “I don't see any immediate (policy) changes,” Ms. Margolis said.

Until health plans issue new coverage provisions, “I don't see employers making changes particularly for something like this that is so controversial,” she added.

Rather than denying benefits, Helen Darling, president of the National Business Group on Health in Washington, said she thinks health plans and employers will begin to put more emphasis on individual patients' decisions with their doctors.

“A woman shouldn't decide to get a mammogram because it's covered or not,” she said. Rather, she should discuss with her physician her individual risk factors, her comfort level, and all the scientific evidence and then make a decision about whether to have a mammogram.

Health insurers said last week that, while they are reviewing the USPSTF recommendations, they are not taking immediate steps to change coverage provisions.

WellPoint Inc.'s position “will remain unchanged for the immediate future and continues to consider annual screening mammography medically necessary for women aged 40-49 years,” the Indianapolis-based health insurer said in a statement. “We will continue to review and analyze the research surrounding breast cancer and other preventive screening procedures and, if appropriate, will evaluate medical policy revisions.”

“The decision about when to have a mammography screening is an individual decision between a woman and her doctor, based on an individual's specific circumstances and medical history,” CIGNA Corp. said in a statement. “Our current coverage policy provides for coverage of screening mammography beginning at age 40—or as young as 25 if a woman is in a high-risk category—and continues to remain in effect.”

Hartford, Conn.-based Aetna Inc. also covers annual screening mammograms for women beginning at age 40 and for women younger than 40 who are at high risk.

“This policy will remain in place while Aetna reviews the USPSTF's recommendations, and conducts a thorough review of the current medical literature and evidence-based guidelines on this topic,” the company said in a statement.

In a statement, Minnetonka, Minn.-based UnitedHealthcare said, “A decision about mammography requires a detailed discussion between the patient and her physician and it should consider the medical evidence, patient preferences, and unique clinical issues for each patient.”

For reprints of this story, please contact Lauren Melesio at 212-210-0707 or email lmelesio@crain.com