Guest opinion: The hidden costs of battling breast cancer
By Dr. Rachel Preisser, guest columnist
As our state leads the nation in cancer rates, consistently ranking second-highest in overall cancer rate, navigating the financial landscape to access lifesaving breast cancer screening and diagnostic evaluation has become increasingly murky for both patients and physicians alike.
When the Affordable Care Act passed in 2010, screening mammograms were one of the few preventative exams that became available without patient cost sharing, meaning co-insurance, deductibles and copayments did not apply. Studies have shown that the rate of women getting a mammogram went up as much as 9% after this action.
For women’s health, that is a success; screening mammograms are the bedrock of any breast cancer surveillance program. They are the highest-resolution study of all breast-imaging modalities, enabling a breast imager to catch breast cancer in its earliest, most treatable stages or even prevent cancers by detecting precancerous or atypical cells that can be removed before they progress onto cancer.
While the implementation of widespread screening has been a major driving force in the 44% reduction in breast cancer deaths over the past 40 years, screening mammograms in many cases are not stand-alone exams. Roughly 10% of all screening mammograms will be considered incomplete, requiring additional specialized pictures or even an ultrasound for more information. For many women, supplemental screening such as a breast MRI is recommended by the American College of Radiology.
Thus, screening mammograms are only stand-alone exams when they are normal and when the patient does not fit any other criteria. For women who have dense breast tissue (about 50%), or who have an increased risk of breast cancer (approximately 30% of my practice here in Iowa), a screening mammogram is only a starting point to completely evaluate their breast health.
Unfortunately, women who need supplemental screening will find that the tests are not mandated to be covered as screening mammography is. To follow the screening plan that is right for them, they are at the whim of the insurer when it comes to what and how much is covered. Whether the supplemental screening is due to an abnormal mammogram or because the patient is at a heightened risk (e.g., dense breast tissue or certain genetic markers), the financial burden often falls heavily on the patient.
In order for a screening program to be successful, there must be robust participation of everyone who is eligible. Even with the ACA mandated coverage of screening mammography, fewer than 70% of eligible women in Iowa are participating. Furthermore, there are many women who are at elevated risk and should be starting before the standard age of 40 who are not necessarily tracked by this statistic.
In May 2024, House File 2489 was signed into law. It went into effect on January 1, 2025, and the impact for patients was both swift and paradoxical. The original bill was penned by the Iowa Army of Pink, in collaboration with contributions from other stakeholders including Susan G. Komen Foundation and this author. The intent of the bill was clear: to increase access to life-saving breast cancer care by eliminating financial barriers.
House File 2489 in its final version required insurance companies and policies in Iowa to cover supplemental and diagnostic breast examinations (including diagnostic mammograms, ultrasound, and MRI) and that the coverage be “no less favorable” than coverage provided for screening mammograms. By federal law, screening mammograms are to be covered with no out-of-pocket cost. However, at some point in the legislative process, all specific references to the elimination of cost sharing as originally written were stripped. The resulting ambiguous language prompted the Insurance Commissioner to issue clarifications after the bill’s passage stating, “Carriers may apply cost-sharing amounts to the covered services under the terms of the consumer’s policies.”
I and many of my colleagues across the state noticed an immediate shift for our patients. The bill required coverage, which meant insurance companies could no longer deny coverage for breast exams as they often had in the past. However, many insurers compensated for the inability to deny by slashing reimbursements. As a result, the unpaid balance was passed on to the patient. There is no recourse for patients or physicians – the bill designed to reduce out-of-pocket costs to patients had exactly the opposite impact for many as individual insurance plans adjusted their math to protect their already substantial profits while anticipating expanded payment demands. This results in most plans having substantial yearly increases in their premiums; patients are paying more for insurance companies to cover less.
I consulted on the crafting of the original bill. I lobbied in subcommittee hearings for its passage. I celebrated its signing. But now I have serious concerns about what the current bill, and subsequent efforts to revise the bill to include language addressing the patient cost sharing component, will do for access unless there is deliberate attention to address the “how-low-can-you-go” mentality of insurance providers. As a small, independent clinic, we review claims on a very granular level, something most physicians in our specialty can not often do. In the setting of screening mammograms, we are legally prohibited from billing a patient as they are federally protected from cost sharing. Our only payment is whatever the insurance company independently decides.
Sometimes what the insurance companies decide to pay does not cover the cost to provide the exam and our practice ends up providing that service at a loss. In fact, coverage from some insurance providers is so poor that many health care providers in our market will refuse to see patients with that plan. If this same model is expanded to all breast imaging, those that provide breast imaging services will not be able to cover their overhead and the services will no longer be available. Since 1989, when mammography began becoming more readily available, we have seen breast cancer deaths decrease by 44%. I shudder to think what will happen when one of the best tools we have in the fight against breast cancer becomes harder to access if not completely inaccessible due to financial avarice.
Axios recently cited a new study by Kaufman Hall showing that physicians are carrying markedly increased workloads, and providing more and more services, while net revenues are barely keeping pace with inflation. This setting of sharply rising costs and stagnant to decreased reimbursements is chipping away at already razor-thin margins. A common response to these statistics is to declare physician salary to be a root cause, when in fact physician salaries make up less than 10% of all health care spending in the country.
Instead, physicians are working more and more and, especially for those of us in private practice, struggling to keep the lights on and our payroll funded while insurance reimbursements continue to be skimmed year after year. Too many independent physician practices are finding that the math doesn’t work, fueling the shift in medicine towards corporatization and private equity.
This is a particularly hard pill to swallow for me as an employer; I see nearly double-digit rate increases for the premiums I pay for my employees, meanwhile insurance companies are slashing reimbursements for the care we provide. The stresses of this system have a fulcrum in physicians who rise again and again to bridge gaps and provide quality care for patients. Financial instability and physician burnout directly impact patient access to quality care. As volume is stressed over quality, patient outcomes suffer and care gaps widen. Physicians train hard to attend their patients and provide them with quality care; it is agonizing that doing so is balanced against mitigating the threat of bankruptcy of their practice.
The health care industry is complex and there are no silver bullet solutions. There has been a rise in direct primary care models, which certainly provide a path to reduced health care cost. However, not every patient has the liquidity to pursue a cash-based care delivery model. Oversight of for-profit insurance companies, particularly their growing practice of setting prices not just well below what is billed, but well below the actual cost to provide care, is a critical component to the puzzle in order to ensure that physicians are even able to provide crucial services. Supporting policies that ensure fair reimbursements to physicians that keep pace with inflation and allow for independent physician direct care to be a sustainable model of care delivery is not just good for physicians, but for all the patients under their care.
In the fight to mitigate the impact of breast cancer in our state, it is often one step forward, many steps back.
Dr. Rachel Preisser is a radiologist who co-founded GRACE Breast Imaging & Medical Spa, Iowa’s only woman-owned imaging center. She is board-certified and fellowship-trained in breast imaging, with over 15 years of experience in the field. Preisser also serves as director of breast imaging services for MercyOne Northeast Iowa acting as co-director of their NABPC accredited Breast Center. She is involved in breast cancer awareness advocacy at a state and national level. She has previously served on the board of directors for Fighting Through Kinship and was a recurring panelist in the Society of Breast Imaging Summer Series. She currently serves on the board of directors for the Iowa Medical Society and has previously chaired a committee for the Society of Breast Imaging. In her free time, she likes to go on family adventures with her husband and three boys.
