Effect of Fee Removal on the Use of Digital Breast Tomosynthesis to Minimize Health Care Disparities

Nina Capiro; Prasidda Khadka; James Sayre; Gelareh Sadigh; Anne Hoyt

doi:10.1016/j.jacr.2025.06.022

Effect of Fee Removal on the Use of Digital Breast Tomosynthesis to Minimize Health Care Disparities

J Am Coll Radiol. 2025 Oct;22(10):1193-1200. doi: 10.1016/j.jacr.2025.06.022. Epub 2025 Jun 19.

Authors

Nina Capiro¹, Prasidda Khadka², James Sayre³, Gelareh Sadigh⁴, Anne Hoyt⁵

Affiliations

¹ Department of Radiological Sciences, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California. Electronic address: ncapiro@mednet.ucla.edu.
² David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California.
³ Department of Radiological Sciences, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California.
⁴ Director of Radiology Health Services and Comparative Outcome Research and Associate Chair for Faculty Development, Department of Radiological Sciences, University of California, Irvine, Orange, California.
⁵ Department of Radiological Sciences, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California; Medical Director, Barbara Kort Women's Imaging Center; Medical Director, Santa Monica-UCLA Integrated Breast Care Clinic; Co-Medical Director of Breast Imaging, UCLA Health; Senior Reviewer, American College of Radiology Mammography Accreditation Program.

PMID: 40543540
DOI: 10.1016/j.jacr.2025.06.022

Abstract

Background: After FDA clearance of digital breast tomosynthesis (DBT) in 2011, many insurers were slow to adopt full coverage without cost sharing. Our institution implemented a $45 out-of-pocket fee for DBT, refunded upon insurance payment. This fee was eliminated in January 2021 after most insurers began covering DBT. We evaluated the effect of out-of-pocket fee removal on DBT versus digital mammography use across patient groups.

Methods: We conducted a retrospective analysis of screening mammograms scheduled at a multisite academic institution between March 2018 and August 2022. A difference-in-difference analysis was performed for women with screening mammography both before and after fee removal to assess the effect of fee removal across patient groups.

Results: Among 13,284 women (mean age, 61.5 ± 11.2 years), DBT utilization increased from 83.7% (11,123 of 13,284) pre-intervention to 91.5% (12,256 of 13,284) postintervention. Relative to White patients, the rise in DBT utilization was greater by 5.0 percentage points (pp) for Asian patients (95% confidence interval [CI] = 3.7-6.2), 6.2 pp for Black patients (95% CI = 5.0-7.3), and 6.2 pp for Hispanic patients (95% CI = 4.9-7.5). Non-English-speaking patients had a larger increase in DBT usage than English-speaking patients (7.1 pp; 95% CI = 6.1-8.1). Medicaid (6.7 pp; 95% CI = 4.8-8.5) and commercially insured (5.1 pp; 95% CI = 3.8-6.4) patients showed a greater rise in DBT usage than patients with Medicare. Patients from more socio-economically disadvantaged areas had a greater increase in DBT utilization compared with those from less disadvantaged areas (5.2 pp; 95% CI = 4.1-6.8).

Conclusion: Eliminating out-of-pocket cost for DBT improved overall utilization and narrowed disparities. However, persistent inequities suggest additional strategies are needed to ensure equitable access to DBT for all women undergoing screening mammography.

Keywords: Breast imaging; health care disparities; screening; tomosynthesis.

MeSH terms

Aged
Breast Neoplasms* / diagnostic imaging
Breast Neoplasms* / economics
Early Detection of Cancer / economics
Female
Healthcare Disparities* / economics
Humans
Mammography* / economics
Mammography* / statistics & numerical data
Middle Aged
Retrospective Studies
United States