NBC6 Reporter Sophia Hernandez explains why patients with dense breasts face challenges getting their cancer screenings covered by insurance.
According to the National Institute of Cancer, the most common form of cancer is breast cancer.
The Centers for Disease Control and Prevention (CDC) say each yearabout 240,000 cases of breast cancer are diagnosed in women in the U.S. and about 2,100 in men. And each year, 42,000 women and 500 men will die from breast cancer.
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That’s why national panels have released new guidance for screenings, but some people are finding out that insurance companies don't cover them all.
Candace Strowbridge is a 40-year-old Fort Lauderdale woman who last year saw news reports and commercials advising women to check themselves.
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“I felt a lump, did a self-exam, and felt the lump and then made an appointment for a mammogram,” said Strowbridge, while waiting for her appointment at Broward Health Hospital.
It was her first mammogram. And that led to a diagnosis of a stage three cancer in her left breast.
“I thought about getting it but I never did,” Strowbridge said. “My best friend just passed away from colon cancer and she never got a chance to do the mammograms or anything either. So, I kind of just checked out on myself and said I have to do something to not have the family worry.”
Health
Strowbridge is proof that the new recommendation released last month by the United States Preventive Services Task Force is essential.
The new directive recommends that all women get screened every other year starting at age 40.
“It’s extremely important, because most patients don’t know what to look for, and we don’t expect you to know what to look for", explained Dr. Alia Abdulla, a Breast Surgical Oncologist at Broward Health.
Abdulla says that she is seeing more and more patients getting diagnosed with breast cancer at a younger age, and more disparities with populations of color.
“African Americans and Hispanics when they are diagnosed with breast cancer it’s typically at younger ages and its typically more aggressive so anything we can do to catch it earlier would help to benefit our patients,” she explains.
According to the American Cancer Society, black women have the highest rate of death from breast cancer compared to other races or ethnic groups, with the median age of diagnosis being 60 years old.
Asian, White, and Pacific Islander women are more likely than other groups to be diagnosed with localized breast cancer.
Because of this new recommendation for those 40 and older to get mammograms every two years, insurance companies will now be mandated to cover these procedures. Abdulla says patients should not have a co-pay.
PROBLEMS WITH INSURANCE
But that’s not the case if additional imaging is done.
It’s something Alexandra Bussa has had to experience, “It is frustrating that the doctor is recommending it, you need it, you genuinely want to have it and there is just a lot of obstacles to that.”
Those obstacles are insurance companies not covering her recommended screenings.
There are different types of screenings.
Mammograms are a form of an x-ray. Ultrasounds, otherwise known as a sonogram, use sound waves to produce an image. And occasionally an MRI is used, using magnetic fields to produce images.
Bussa has had all three screenings. She was diagnosed at the age of 38 with dense breasts, and every time she gets checked, she pays.
“When she told me I needed a mammogram, then that’s when I tried to utilize my insurance benefits. And going through those loops and they weren’t covering at all, I had to pay out of pocket. It was several hundreds of dollars to have that testing done,” explains Bussa.
She says ultrasounds have cost her roughly $600 and MRI’s about $500. She’s hoping now that she’s 40, she won’t have to pay for mammograms. But, she will still have to pay for other procedures.
"Healthcare in our society is not warranted or geared towards prevention, it’s geared towards you are already sick or you already have an active diagnosis. So young women like myself, like ourselves, who want to have that preventative testing in place to avoid the diseases and conditions, I don’t think the platforms and the structures of insurances right now are really set up to really facilitate that for us, unfortunately.”
NBC6 reached out to all the top insurance companies utilized in the state of Florida. Among the list are:
KAISER PERMANENTE
CIGNA
AETNA/CVS PHARMACY
UNITED HEALTHCARE
AMBETTER
OSCAR
FLORIDA BLUE
FLORIDA HEALTHCARE
CAPITAL
HEALTH FIRST
AMERIHEALTH CARITAS
MOLINA HEALTHCARE
AVMED
BLUE CROSS BLUE SHIELD
Some of these companies answered questions as to whether or not they cover screenings for those with dense breasts.
UnitedHealthcare released this statement saying:
Preventive services are an important part of staying healthy, and UnitedHealthcare’s commercial benefit plans already cover a preventive screening mammography, for members age 40 and older, without member cost sharing in accordance with the Affordable Care Act (ACA) and applicable state law.
We also generally cover diagnostic ultrasound and digital mammography for members with dense breasts, according to their benefit plan.
A spokesperson for Florida Blue shared:
“Florida Blue’s policies and services are guided by evidence-based clinical standards of care. Since 2002, under our preventative care policies, all of our plans have covered annual screening mammograms for women aged 40 and older, many for as low as a $0 copay. For members with dense breast tissue, we cover additional screenings such as ultrasounds and magnetic resonance imaging, or MRI, when it is deemed medically necessary by a member’s physician. More information about breast cancer screening is available on www.Floridablue.com.”
Health First shared this response:
Health First, a not-for-profit healthcare system, is committed to the early detection and prevention of breast cancer. We continually review and align our services with the recommendations from the U.S. Preventive Services Task Force (USPSTF) and the Woman’s Preventive Services Initiative (WPSI) to ensure our members have access to essential preventive services.
To address your specific questions:
- Mammography Coverage: Health First Health Plans, our not-for-profit health insurance service, provides coverage for preventive mammograms for women aged 40 and over, annually. We also cover one baseline screening mammogram for women aged 35-39 within a 5-year period, recognizing the importance of early detection across different age groups.
- Ultrasound Coverage for Dense Breasts: For women who require additional testing due to dense breast tissue or other factors, medically necessary ultrasounds are covered under their applicable plan benefits. This ensures that our members receive comprehensive diagnostic services when a standard mammogram might not provide clear results.
And Aetna Insurance released this statement:
Aetna clinical policies are evidence-based and follow the recommended screening guidelines of several medical professional organizations that already support annual mammography screening beginning at age 40. We will continue to encourage our members to complete preventive screenings such as mammograms so they can address health issues as early as possible.
The USPSTF noted that there is insufficient evidence to support breast ultrasound as a primary screening recommendation. Aetna covers breast ultrasound under either the medical benefit or preventive benefit in compliance with federal and state regulations and plan-specific benefits. Members should call Aetna customer service for plan-specific benefit information.
The question is, what would supply sufficient evidence to get ultrasounds covered for those with dense breasts at any age?
“In order to have the USPSTF create a recommendation that mandates ultrasounds for dense breasts we would need strong evidence, so that means level 1 evidence and double-blind studies. So, in general we need more research related to breast cancer,” states Abdulla.
Abdulla says right now, there is no clear evidence that ultrasounds are absolutely necessary. Which is why if you are 40 and older, you typically will first be offered a mammogram. But those who have dense breasts, and haven’t met the age threshold of 40 for a covered mammogram, are expected to keep paying.
“If we are diagnosed earlier or sooner, we will prevent other expenditures or healthcare costs down the road. So, I hope that there is an ease or facilitation between young healthy women who are pre-disposed to certain conditions and getting the screenings they need, especially at the doctors’ recommendations. And maybe even having other things like pre-authorizations or other policies that they could implement for people like us who need every six months,” says Bussa.
“Every year isn’t going to cut it, we need six months. So, hopefully that will happen. I don’t think that’s in place now but hopefully that insurance structure will change.”
Strowbridge is now in her second round of chemo, encouraging others to make an appointment.
“It’s very important. As mothers, we don’t always, we let daily life go by, we don’t check up on ourselves all the time it’s always family. So, to get that checked out early enough to get that treated in the proper way, that will be good.”
She wishes if she did things differently, she would have get checked sooner because "the earlier the better. I think the earlier the better.”
If you believe you might have dense breasts, a lump, or want to receive care, below are names of Diagnostic Centers, Cancer Institutes, and Hospitals in Miami-Dade and Broward County that offer care.
