Impact of copayment elimination on annual and biennial screening mammography utilization among rural U.S. women

Reporter: Saumil Gandhi, MD PhD
The Abramson Cancer Center at the University of Pennsylvania
Last Modified: June 7, 2013

Presenter: Jeffrey M. Peppercorn, MD, MPH
Presenter's Affiliation: Duke University


  • Breast cancer is the leading cause of cancer death in women. Approximately 225,000 women are diagnosed with breast cancer and about 40,000 women die from the disease in America each year.
  • Although a significant number of breast cancers are first detected on breast exam, the vast majority of breast cancers in American are diagnosed by an abnormal screening study.
  • There is a strong consensus, based on multiple randomized trials, that routine screening mammograms should be offered to women over the age of 40.
  • Early detection of breast cancer with screening mammograms leads to earlier stage at diagnosis and improved survival.
  • Early detection also allows for a wider range of surgical and medical treatment options.
  • Many studies have shown that rural American women are less likely to receive screening mammograms compared to their urban counterparts.
  • It has been hypothesized that copayments for mammograms are potential barrier to screening and elimination of copayments may improve screening rates.
  • In this study, the authors examine whether eliminating copays improves annual (aSMU) or biennial (bSMU) utilization of screening mammograms by rural women.


  • This study used an insurance claims database of the National Rural Electric Cooperative Association (NRECA), which insures over 100,000 electrical workers and their families across the nation.
  • The authors identified women between ages 40 and 64 without any prior history of invasive breast cancer or DCIS (based on ICD-9 codes) and captured claims for aSMU and bSMU between 1999 and 2009.
  • Annual and biennial rates of utilization were examined before and after NRECA eliminated copayments for screening mammograms and well-women exams in January, 2006.
  • Chi-squared tests were used to compare aSMU and bSMU rates by age group. All p-values are two-sided.


  • Over 20,000 women between the ages 40 and 64 received health insurance through NRECA each year.
  • The average cost of a mammogram to the patient decreased from $17 to $13 with the elimination of copayments.
  • The median cost decreased from $3 to $0 with the elimination of copayments.
  • From 1999 to 2009, aSMU increased from 38.1% to 49.5%, while bSMU increased from 57.2% to 68.1%.
  • Screening increased significantly following elimination of copayments in 2006 (p = 0.0004). Specifically, for the period 2006-2007 compared to 2004-2005, the percentage of women undergoing at least biennial screening increased from 60.9 to 68.8% (p < 0.0001).

Author's Conclusions

  • Insurance claims data from rural American women shows that a large percentage of rural women between ages of 40 and 64 do not undergo even biennial breast cancer screening.
  • Elimination of copayments improves both annual and biennial screening rates in all age groups, but does not eliminate all barriers.
  • Further investigation is needed to understand financial and non-financial barriers to screening and attitudes towards current screening recommendations.

Clinical Implications

  • The data presented here shows that between one-third to one-half of rural American women do not receive screening mammograms at the recommended intervals.
  • While elimination of copayments showed a modest improvement in utilization of screening mammograms, there is still significant room for improvement.
  • Improvement in rates of mammography screening has the potential to significantly improve the overall survival in this group of patients.
  • Further research is needed to determine non-financial barriers to obtaining annual screening mammograms. Lack of education, lack of access because of distance, and fear are just some of the possible causes.
  • Better understanding of the underlying causes will ultimately allow us to design programs that aim to improve the screening rates.


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