Oregon Medicaid to consider 3-D mammography

Published 3:47 pm Wednesday, March 15, 2017

Six years after the federal government approved the use of 3-D mammography machines, all of Central Oregon’s imaging providers have switched from 2-D to the newer technology, which offers a more precise window inside the breast.

But Oregon’s Medicaid program, called the Oregon Health Plan, doesn’t cover 3-D mammography, also known as digital breast tomosynthesis. Local providers say they’re giving those patients the more expensive 3-D scans anyway, they’re just only getting paid for the 2-D ones.

At its meeting Thursday, the commission that decides what OHP covers may vote on whether the program will pay for 3-D mammography for women ages 40 to 74 with an average breast cancer risk. The program for low-income individuals currently covers 2-D mammography for that population.

So far, the odds aren’t in favor of a policy change. Two subcommittees that took up the question prior to the full Health Evidence Review Commission recommended against coverage for 3-D mammography, arguing in draft guidelines that there’s only “low-quality” evidence that it improves cancer detection rates and no evidence that it detects cancers at earlier stages or reduces deaths from all causes. The subcommittees acknowledged some evidence that 3-D mammography cuts the rate of people called back for follow-up screenings, but said it’s also of low quality.

Dr. Alison Little, medical director for Medicaid with PacificSource Community Solutions, the group that administers Medicaid in Central Oregon, said she agrees there’s not enough evidence 3-D mammography improves outcomes or decreases deaths.

“They can’t even tell if it increases cancer detection rates,” she said, “and it significantly increases cost. So I agree with what they’ve done.”

Although the studies the commission looked at found that 3-D mammography detected more cancers than 2-D, the commission noted that they weren’t randomized controlled trials, the gold standard for scientific research.

A number of health care providers took issue with that point in submitted comments. Legacy Health, for example, submitted six additional studies to the original five the commission cited that show “significant increases in cancer detection” with 3-D mammography. Altogether, the 11 studies encompass nearly 900,000 mammograms, Legacy wrote.

“The evidence is clear and consistent: tomosynthesis has a higher cancer detection rate than digital mammography alone,” Legacy wrote.

Some wrote they feel the commission is unnecessarily holding a screening method — mammography — to the same standards it would a drug or other treatment method, for which there would need to be evidence it reduces deaths.

Dr. Sally Herschorn, an associate professor of radiology in the University of Vermont’s Larner College of Medicine, said in an interview that many large-scale studies have shown 3-D mammography detects more cancers than 2-D, although that increase has not been shown among the roughly 10 percent of women who have extremely dense breasts.

“That burden of proof is just too high,” Herschorn said.

Coverage for 3-D mammography is a contentious subject. The U.S. Preventive Services Task Force last year concluded there is not enough evidence to say whether the risks of 3-D mammography outweigh the benefits. Radiology groups were quick to criticize the task force’s findings, arguing — as they still do — that the evidence is clear 3-D reduces recalls and detects more cancers.

Herschorn was an author on a recent study in the Journal of the American College of Radiology that predicted state Medicaid programs would save $8.14 per patient by switching from 2-D to 3-D mammography, even after accounting for the cost increase associated with 3-D technology. The study, which used data from several states on more than 31 million Medicaid enrollees, arrived at that figure by assuming a 10 percent recall rate with 3-D mammography compared with a more than 14 percent rate with 2-D.

Applying that to Oregon, Herschorn wrote in a letter to a commission leader that assuming 18,500 women on Medicaid are screened annually, switching to 3-D would save the state about $150,000 per year.

To be clear, Herschorn said she thinks the medical evidence alone shows a clear enough benefit for switching to 3-D, but hopes the economic benefits also encourage a change. Women on Medicaid are at a higher risk for being diagnosed with breast cancer at later stages, she said. And policies like Oregon’s put them at higher risk for recalls, she said.

“I don’t think they should be second-class citizens,” she said.

Herschorn’s study was funded by Hologic Inc., a company that manufactures 3-D mammography machines, and Herschorn is a former Hologic shareholder, although she said neither fact affected the study’s findings.

Washington state’s Medicaid program opted to cover 3-D mammography for average-risk women ages 40 to 74 in 2015. There’s a big caveat to that, though: The program does not pay more for the 3-D screenings than it would pay for the 2-D screenings, which tend to cost less.

Before Washington’s decision-making committee voted six to four in favor of coverage, it rounded up data on several questions. Committee members wanted to know about 3-D’s effectiveness in detecting cancer, especially compared to other methods, its potential harm and cost effectiveness.

Josh Morse, program director for the Washington State Health Care Authority’s Health Technology Assessment program, which gathers data for the committee that makes coverage decisions, said the decisions are never simple.

“The work we take to this group, these are not the slam dunks,” he said. “There is no reason to go through an energy-intensive process like this for easy decisions. They do not face easy decisions most of the time.”

Dr. Karen Lynn, a radiologist with Central Oregon Radiology Associates, said she hopes the commission changes course and decides to reimburse for 3-D mammography. Although her office is currently providing them for Medicaid patients, they aren’t reimbursed fully for the exams, which take twice as long to interpret and more data to store compared with 2-D exams.

Still, Central Oregon Radiology Associates, which serves patients across Central Oregon, performs the 3-D screenings because the providers have found that, in their experience, they work better, Lynn said.

“We’re finding invasive cancers that would have otherwise been masked,” she said. “We don’t have our data to prove that, but that’s kind of how we have felt as a breast center as we have implemented this technology.”

— Reporter: 541-383-0304,

tbannow@bendbulletin.com

So far, the odds aren’t in favor of a policy change. Two subcommittees that took up the question prior to the full Health Evidence Review Commission recommended against coverage for 3-D mammography, arguing in draft guidelines that there’s only “low-quality” evidence that it improves cancer detection rates and no evidence that it detects cancers at earlier stages or reduces deaths from all causes.