Removing modest fee boosts access to 3D mammography among underserved groups

A new study by UCLA researchers shows that removing a modest $45 out-of-pocket fee significantly improved access to digital breast tomosynthesis (3D mammography), an advanced breast cancer screening technology. Researchers found that eliminating the fee increased overall usage several percentage points and particularly benefited underserved patient populations, including racial and ethnic minorities and non-English speakers. The study appears in the Journal of the American College of Radiology.

Why it matters

Even small financial barriers can prevent patients from accessing potentially life-saving medical technology. Digital breast tomosynthesis provides more detailed breast images than traditional mammography, improving cancer detection while reducing false positives. Ensuring equitable access to the best available screening technology is critical for reducing health disparities. The new study provides concrete evidence that eliminating patient cost-sharing can be an effective policy tool for improving healthcare equity.

What the study did

Researchers analyzed screening mammography data from 13,284 women at a multi-site academic institution between March 2018 and August 2022. The institution had implemented a $45 patient fee for digital breast tomosynthesis that was refunded if insurance later covered the procedure. This fee was eliminated in January 2021 because most insurers were providing full coverage. Of note, all patients in the study were imaged at sites with digital breast tomosynthesis available, thus women had the option of choosing DBT or 2D mammogram. The research team used a statistical method called difference-in-difference analysis, which compares how different patient groups changed over time relative to each other, helping isolate the specific impact of the fee removal from other factors that might have influenced screening choices, examining how the institutional change affected different patient groups based on race, ethnicity, language, insurance type, and socioeconomic status.

What they found

Overall digital breast tomosynthesis utilization increased by 7.8 percentage points after fee elimination (from 83.7% to 91.5%). The benefits were particularly pronounced among historically underserved groups: Asian, Black, and Hispanic patients showed additional increases of 5.0, 6.2, and 6.2 percentage points respectively beyond the gains seen in white patients. Non-English-speaking patients experienced a 7.1 percentage point greater increase than English-speaking patients. Patients with Medicaid insurance and those from more socioeconomically disadvantaged areas also showed greater improvements in access. Despite these gains, some disparities persisted, indicating that additional strategies beyond fee removal may be needed.

From the experts

"These findings demonstrate that even modest out-of-pocket costs can create meaningful barriers to accessing advanced screening technology," said Nina M. Capiro, MD, lead author and diagnostic radiologist at UCLA Health. "While we saw encouraging improvements across all groups after removing the fee, persistent disparities indicate that additional approaches are needed to ensure truly equitable access. This research shows how policy changes can have measurable impacts on health equity, but it also reminds us that eliminating financial barriers alone may not be sufficient to address all access challenges."

What's next

The findings suggest that healthcare systems should examine how patient cost-sharing affects utilization of advanced medical technologies. Future research could explore what additional interventions might be needed to fully eliminate disparities in access to digital breast tomosynthesis and other screening technologies. Healthcare policymakers may also consider these results when designing insurance coverage policies and patient financial assistance programs. The study provides a model for evaluating the equity impacts of healthcare financing decisions.