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Importance: Digital breast tomosynthesis (DBT) is a breast cancer screening modality that has gained popularity in recent years. Although insurance coverage for DBT is not mandated under the Patient Protection and Affordable Care Act, several states have required coverage without cost sharing for private insurers., Objective: To evaluate the association between state-level insurance coverage mandates for DBT and changes in DBT use, price, and out-of-pocket payments., Design, Setting, and Participants: This cohort study used an event-study design with repeated cross-sectional observations of US states. Data were obtained from the Blue Cross Blue Shield Axis database for commercially insured women aged 40 to 64 years who underwent screening mammography between January 1, 2015, and June 30, 2019. Data were analyzed between January 14, 2021, and January 20, 2022., Interventions: Passage of state-level legislation requiring insurance coverage of DBT., Main Outcomes and Measures: Change in DBT use among women screened for breast cancer, overall DBT price, and out-of-pocket payments for DBT in states with mandates for coverage of DBT compared with states that did not pass legislation., Results: This study included 9 604 084 screening mammograms from 5 754 123 women (mean [SD] age, of 53 [6.7] years). During the study period, 15 states enacted DBT coverage mandates and 34 states did not. In states with coverage mandates, DBT use increased by 9.0 percentage points (95% CI, 1.8-16.3 percentage points; P = .02) 2 years after the mandate compared with states without coverage mandates. Coverage mandates were also associated with a net $38.7 (95% CI, $13.4-$63.9; P = .003) decrease in the mean price of DBT compared with no coverage mandates. There was no association between coverage mandates and out-of-pocket payments 2 years after mandate passage ($-2.1; 95% CI, $-5.3 to $1.0; P = .18)., Conclusions and Relevance: In this cohort study, DBT coverage mandates were associated with an increase in DBT use but not with any change in out-of-pocket payments. The findings suggest that coverage mandates for DBT may have been associated with broader use but were not associated with changes in direct costs to patients.

Background: Breast cancer screening for women aged 40-49 years is prevalent and costly, with costs varying substantially across US regions. Newer approaches to mammography may improve cancer detection but also increase screening costs. We assessed factors associated with regional variation in screening costs., Methods: We used Blue Cross Blue Shield Axis, a large US commercial claims database accessed through secure portal, to assess regional variation in screening utilization and costs. We included screening mammography±digital breast tomosynthesis (DBT), screening ultrasound, diagnostic mammography±DBT, diagnostic ultrasound, magnetic resonance imaging and biopsy, and evaluated their utilization and costs. We assessed regional variation in annual per-screened-beneficiary costs and examined potential savings from reducing regional variation., Results: Of the 2,257,393 privately insured women, 41.2% received screening mammography in 2017 (range: 26.6%-54.2% across regions). Wide regional variation was found in the DBT proportion (0.7%-91.1%) and mean costs of DBT ($299; range: $113-714) and 2-dimensional (D) mammograms ($213; range: $107-471). In one-fourth of the regions, the mean DBT cost was lower than the mean 2D mammography cost in the full sample. Regional variation in the per-screened-beneficiary cost (mean: $353; range: $151-751) was mainly attributable to variation in the cost of DBT (accounting for 23.4% of regional variation) and 2D mammography (23.0%). Reducing regional variation by decreasing the highest values to the national mean was projected to save $79-335 million annually., Conclusions: The mean mammogram cost for privately insured women ages 40-49 varies 7-fold across regions, driving substantial variation in breast cancer screening costs. Reducing this regional variation would substantially decrease the screening costs., Competing Interests: N.K. reported funding from the Research Council of Norway and LINK Medical Research (grant numbers 276146 and 304034) during the conduct of the study, and personal fees for speaking from Thermo Fisher Scientific. X.X. reported receiving research support through Yale University from the Centers for Medicare & Medicaid Services to develop and maintain performance measures, and grants from the American Cancer Society during the conduct of the study. S.H.B. reported receiving research grants from the National Institute of Health, the Robert Wood Johnson Foundation, the Donaghue Foundation and the American Cancer Society during the conduct of this study. K.A.K. reported receiving research support through Yale University from the Centers for Medicare and Medicaid Services to develop and maintain hospital performance measures during the conduct of the study. S.T.L. is the founder and co-owner of NowPow, LLC and reports receiving royalty payments from UpToDate. I.B.R. reported receiving grants from the National Institutes of Health/National Center for Advancing Translational Sciences during the conduct of the study and personal fees from the Centers for Medicare and Medicaid, outside the submitted work. C.P.G. reported receiving research grants from the National Comprehensive Cancer Network-(funded by Pfizer/Astra-Zeneca), funding from Johnson & Johnson to assist with developing new approaches to sharing clinical trial data (through the Yale Open Data Access Project), and funding from Flatiron Inc. for travel/speaking, outside the submitted work. J.B.L. declares no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: To evaluate the association of state dense breast notification (DBN) laws with use of supplemental tests and cancer diagnosis after screening mammography., Methods: We examined screening mammograms (n = 1 441 544) performed in 2014 and 2015 among privately insured women aged 40 to 59 years living in 9 US states that enacted DBN laws in 2014 to 2015 and 25 US states with no DBN law in effect. DBN status at screening mammography was categorized as no DBN, generic DBN, and DBN that mandates notification of possible benefits of supplemental screening (DBN+SS). We used logistic regression to examine the change in rate of supplemental ultrasound, magnetic resonance imaging, breast biopsy, and breast cancer detection., Results: DBN+SS laws were associated with 10.5 more ultrasounds per 1000 mammograms (95% CI = 3.0, 17.6 per 1000; P = .006) and 0.37 more breast cancers detected per 1000 mammograms (95% CI = 0.05, 0.69 per 1000; P = .02) compared with no DBN law. No significant differences were found for generic DBN laws in either ultrasound or cancer detection., Conclusions: DBN legislation is associated with increased use of ultrasound and cancer detection after implementation only when notification of the possible benefits of supplemental screening is required.