Cash for Mammograms Is 'Ethically Troubling'

Megan Brooks

September 08, 2015

Offering women money, paid time off, or other incentives to undergo mammography screening is "ethically troubling," contends the author of a viewpoint published in the September 8 issue of JAMA.

A better idea is to offer women incentives for using evidence-based decision aids, irrespective of their ultimate decision for or against screening, says Harald Schmidt, PhD, from the Department of Medical Ethics and Health Policy and the Center for Health Incentives and Behavioral Economics at the University of Pennsylvania Perelman School of Medicine in Philadelphia.

Patient health incentives are increasingly common and can help prompt health behaviors that ultimately lead to a longer and better life, Dr Schmidt noted in an interview with Medscape Medical News. Take quitting smoking or losing weight. "If you achieve what the incentive provider asks for, you only gain health. But with breast cancer screening, you might get a false-positive diagnosis and receive treatment that you don't actually need," he explained.

"The decision to undergo breast cancer screening is really very complex, yet the idea has been ingrained that screening will detect all cases of breast cancer and they will detect them early and save lives," he noted.

Screening mammography does save lives, "but it's a blunt tool. We need to have much more appreciation of that, and incentives can cause a problem in the decision-making process," Dr Schmidt said. "Ultimately, women need to be aware of the benefits and the harms, and then decide if they want to be screened or not. The problem is the benefits get all the attention," he said, but the potential harms get little attention.

Offering incentives to complete mammography is an "ethically disconcerting distraction in a complex decision-making process," Dr Schmidt writes. He favors "incentivized active choice" — giving the incentive for using a decision aid to make an individual decision.

I completely agree with the argument made.

That idea is wholeheartedly supported by Nancy Keating, MD, professor of healthcare policy at Harvard Medical School and a primary care physician at Brigham and Women's Hospital in Boston. "The author is right, I completely agree with the argument made," she told Medscape Medical News.

Echoing Dr Schmidt, Dr Keating pointed out that there are certain types of care for which there really is no argument that it's good. "Smoking cessation really benefits everyone, but for mammography screening, the benefits and harms are much different. I think the general feeling now is that decisions about mammography really should incorporate an individual's values and preferences, which means it might be very appropriate for two different people to come up with different ideas about what's right for them if they really are well informed," Dr Keating explained.

Better Decision Aids Needed

The "biggest challenge," is contained in that goal of individualizing decisions, she explained. "We need, pretty urgently, more tools, better tools, and more accessible tools to help with this. Some provider organizations have started creating tools, but a lot of doctors don't have the data at their fingertips to help a woman make a really good informed decision on mammography. I think a lot of doctors are just recommending it, or saying hold off until you're 50."

Exactly how many companies or payers are actually giving incentives to get women to undergo screening mammography is not known. "I think it's happening less than for incentives for smoking cessation and weight loss, but I do think some employers are offering incentives for mammography, like giving people time off work to get screened. I haven't seen anyone paying to do it," Dr Keating said.

It is a real scandal.

The Affordable Care Act has made the use of incentives more attractive. However, Dr Schmidt said that it has not required central gathering of data on who uses incentives, how much money is put on the line, and for what kind of activities.

"It's an enormous missed opportunity, especially in this case, where there are real harms at risk. I would argue that the regulators should have an interest in knowing the answer to these questions and require that the data be collected so we can learn where incentives work well and where there are problems. To me, it is a real scandal; incentives have a lot of potential, but we simply are not set up to learn about which incentives work and which don't," Dr Schmidt said.

Dr Schmidt has disclosed no relevant financial relationships. Dr Keating reports receiving research funding from the National Cancer Institute, the American Cancer Society, and the Komen for the Cure Foundation.

JAMA. 2015;314:995-996. Full text


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