Is it ethical to incentivize mammography screening in medicaid populations?– A policy review and conceptual analysis

Mammography screening is controversial, as screening decisions are preference-sensitive: equally well-informed women do not universally get mammograms. Offering financial incentives for screening risks unduly influencing the decision-making process and may undermine voluntariness—yet incentives are being used in 4 US states (Arizona, Indiana, Kentucky, Michigan) under Section 1115 waivers. These initiatives are especially problematic in Medicaid populations who typically have lower health literacy and face the potential threat of disenrollment if they opt out. From June 2018 to January 2019, we analyzed publicly-available information on mammography incentives from the Centers for Medicare and Medicaid Services (CMS) and identified criteria (i.e. starting age and frequency of mammography) for incentive eligibility; income brackets of the affected beneficiaries; whether incentives were financial rewards or penalties; and evaluation arrangements. Several ethically relevant differences emerged: all states except Michigan incentivize screening at starting ages and frequencies that conflict with the US Preventive Services Task Force guidelines. Some incentives are rewards (e.g. reduced cost-sharing), and some penalties (e.g. disenrollment). Across states, rewards range from the equivalent of