Necessity of Legislative Process in the Realm of Women’s Imaging
Amy Kirby, MD
Chair, AAWR Legislative Committee

Mammography has long been the stepchild of radiology departments nationwide. Despite the no call and no weekends appeal, it is not sought after by radiologists as a career. Why? Imagine perusing this ad in the search for a radiology job:
Join our practice! Become involved in a subspecialty that pays low wages compared those of your radiology colleagues, has extremely high liability, and is both difficult and not well respected in the radiology community.

Mammography facilities over the past decade have been closing nationwide and waiting time for women wanting mammography services is increasing. In 2004, the Institute of Medicine released a report with disturbing results showing that women's access to breast cancer screening is threatened due to the shortage of physicians performing breast imaging interpretation. Between 2000 and 2003, there was an 8.5% decrease in the number of mammography facilities operating in the United States, dropping from 9,400 to 8,600. As a result, women in some areas experienced delays of up to five months for screening mammography services. For a recommended annual screening exam, these delays make it almost impossible for women to adhere to such recommendations. The reasons for the closures are several fold: lack of profitability/funding and high medical liability for such services being the two biggest factors.

Most centers that offer mammography services do so at a loss, and those that run a profitable center are few and far between. Why? Reimbursement has been historically low for such services. Medicare reimbursement increased only modestly between 1997 and 2000 by 1.5%. At that time, the Medicare reimbursement rate for a screening mammogram was $69.23, well below what it cost most centers to perform the service. Reimbursement for the technical component of a screening mammogram was just over $46, thus limiting the professional fee to less than $13 a screen. Recognizing an impending crisis, legislative efforts ensued, driven largely by the American College of Radiology Government Relations as well as by their Economics Department. Cost surveys conducted clearly demonstrated the need for increased reimbursement to keep facilities open and to keep screening available to women nationwide. In 2002, due largely to these legislative efforts and resultant political pressure, Sen. Tom Harkin and Rep. Peter King took the initiative to introduce legislation that ultimately resulted in the Centers for Medicare and Medicaid Services (CMS) increasing the reimbursement from $69.23 to $81.81. While this may seem small, it translates into $54 million annually for those centers and for the radiologists who perform and interpret screening mammograms.

In late 2003, Congress passed the Medicare Prescription Drug, Improvement and Modernization Act of 2003, which contains a provision relating to Medicare reimbursement for mammography services. Specifically, both diagnostic and screening mammography services are paid under the Medicare Physician Schedule, regardless of site of service, beginning in January of 2006. This results in a 13 percent increase in the technical component for unilateral mammograms ($35.89 to $40.10) and a 39 percent increase for the technical component for bilateral mammograms ($35.89 to $50.02). The Congressional Budget Office stated that this provision would add $200 million over ten years to the mammography system.

This allows for hospital-based facilities to be reimbursed the same as those centers who function in an outpatient setting. What does this mean for the patient? Because many of the Medicare patients receive care in hospital-based facilities, this elderly population has more access to screening. Because screening detects more cancers than breast exam alone, this means saving more lives.

Currently, the 2005 Medicare Reimbursement for Radiology Services pays $85.65 for radiographic screening mammography, $135.29 for digital mammography, and an additional $19.71 for Computer Aided Detection. Yes, reimbursement has increased in the last five years. However, profitability for these centers is still marginal at best. Despite the groundwork being laid by these two significant increases in reimbursement, more needs to be done within the specialty. One of the crucial issues revolves around medical liability.

Breast imaging, although an effective screening tool for breast cancer detection, is far from perfect. The Report of the International Workshop on Screening for Breast Cancer (2), which reviewed current clinical trial data, both published and unpublished, and then summarized screening test performance for mammography, showed that sensitivity using mammography alone averaged about 75%, while estimates for mammography combined with Clinical Breast Examination (CBE) ranged from 75% in the Health Insurance Plan of Greater New York (HIP) to 88% in the Edinburgh trial and the Canadian National Breast Cancer Screening Study in women aged 50-59 (NBSS 2). Specificity estimates ranged from 98.5% in the HIP trial to 83% in the Canadian NBSS 2. Notice that these are not 100% for either specificity or sensitivity. However, the misconception exists that this is a perfect test and should detect all cancer. As a result, mammographers are practicing more defensive medicine, and performing more biopsies and procedures than in the past.

According to the Physicians Insurers Association of America (PIAA), breast cancer leads to more malpractice claims than any other medical condition, usually cited for delay in diagnosis. This is second only to newborn neurologic impairment in terms of paid claims. The PIAA have also shown that based on their claims, breast cancer continues to be the condition for which a patient most frequently files a medical malpractice claim. In 1995, radiologists represented 24% of defendants in breast cancer malpractice cases; in 2002, it rose to 33%. (3).

Recognizing that a solid patient relationship, communication, and modalities such as CAD can significantly decrease liability risk, the real issue is reform. Until medical liability reform becomes a reality for the nation, these statistics are unlikely to improve. In October 2003, high-risk procedures were no longer offered by nearly 14% of physicians previously performing them, according to a study by the Georgia Board for Physician Workforce (GBPW of Atlanta) as a result of unreasonable malpractice insurance premiums. This followed a 17.8% reduction in 2002. Of those services no longer performed, mammography was a frontrunner, and 19% of the physicians opting out were radiologists. This study also addressed the issue of not only paying unreasonable malpractice premiums, but in some cases, finding an insurer at all for such high-risk specialties.

These are frightening statistics for neophyte radiologists, trying to decide on a career path. What does legislation have to do with this? And why does it matter? Breast cancer is prevalent, with 200,000 women diagnosed every year. In addition, it is a killer. Mammography, in conjunction with Clinical Breast Examination, significantly decreases breast cancer mortality by earlier detection. Without mammography or mammographic interpretation, more people die from breast cancer. Legislative efforts on both the economical front and the liability front are not only necessary to make mammography an attractive specialty to future radiologists, but are critical to its survival as well. For more information on medical liability reform, visit www.ama-assn.org. For more information on legislative efforts by the ACR, visit www.acr.org.

References
Institute of Medicine. Saving women's lives: strategies for improving breast cancer detection and diagnosis. June 10, 2004. Available at: http://www.iom.edu/report.asp?id=20721. Accessed February 16, 2006.

Fletcher SW, Black W, Harris R, et al. Report of the International Workshop on Screening for Breast Cancer. J Natl Cancer Inst 1993;85:1644-1656.

Physician Insurers of America. Breast Cancer Study. 3rd ed. Spring 2002.

Georgia Board for Physician Workforce. The effect of rising medical liability premiums on physician supply and access to medical care in Georgia follow-up. Available at: http://gbpw.georgia.gov/vgn/images/portal/cit_1210/ 15895593Fact%20Sheet%20-%20Medical%20Liability %20Follow-Up%202003.pdf. Accessed February 16, 2006.