No area of Radiology has captured more public attention than
mammography. The increased incidence of breast cancer has
dramatically raised the American woman's anxiety about this
disease. As it became apparent that mammography was the most
effective diagnostic tool for this disease, the number of
facilities in the U.S. providing mammography increased
significantly. Many of these facilities, however, were supervised
poorly and provided substandard quality. Several popular television
programs have publicized the problem of poor-quality
mammography.
The highest standards must be maintained when performing
mammography, in particular, technical quality and close supervision
are essential. With great insight, the American College of
Radiology addressed the issue of mammography quality by developing
their quality assurance program, which was later adopted by the
Federal government. Today, through the Mammography Quality
Standards Act (MQSA), there are definite safeguards to assure
American women of high quality mammography.
With the increase in Federal regulations, the costs of providing
mammography have risen. The most recent version of the MQSA
regulations requires that each patient receive a report in language
that she can clearly understand. This adds costs in addition to
those resulting from equipment requirements, inspection programs,
and physician performance audits.
There is no question that the quality of mammography has
improved enormously since the American College of Radiology
instituted their quality assurance program and the FDA adopted many
of the requirements. High-quality mammography is now available to
most American women. This availability is threatened, however, by
the low reimbursement rate for mammography and the high cost of
complying with the increasingly complex regulations.
Radiologists are in the incongruous position of doing better
work than has ever been done before, while being asked to comply
with more expensive regulations and being paid less. In academic
departments across the United States, chairmen have discovered that
their departments are losing a significant amount of money in the
operation of their breast centers. The situation has become so
serious that some practices are limiting the amount of screening
mammography they will perform. One would have hoped that with
larger volume practices, costs could be amortized and the
mammography program would be profitable. Recent studies by Dr.
Dieter Enzmann, Chairman of Radiology at Northwestern University
Hospital, however, have demonstrated that with increased volume the
losses increase even further. Our experience at the Medical College
of Wisconsin during 1998 resulted in a $71,000 loss for the
professional aspects of our Breast Center. The problem is
particularly severe with Medicare patients; our standard
professional charge for a diagnostic mammogram is $86.00, but
Medicare pays only $37.50 for the professional service.
There are many adverse effects of this inadequate reimbursement
for the diagnosis of breast diseases. First, because of the large
losses, departments are unwilling to expand their mammography
operations despite increasing demand. There is less incentive to
purchase new equipment, which in turn provides less incentive to
manufacturers to develop and produce innovative new equipment. The
poor reimbursement rate particularly threatens the introduction of
digital mammography, which will incur significantly higher costs.
There will also be less incentive to do double readings or to
utilize computer-assisted diagnostic methods.
There are also other subtle but far-reaching effects of this
problem. Residents in radiology are an intelligent group of
individuals who understand economic trends. As a consequence, fewer
finishing residents will choose to enter mammography fellowships,
and, indeed, already there is less funding for these training
programs. The trend toward large independent mammography centers,
such as those in Europe, will be diminished. Increasingly,
mammography will have to be carried as a loss leader in large
departments that provide other services that can make up for the
deficits engendered by mammography. Although there are significant
research dollars available at the Federal level and from
foundations for research in breast diseases, there will be fewer
qualified individuals available to pursue the existing research
opportunities.
Somehow there must be an increasing awareness on the part of
HCFA and the insurance carriers of how inadequate the funding is
for the provision of mammography. Unfortunately, as long as
radiology remains among the highest-paid specialties, there will be
very little public or governmental empathy for improved
reimbursement. In the absence of an improved reimbursement climate,
however, there will be less innovation, less development of major
centers, less availability of quality screening, longer waiting
times for appointments, and fewer quality radiologists choosing
mammography as a subspecialty area.
Dr. Youker is Chairman of the Department of Radiology at the
Medical College of Wisconsin and Director of Radiology at
Froedtert Memorial Lutheran Hospital in Milwaukee, WI. He is also
a member of the editorial advisory board of this journal.