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.