CHICAGOUnless relative value reimbursement units for
mammography services rise by a factor of three, the US health care system will
not be able to keep up with the expected demand for diagnostic and screening
examinations for breast cancer, a panel of radiologists said at the annual
meeting of the Radiological Society of North America (RSNA).
The number of screening examinations performed in the United
States doubled over the last 10 years, said Stephen Feig, MD, director of
breast imaging, Mount Sinai Medical Center, New York. There are now 56 million
American women who are age 40 or over, and among them, about 60% had a
mammogram in the past 2 years.
"Today, the medical care system is unable to keep up with
this increasing demand by providing mammography in a timely manner," Dr.
He explained that many hospitals and medical offices are unable
to purchase enough equipment, hire new technologists and radiologists, and
allocate enough office space for breast imaging, because the current Medicare
reimbursement rates$67 for a screening mammogram and $81 for a diagnostic
mammogramare less than the cost of providing these exams, even excluding the
physician time for interpretation.
Moreover, reimbursement rates for mammography have increased at
less than 1% per year, and they have not kept up with the increased costs of
performing mammographic examinations.
According to Dr. Feig, the lack of adequate reimbursement is
leading hospitals and imaging centers to downscale their mammography
operations. As a result, waiting time for a mammogram has increased at more
than 50% of mammography facilities over the last 2 years.
At Memorial Sloan-Kettering Cancer Center, the wait for a
diagnostic mammogram is 4 to 6 weeks, said D. David Dershaw, MD, director of
breast imaging at Sloan-Kettering.
Waiting times at New York University Medical Center are in
excess of 4 months, said Gillian M. Newstead, MD, director of breast imaging at
NYU. The NYU Medical Center recently closed one of its mammography centers, in
fact, because "we lost money on every patient we saw," Dr. Newstead
said. "We are still paying rent on the space because it’s cheaper to pay
the rent and not see patients."
Decisions to Close Centers
Dr. Feig stressed that "the decisions to close mammography
centers are not being made by radiologists. These decisions are being made by
hospitals, by administrators of other organizations who are strictly looking at
the bottom line of costs and losses from mammography."
Hospitals and other imaging centers also are reluctant to
assign radiologists to interpret mammograms because mammography is an area that
is losing money, Dr. Feig said.
The ripple effect from this posture is a drop in the number of
radiologists and technologists who specialize in breast imaging.
"There is a reluctance among radiologists to go into
breast imaging if they feel the hospital may curtail or shut down the imaging
facility," Dr. Feig said. "There is evidence that the salary scale
for mammography technologists is lower than for technologists in other areas of
radiology because the reimbursement rates can’t support higher
Training of future mammographers is suffering as a result, the
panelists said. Memorial Sloan-Kettering Cancer Center typically has five
openings in its mammography fellowship program every year. Last year, the
program had 40 applicants for these slots; this year, the number of applicants
is down to 12.
Applicants to the fellowship program at New York University
Medical Center dropped by 75% between 1999 and 2000.
For mammography programs to even begin to break even on their
diagnostic mammograms, Medicare relative value reimbursement units would have
to rise by a factor of three, said Dieter Enzmann, MD, chair of the Department
of Radiology, Northwestern University Hospitals, Chicago.
Dr. Enzmann hesitated to give a specific break-even price for
mammography because of differences in resource use and demands across the
country. He based his conclusions about the need for a threefold rise in
relative value units on a pair of studies of the profitability of mammography.
The first study determined the direct and indirect costs for
seven medium to large university-based mammography or breast imaging programs
in various parts of the country. The size of the programs was determined by the
number of mammographers, which ranged from one to eight, as well as the total
number of mammogram studies performed each year, which varied from 10,000 to
‘Every Program Was Unprofitable’
"The upshot of the survey was that, overall, every one of
the programs was unprofitable. The slightly worse news was that the larger the
program, the more unprofitable it was. The contribution margin was negative,
which means that the more mammograms you do, the more you lose," he said.
To learn more about the aspects of mammography that contributed
to this negative financial picture, Dr. Enzmann conducted a comprehensive
activity-based costing analysis involving intensive time and motion studies of
individual mammographers who performed
tests at one breast imaging center.
The key factor emerging from this study was the cost of the
diagnostic mammogram. This is an exhaustive problem-solving procedure for
establishing a definitive diagnosis of breast cancer in a woman with a
suspicious lesion, palpable lump, or demonstrated cancer in the opposite
"The current market-based pricing mechanism does not value
a diagnostic mammogram enough to cover its cost. The reimbursement for the
professional side would have to be multiplied by a factor of three to break
even," Dr. Enzmann said.
Medicare reimbursement for diagnostic mammograms will decline
further if the Health Care Financing Administration (HCFA) goes ahead with its
proposed new Hospital Outpatient Prospective Payment System and its Ambulatory Payment Classification (APC), the panelists said.
According to the American College of Radiology, the APC for a
diagnostic mammogram would pay a provider $33.94 for the technical aspects of
the examination, which is 26% less than the congressionally mandated rate for
the technical reimbursement for a screening mammogram.
In a May 16, 2000, letter to HCFA, Pamela J. Kassing, ACR’s
director of economics and health policy, wrote that "a reimbursement rate
of $33.94 will not allow hospital outpatient departments to cover their costs
for this procedure. Hospitals may elect to discontinue offering this service as
a result. This will significantly limit the number of facilities offering
diagnostic mammography as well as shift these services to freestanding
Diagnostic mammograms are not the only money-losers for breast
imaging centers. Other mammography programs, such as Dr. Dershaw’s, are
losing money on their breast screening examinations.
"It depends on the numbers of tests that you are doing,
the reasons for doing them, whether you’re a fixed site or a mobile unit.
There are a lot of variables, but the bottom line is that even when mammography
is profitable, it’s marginally profitable, and when it loses money, it
hemorrhages," Dr. Dershaw said.
Baby Boomers Reach Screening Age
With the demand for mammography expected to grow by 1 million a
year over the next 5 years as more Baby Boomers reach breast cancer screening
age, "it doesn’t take much imagination to figure out that within the
next decade, if something doesn’t happen to correct the situation the way it
is now, we are not going to be able to provide this service to a considerable
portion of the population," Dr. Dershaw said.
Added Ellen Mendelson, MD, director of the Breast Diagnostic
Imaging Center, Western Pennsylvania Hospital, Pittsburgh, "Ultimately, we
can’t continue to offer services that don’t pay for themselves."