Low Reimbursement Jeopardizes Mammography Services

CHICAGO—Unless 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. Feig said.

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 mammogram—are 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.

Long Waits

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 salaries."

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.

Profitability Studies

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 40,000.

‘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 breast.

"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 facilities."

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."