Beware the ides of March.
Last month, Blue Cross Blue Shield (BCBS) of Illinois announced that it would no longer reimburse for full-field digital mammography (FFDM) on the grounds that it is investigational.
A little history is in order. The FDA cleared the first commercial FFDM unit for use in the United States in January 2000; the second was cleared in September 2001; and a third was cleared in March 2002. In a move that elicited both surprise from radiologists who have grown accustomed to bad news on the mammography reimbursement front and delight from vendors of FFDM, CMS announced a new code for FFDM in 2001 that represented a generous increase on the technical side (nearly $50) over and above what would be paid for an analog screening mammogram, which also was increased though not enough to meet the American College of Radiology (ACR) then-estimated break-even cost of about $95. The new code drew criticism from the ACR and dissent among many mammographers who believe that there should be one code for all screening mammograms that would at least cover the costs of doing the examination on an analog machine while awaiting results of the ACRIN trial comparing the analog and digital technologies.
BCBS of Illinois cites an assessment of FFDM performed by the BCBS Association Technology Evaluation Center (TEC). Five criteria need to be met in order to be approved by TEC, which maintained that the technology met only the first criterionapproval by the appropriate governmental regulatory bodies. It was the opinion of TEC that the remaining four were not met ( http://www.bcbs.com/tec/vol17/17_07.html ).
BCBS of Illinois is not the first payor to attempt to slow the march of technology. But it does represent a curious reversal of the payor’s previous practice of reimbursing for FFDM. Did it use new data on which to base its decision? No, the decision was based on a report dated July 2002 that cited old data generated on technology that has had at least two iterations since then. In fact, several newer studies were ignored. Will the payor cave into pressure from Illinois mammographers and agree to reimburse for FFDM…but at the analog rate?
The question must be asked: Is this about money or science?
The rising cost of health care is a serious issue. The same week BCBS of Illinois announced its decision, a report from the trustees of Medicare and Social Security predicted the Medicare fund would be bankrupt in 2019, 7 years prior to what was predicted just 1 year ago. But if BCBS of Illinois wants to cut costs, why not look at the dramatic rise in office-based imaging done by nonradiologists (see “Who Gets Paid What?,” page 11), and support breast imaging programs instead of imperiling them. FFDM is FDA approved, it has proven patient, provider, and payor benefits, and it is the linchpin of the future of the digital radiology department. Women at some facilities are now dependent on the digital technology for their breast health. In the meantime, the ACRIN trial recently stopped accruing patients at about 50,000 and results are expected in 1 year. At this point one thing is certain: In the absence of consensus will rise the hegemony of the payor. n