R. James Brenner, MD, JD

When the front page headline of USA Today announced in its March 24, 1997 issue that the American Cancer Society had decided to recommend annual screening mammography beginning at age 40-and that the National Cancer Institute would soon do the same after two controversial consensus conferences arguing the contrary position-proponents of screening mammography hailed this decision as a triumph, as opponents decried the unwarranted diversion of resources and unnecessary diagnostic procedures resulting from such studies. But now, even the advocates of screening mammography have taken note of the dilemmas incurred by such successes, reinforcing the old adage: Be careful what you wish for.

The high incidence of breast cancer combined with the proven efficacy of properly performed mammography has provided the backdrop for one of the few nationally endorsed screening efforts in the United States. Unlike many other countries, the national health is underwritten not by a central government- Medicare covering only part of the population-but by a variety of programs. The evolution of mammography as a national priority follows a series of developments beyond clinical trials, from the NEXT (Nationwide Evaluation of X-ray Trends) in 1985 identifying the extreme variability of mammographic film quality, to the state and finally national legislation in the late 1980s providing for reimbursement for screening mammography. Breast cancer was a disease that affected young and old alike, could be found early, could be treated successfully, and was a concern for a population of 50 million women whose health had, according to some, suffered a history of inattention. Consumer groups joined legislators in helping to allocate research funds with unprecedented success.

Radiologists joined in this effort, promoting quality control mechanisms internally (American College of Radiology [ACR] Mammography Accreditation Program), low cost access, and new technologies. The federal Mammography Quality Standards Act of 1992 and its subsequent regulation by the Food and Drug Administration (FDA) increased the likelihood that the bar for mammography practice would be raised.

But something happened along the way.

That something was a market economy that neither responded to the increased demands required to ensure quality studies, nor apportioned the burden of providing that service in an equitable manner. The more than $1,500 fees required for FDA facility approval were not subsidized by a society that asked radiologists to commit to a public health service, but rather levied on the provider what is tantamount to a tax. Statutory reimbursement remained frozen, while the costs-inflationary and otherwise (eg, equipment to meet new standards)-of providing services continued to rise. Diagnostic studies derivative to screening were undercompensated, inviting little relief from budget-neutral federal allocations, and payors who predicated their position on HCFA’s reluctance to increase reimbursement.

The zeal of radiologists began to wane, as the whole that they had helped to create became less than the sum of the parts. The closing of breast centers for financial reasons has been reported in the Wall Street Journal, the Boston Globe, and other publications. Radiologists who have not been able to close such services have suffered financial losses routinely. While political leaders continued to rally behind screening mammography, radiology providers were denied the reimbursement tools to carry out this mission.

Last year, Congress appropriated a temporary increase reimbursement schedule for digital mammography and computer-aided detection, responding to lobbying efforts by companies attempting to improve the quality of service, but answerable to shareholders demanding a return on investment. The American College of Radiology focused on a more global approach to increasing reimbursement for screening and diagnostic mammography for all providers. The Health Care Financing Administration (HCFA) is now considering modest increases for diagnostic studies, which compete with all other medical procedures for a smaller piece of the pie. This included an increase in RVUs as well as practice expenses that have escalated beyond all projections, even by the government’s own calculations. Historically, Congress has funded screening mammography via a direct legislative routine in order to ensure adequate reimbursement for this national effort. A last-minute provision in last year’s appropriation bill shifted this program to HCFA, thus forcing screening to carve out funding from a static budget that already restricts reimbursement for most procedures. The shift needs to be reversed as the screening of 50 million women is unlikely to find accommodation in the political trading involved with the process by which the Relative Value Scale Update Committee (RUC) assigns priority.

Following such reversal, the ACR will attempt to partner with industry, government, and consumer groups in helping Congress to understand the inconsistency of a publicly endorsed policy without sufficient funding. The impact of increased reimbursement allotted digital mammography on this larger effort is unknown. Ultimately, widespread improved technology will invite even greater commitment and the dance between scientific advancement and payor support will require the kind of practiced coordination that current efforts at increasing global reimbursement are now attempting.

R. James Brenner, MD, JD, is chairman of the ACR Task Force on Mammography Practice, director of breast imaging at Tower Imaging, Los Angeles, and the Eisenberg Keefer Breast Center, Santa Monica, Calif, and clinical professor of radiology at UCLA.