If screening for breast cancer currently figures into a health care organization’s service mix but it is utilizing analog technology to perform those examinations, then there is a likelihood that it will be stepping up to full-field digital mammography at some point in the future (and perhaps sooner than expected). Intense marketplace demand will be the most probable prod. Thank manufacturer direct-to-consumer advertising for that.

“Women were seeing TV commercials and magazine ads promoting digital mammography before there was hardly any penetration of the technology in markets around the country, and that has resulted in mammography centers being inundated with requests from women for digital mammograms,” says Gerald R. Kolb, president of Breast Health Management Inc in Bend, Ore, who adds that he finds it unsurprising that women would be such enthusiastic advocates of digital. “Women’s awareness of the issues surrounding breast cancer is remarkably high. They know we still have more than 40,000 breast cancer deaths each year and they are now convinced that an innovation like full-field digital mammography will make a strong contribution to reducing that fatality rate. It is also personal with them. They see digital mammography as better technology than what has been available, even though analog mammography is an excellent imaging tool. They want for themselves what they believe is screening with the best tool available, and the best in their thinking is now full-field digital.”

With so much clamor for digital, it might seem a no-brainer to rush right out, acquire a unit, and thrust it into service. But is it a sound investment? Kolb contends that it can be. Certainly, at least, the income potential for it is there.

“Full-field digital mammography screening is generously reimbursed by Medicare and by many commercial payors,” says Kolb, a consultant who offers advice and planning services to hospitals, imaging centers, physician practices, and industry with regard to the establishment and smooth, financially sound operation of breast centers. “The reimbursement is particularly attractive when you add on computer-aided detection [CAD].”

Pending President George W. Bush’s approval of the latest federal appropriations budget, Medicare is poised to now pay a nationally averaged global fee of $133.58 for a full-field digital screening examination, according to Kolb. If CAD is involved, it adds $18.82 for a total of $152.40. That compares to $81.45 for an analog screening examination.

“There’s definitely an economic motivation to be able to offer digital mammography,” he assures.


Even so, the idea of spending a half-million dollars or more on a digital mammography machine as a replacement for an analog unit that may have cost only around $75,000 gives pause to most decision-makers. As well it should, Kolb suggests.

“Digital mammography won’t prove beneficial for every enterprise,” he warns. “The small center that is small because of the area it serves will find justifying the acquisition of digital a huge challenge. The irony there is that in rural America, digital has extremely high promise because you can send mammograms anywhere in the world for readingyou could send them to a major university where the radiologists possess an extremely high level of expertise in mammography, which would be a huge benefit for that rural market. However, the cost of that technology to that community is very, very high, since it’s a market not likely to yield a sufficient volume of studies to make the investment pay. Also, in that market there might be only one radiologist: to send mammograms out of the area for reading will take income out of his pocket.”

However, digital mammography could prove economically infeasible for some providers in large metropolitan markets as well because adjunct expenses can be steep. Take service contracts, for example. According to Kolb, the technology is complex enough that fees for 1 year of upkeep and system upgrades can be as much as the cost of a new analog mammography machine.

There also is the cost of image storage and retrieval. “A four-view image series for one study can consume around 100MB of storage, depending on the technology used,” says Kolb. “You can put studies on DVDs, but you are going to amass a lot of DVDs in no time at all and then you will have to buy a big, expensive jukebox for them.

“Processing time is another factor. A good breast radiologist can read and report an examination a minute, so you need to have fast enough storage and a broad enough pipeline that you can be quickly presenting the current and prior years’ studies for that radiologist, otherwise you’ve got him standing around waiting and being unproductive. Here you’re talking maybe 500MB of information that needs to go up on the monitor.”

One more cost could be the price of film or CD-ROMs. Digital mammography is supposed to eliminate film from the equation, yielding savings. But Kolb thinks it may be a good marketing technique to hand each patient a CD of her study as a take-along that can be passed to a referring physician or kept at home as a personal record.

Even if a facility opts against doing that, it still will face hard-copy costs for the first year or so after digital implementation.

“You’ll have your feet in both worldsdigital and analogbecause for a long while afterward you will still be looking at priors produced on film,” Kolb says. “Plus, it is going to take time for your radiologists to get comfortable looking at images in purely soft-copy mode.”

Although the total of those various adjunct costs might dampen a decision-maker’s initial exuberance toward digital mammography, the technology still can be a very good economic move, Kolb insists.

“It all comes down to volume,” he says. “Because the fixed costs of the digital investment are so high, the more studies you can amortize those fixed costs over, the lower the cost per mammogram and the quicker you’ll achieve payback.

“You need to be a high-volume mammography screening facility to begin withat least 15,000 to 20,000 mammograms annuallyto make the investment in digital work optimally.”

To obtain the best possible return on investment, Kolb recommends reengineering work flow in order to optimize throughput.

“One of the things I find is that the implementation of digital mammography has very rarely been well thought out,” Kolb says. “If, for example, you replace an analog unit that is 65% utilized with a digital unit that is 65% utilized, it’s never going to pay for itself.

“I believe a truly successful investment depends above all on how appropriately the technology and, by extension, the staff are utilized. Full-field digital mammography will allow you to easily double throughput. You can realistically put patients through the unit at a rate of one every 6 minutes. Creating a comfortable patient experience from this short a time presents a continuing challenge.”


Kolb advises that prospective purchasers of full-field digital mammography probably would do well to take a conservative approach when projecting volumes and income for digital mammography. It is too easy to be burned. The Breast Center at Houston Northwest Medical Center (HNMC) in Houston has had to educate patients and payors about digital mammography. “As with all new technology and advances, not all payors jump on board as quickly as we would like,”? says Breast Center Director Ellen Williams, RN, MS.? Expecting to do most screening with its new digital mammography systeminstalled in May? 2002, and made fully operational a month laterthe center experienced a setback when three major commercial payors denied claims submitted for the screenings.

“Using this new machine, we have screened as many as 57 patients in an 8-hour day,” Williams says. “In our analog room, we book one patient every 15 minutes for a screening mammogram. But in the digital room, we double-book those patients, which lets us take two patients every 15 minutes. It got to the point that we were doing two thirds of our screenings on the digital unit.

“By this past November, as we started to see the rejection of claims from three large preferred payor organizations, our digital screening activity was pared back. A month later it was even less than that.”

The reason for the reimbursement denials was a refusal on the part of the payors to recognize the technology as standard of care rather than investigational and the use of a “G” code CPT may also have factored in, says Williams.

At least one of those payors has a policy statementposted on its web siteindicating that it considers digital mammography and CAD as investigational modalities.

“We’re trying to educate them that it’s still a mammogram, there’s still compression, there’s still positioning, and it’s not investigational,” says Williams. “It’s just a different way of acquiring, reading, and archiving the film.”

Williams says progress on this front is coming very slowly. The Breast Center has a lot riding on getting this resolved satisfactorily to meet the pro forma for ROI. HNMC is a Tenet Health System hospital with high expectations for quality and performance, she notes.

“We sold this acquisition on the basis that full return on investment (ROI) would be achieved in less than 3 years,” Williams reveals.

However, ROI based on reimbursements was only part of the calculus the Breast Center team presented to administration in attempting to demonstrate the worthiness of an investment in digital mammography. As Williams and her colleagues explained, the introduction of digital mammography would relieve pressure on the center’s film storage operation. Because the on-site film library was filled to capacity, the oldest images had to be kept at an off-site facility not easily accessed. Williams was never really comfortable entrusting films to an outside party since she had no direct control over the individuals who handled those images in the course of filing, retrieval, and refiling. With digital mammography, images could be archived in electronic form only, meaning no more films.

“Images would instead be archived onto disks,” she says. “The only time we would be printing film is if a patient had an abnormality and she needed to have her referring physician look at that.

“The biggest savings we knew we could achieve was on film. Immediately, we experienced a 35% decrease in film costs. And the decrease will continue as the payors understand and realize the benefits of the technology.”


The ROI picture sharpened when the Breast Center team suggested that the enterprise could forego a major marketing campaign in support of the added technology.

“We would be acquiring just one machine, and we knew we couldn’t accommodate the demand we predicted would be generated by a big outreach campaign,” says Williams. “Were we to have done a big campaign, we could envision every woman in the area calling in for an appointment, swamping us and putting us in the position of having to turn them away.”

Instead, the Breast Center engaged in a low-key form of marketing by limiting discussion of the new unit mainly to the pages of the hospital’s in-house magazine.

(In the months ahead, the Breast Center plans to give a bit more visibility to its digital capability by putting up highway billboards. “They’ll basically say that digital mammography is here,” says Williams. “But we’re holding off on this until the reimbursement issues are resolved.”)

A related selling point was the value of digital mammography to the hospital’s efforts to attract patients. “We factored in the higher-level imaging studies and surgeries that mammography brings into the hospital,” Williams recalls. “We find 4? or 5 new cancers in every 1,000 asymptomatic women who walk through the door of the Breast Center. So, even though reimbursement is not as high as we might like, digital mammography brings the hospital an opportunity for providing other more profitably reimbursed services.

“We made a similar point by noting that the Breast Center sees in the span of a year a number of women equal to the hospital’s entire inpatient census during that same time. What that means is that, in the 30 minutes a woman is at the Breast Center, we have a unique opportunity to introduce her to HNMC, which is important in the sense that she is in all likelihood the health care decision-maker for her household. So, if we can make a favorable impression on her in the course of her time in the Breast Center, there is an increased probability that HNMC will be the place she will choose the next time she or a member of her household has a health care need.

“And with 25,000 women passing through our doors annually, that is a lot of decision-makers we’re gaining access to. The bottom line is that digital mammography would bring the hospital both direct and indirect revenues, making it a worthwhile investment.”

It helped, too, that the Breast Center made its appeal to a sympathetic group of decision-makers. “We were fortunate first of all that the CEO of the hospital has a heart and a real passion for the fight against breast cancer,” says Williams. “Second, there is incredible physician support for the Breast Center, and has been for all these years. The absolute key to the success of the center is that virtually every Friday we have a pretreatment planning conference for our patients. Every newly diagnosed cancer is discussed by about 20 physiciansfrom genetics to psychiatry, radiation oncology, surgeons, radiologists, and pathologists. When the hospital ownership and our administration saw our physicians so committed to working together with the Beast Center, they decided that the center needs to continue to developand one way that could be done was by ensuring that the center was given the best tools available.”

Proponents of the purchase also invited decision-makers to remember the hospital’s mission when evaluating the worth of the equipment.? “It can prove advantageous to encourage administrators to not look at the investment from a purely financial perspective,” says Williams. “We mentioned to them that our commitment is to find these cancers at their earliest, most curable stage, and that the digital mammography unit was an essential tool in that effort.”

These two factors were crucial because HNMC, like most other enterprises in its class, had only limited funds available for capital equipment investments but a surfeit of purchase requests, Williams notes.


Still another reason given in favor of investmentand this was the one that pushed it over the top, Williams indicateswas the idea that buying a digital mammography unit would spare the hospital any need in the foreseeable future to increase the space available for the Breast Center.

“Our most scarce resourcepossibly even more than capitalis physical space,” Williams says, adding that the Breast Center operates in 3,500 square feet within the hospital’s main building. “The hospital had almost no space to accommodate further physical expansion of the Breast Center. Yet we desperately needed more space as a result of continually increasing business and services, with breast care getting more complex in the form of adding nurses and programs and high-level procedures.

“Because of this, our decision-makers were ready and willing to listen to how this digital mammography unit would enable us to remain in our same space. They recognized that it would be less expensive and less disruptive to simply buy the digital mammography unit than to move things around in order to carve out more space for the Breast Center.”

Finally, Williams took pains to showcase the ROI in a completely digital environment rather than the hybrid digital-analog state in which the new mammography machine would operate for at least the first year, since this would result in the most compelling numbers.

“It’s only when film goes away completely and you eliminate those costs plus those involved in processor maintenance and consumables that a facility sees real efficiency, real profitability, and real return on investment,” she says.

Rich Smith is a contributing writer for Decisions in Axis Imaging News.