Return of the Self-pay Mammogram

Radiologists seeking to demonstrate their value to unsuspecting health systems, to the innocent public and to clueless private payors need look no further than breast tomosynthesis.  The modality was approved by the FDA, validated as superior to digital mammography on several fronts by studies conducted within the international radiology community (see The Breast Tomosynthesis Discrepancy, page 26) and widely embraced by U.S. hospitals eager to support—and be seen as supporting—the fight against breast cancer.

Most modality vendors either have an iteration of breast tomosynthesis or are planning an introduction pending FDA approval. Many imaging informatics vendors also stepped up to the plate with PACS workstations capable of handling breast tomosynthesis workflow—no longer do radiologists have to jump between PACS and the modality workstation when reading studies and comparing them to prior studies. This, in and of itself, is a fine example of market forces at work to bring about innovation in our quasi-private, quasi-public healthcare system.

Finally, radiologists—breast imagers, specifically—also embraced the modality, struggling through clunky workflow widely acknowledged to lengthen the interpretation by 2.5 times because they believed it would improve breast cancer detection and reduce recalls—even before there was a CPT code and a $56 supplement for their troubles, the assessed value of the extra professional work.

Private payors, however, are dragging their feet such that when I went in for my annual mammogram recently, I was offered a breast tomosynthesis exam but was required to sign a form acknowledging that many insurance companies refuse to pay for the exam. If my insurance company refused to pay, my signature meant I agreed to cover the additional $56.

Impeding progress

Great advances have been made in the fight against breast cancer, but last year the disease claimed the lives of an estimated 40,450 women. The American Cancer Society estimates that 246,660 new cases of invasive breast cancer and 61,000 new cases of ductal carcinoma in situ will be diagnosed in 2016.

Mammography has been attacked repeatedly, mainly by health policy researchers using meta-analyses of data so long in the tooth that it carbon-dates to the analog days. They say that there are too many false positives and that the evidence is lacking to support the role of mammography in reducing deaths due to breast cancer. Radiologists would be the first to acknowledge that x-ray is not the ideal modality for viewing breast tissue, and they have developed protocols for adjunct studies when indicated.

Why aren’t private payors paying for breast tomosynthesis when Medicare has determined that women 65 and older should have access to the study? Let’s give private insurance companies the benefit of the doubt and assume that they are waiting for answers to the hard questions that breast imaging experts interviewed in this issue say need more research to answer:

• Can breast tomosynthesis alone be as effective as when it is used as an adjunct to digital mammography?
• Are the increased cancers found by breast tomosynthesis life-threatening cancers that need to be treated?
• Will every woman benefit from breast tomosynthesis or just selected sub-groups?
• Can it save lives?

$ is for stonewalling

Because private payors tend to follow Medicare (albeit, usually down the reimbursement scale), this stubborn stance feels more like economic stonewalling.  As reported by the U.S. Food and Drug Administration, 39,160,019 mammograms were performed in the past year, and if each exam included breast tomosynthesis, an additional $2.1 billion would have been spent. What we don’t know is how many diagnostic mammograms would have been prevented because of greater certainty provided by tomosynthesis.

I am grateful that I was able to agree to pay the additional fee (if Blue Cross declines to pay) and didn’t have to earmark the $56 for groceries or housing, a choice women of Medicare age also do not have to make. Others between 40 and 65 may not have that luxury, and that is how healthcare disparities begin.

The march of science can be frustratingly slow. After all, a march proceeds one step after another, not always in the same direction and not in the warp drive speed of science fiction.

Surely, breast tomosynthesis provides additional information with its multi-slice tomographic x-ray maps of the breast, suggesting an improvement over standard digital mammography. The FDA, CMS, hospitals, radiologists and even patients have acknowledged the value this confers. Now it is time for private payors to stop stonewalling, so that the community can move forward together toward answering the difficult questions, including which women will benefit most from the examination. Right now, no one knows for sure.