Mammography’s Crisis Offers Opportunity, Too

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Michael N. Linver, MD, FACRMichael N. Linver, MD, FACR, is committed to mammography screening to detect breast cancer—what he calls screening’s role in saving women’s lives. When it comes to mammography, Linver also has a combative side: Now that screening mammography has come under attack from some critics as a possibly less-than-effective technique, Linver is fighting back. He has cited study after study showing that the death rate from breast cancer has dramatically fallen because of mammography screening. “If every woman in the United States had a mammogram now, we would find 500,000 breast cancers, and save 15,000 lives, this year alone,” Linver told the audience at a breast-imaging event held in White Plains, New York, on October 5, 2010, and hosted by Sectra AB, a global RIS/PACS solution provider with US headquarters in Shelton, Connecticut. While thousands of women could be kept alive with universal mammography screening, Linver says, the reality is that draconian measures to curtail mammography screening might end up costing lives. If guidelines set forth by the US Preventive Services Task Force (USPSTF) are adopted, each year, Linver says, “6,500 more women will die” from breast cancer in the United States. Linver, who practices at X-Ray Associates of New Mexico, PC, an Albuquerque radiology group, is vice president of the National Consortium of Breast Centers and a past president of the New Mexico chapters of both the ACR® and the American Cancer Society. He served on the original National Mammography Quality Assurance Advisory Committee to the FDA from 1994 to 1997. Even though the USPSTF guidelines have not yet been enacted, just the threat of them—and the discouraging appraisal of screening that they offer—is keeping women from pursuing mammograms, Linver says. Since the guidelines were released, a year ago, mammographic-screening volumes in the country have fallen by 20%. “Some of that is due to the economy,” he says, “but by far, the bulk of it is due to the guidelines.” Linver calls on radiologists, primary-care physicians, mammographers, gynecologists, and their clinical staffs to rally to the cause and fight back on behalf of breast-cancer screening. “To say nothing and do nothing is to give tacit approval to these murderous guidelines,” he says. What USPSTF Advocates The guidelines that so concern Linver call for a reduction in mammography screening—the exact opposite of the expanded screening that Linver says he’d like to see. “The fastest-growing segment of the US population is women aged 100 to 110,” Linver says. “People are living longer. A healthy 85-year-old woman still needs to get a screening mammogram.” Instead, the USPSTF guidelines issued last year call for a cessation of mammography screening for women aged 40 to 49—except for high-risk patients—and no screening for women over 74, Linver says. The USPSTF guidelines also call for mammography to be performed every two years for women between 50 and 74. Breast self-exams are not recommended, nor are routine clinical breast exams, Linver adds. When the USPSTF guidelines were issued, they were based on faulty research, Linver charges. That research suggested that false-positive results, stress from unnecessary patient call-backs, and the number of patients who needed to be screened to find relatively few cancers outweighed the benefits of screening in the age groups denoted, Linver acknowledges, but he says that the research was wrong. Studies in the United States and all over the world have consistently shown at least a 30% reduction in breast-cancer mortality rates due to screening, he says. “To say that 1,904 women must be screened for every life saved, as the USPSTF stated in its report, implies that women 40 to 49 aren’t worth saving,” Linver says. In the United States, he says, death rates from breast cancer have fallen 30% since the implementation of widespread screening in the 1990s. “That’s with only 50% of the eligible population getting screened,” he adds. He shares a letter that he wrote to referring physicians, explaining that 25% of the cancers detected by mammography at his breast-imaging center have been in women under 50. “Age 50 is a totally artificial division that somebody seized upon,” he says. Linver says that he was gratified that the old guidelines calling for women to begin routine mammographic screening at 40 have been retained by the American Cancer Society (and mandated by Congress, in some instances), but he says that the threat of the USPSTF guidelines is still ominous. He noted that at least one private health plan and 18 states have reduced coverage for mammography to the guidelines set forth by the USPSTF. Screening mammography has been launched on a perilous journey that might turn into a perfect storm, he says. In addition to the effects of the guidelines from the USPSTF, there are insufficient mammographers to complete the screenings that need to be done, Linver says. Reimbursement is becoming increasingly uncertain, and mammographers are more frequently being sued for malpractice because of unrealistic expectations on the part of the public that all cancers can be detected by screening mammography, Linver adds. Moreover, calls for bundled services, greater accountability, pay for performance, and comparative-effectiveness research will place even more pressure on mammographers to perform high-quality exams, in more efficient settings that maximize reimbursement, if they hope to survive professionally, Linver says. Driving Revenue Through Mammography All these challenges can be turned on their heads, however—and mammography can succeed in saving lives and prosper as a viable imaging modality—if screening is vigorously promoted and rigorous quality and economic efficiency standards are put in place, Linver says. Radiology practices are taking a hit from teleradiology entrepreneurs, and radiology as a whole is becoming commoditized, moved to radiologists offshore (in some cases), and intruded upon by nonradiology specialists seeking imaging revenues, he notes. Mammographers, though, have an advantage that most diagnostic radiologists don’t have, Linver says. That advantage is patient contact. Because mammographers often meet with patients to discuss screening results, mammography services as part of radiology practices can attract patients who will return for other types of imaging tests, Linver suggests. “The high visibility of mammography can be used to showcase a whole practice,” he says. “Mammography can become the face of radiology,” he adds. “It can lead the way out of the darkroom and into the public eye.” Linver goes so far as to suggest that mammography, as part of a radiology practice, is “the best hope for the survival of radiology as a specialty,” he says. Sustaining Success To succeed as the face of a radiology practice, a breast-imaging center needs to follow certain rules, Linver says. First, the center must perform consistently high-quality mammograms and render consistently high-quality interpretations. Second, the center must integrate newer technologies such as breast MRI and full-field digital mammography. Third (and perhaps most important for its financial health), the breast-imaging center must maximize reimbursement through careful coding and billing, and it must just as carefully study its operations to decrease overhead. Taking these steps prepares the breast-imaging center to deal with the new health-care paradigms being promulgated, Linver says, and sets the stage for contract negotiations with payors. To maximize efficiency, Linver says, breast centers should separate patients being screened from those undergoing diagnostic procedures. “We do separate patients from the outset,” he says. “We have a screening waiting room and a diagnostic waiting room. It creates an easy workflow, and at the same time, it’s efficient. We also use a lot of medical assistants.” Mammographers should read screening cases in batches, in settings where there is no interruption and the physician “never takes his or her eyes off the screen,” he says. He advises eliminating all ambient light to improve efficiency and interpretation. Radiologists should perform an ongoing complete audit of their mammography results to ensure good outcomes. Personnel changes based on audit results should be made as needed, not only improving practice quality, but also decreasing medicolegal exposure, he says. Audit data can also be used as a bargaining tool when negotiating with third-party payors. “We were able to get a carveout with our largest payor when we showed it that the smaller invasive cancers we found saved it a lot of money,” he says. Billing and Claims To maximize reimbursement and lower expenses, Linver calls for vigilance from physicians and staff. All staff must continually check for errors in patient identification and billing codes. Interpretative reports should detail “clear findings and conclusions,” he says. Be aware, he adds, that payors routinely reject or ignore fully a third of all claims submitted. “That’s how they make money,” he says. Breast clinics should track accounts receivable, the length of time that billings remain in accounts receivable, the distribution of accounts receivable, and the payor mix carefully, Linver says. It’s important to make sure that all services are billed, he adds, since some services can easily be overlooked (especially for procedures such as core needle biopsies, for which there are multiple charges). He advises careful review of all billings and coding. “Overbilling or underbilling will be a big red flag for federal auditors,” he says, “and try not to rebill—that’s always a red flag.” In conclusion, Linver repeats his call for expanded breast-cancer screening. “The highest risk factor for breast cancer is just being a woman,” he says. He reminded his listeners that a lot is at stake in mammography screening. “We have been given a great gift: the power to save a human life,” he says. George Wiley is a contributing writer for