From the Editor

Low reimbursement + excessive liability = long waits for mammography

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The wait for a screening mammography in our clinical network is about 180 days. Why has such an important service become so difficult to schedule? Two reasons: Mammography is poorly reimbursed, and radiologists who specialize in this service are exposed to high professional liability.1,2

This situation deserves focused attention because the same combination of circumstances is likely to occur in other areas within the next decade.

Reimbursement averages about $86 per screening mammography (Medicare pays about $82), yet costs range from $87 to $140. In many areas, providers lose money on every screening. Despite the medical economics joke, “We lose money on every case, but we make it up in volume,” managers know to reduce volume when payments do not cover expenses.

The federal government could increase the likelihood that screening mammography will be conveniently available by increasing Medicare reimbursement.

Easy target

Mammography services are a target of litigation because of the nature of breast cancer, which begins as a minute, undetectable tumor that grows slowly over many years. These tumors can be detected by mammography only when they reach 1 to 2 cm in diameter. Since mammography is often performed annually, once a tumor is detected, a plaintiff’s expert can review previous mammograms and claim that the lesion was detectable earlier—and that the cancer could thus have been treated at an early, curable stage.

The stress of extreme liability is causing many radiologists to suspend mammography services and switch to better-reimbursed, lower-liability fields (eg, magnetic resonance imaging, computed tomography). Many systems now require every mammogram to be read independently by 2 radiologists. While this reduces professional liability risk, it also increases the service’s cost—inflating the financial loss. During the past 2 years alone, about 700 mammography centers have closed.

One small ray of hope is that computerized detection systems will allow for a stronger defense at trial. The defense argument would be, “The computer did not detect the lesion on the previous mammogram.” What will plaintiffs do? Sue the computer?

Are delivery services next?

Central planning of medical services using the relative value unit system—as engineered by the federal government—slows the speed at which economic adjustments can be made to respond to shortages of medical services. If central planning of health services continues, additional shortages will likely arise in other areas with low reimbursement and high professional liability. One such area is likely to be delivery services for pregnant women.

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