Feature | March 19, 2013 | Greg Freiherr

When Government Treads on Medical Practice

dense breast tissue

Dense breast tissues make mammograms (right) difficult to read, which may require complementary testing, such as MRI (left). Efforts by state legislatures mandating that physicians inform patients of the challenges of dense breast imaging raise both opportunity and risk for readiologists.

For many years mammographers have been saddled with low reimbursements. Recognizing this, women’s health advocates lobbied successfully last decade for higher rates for mammograms produced with digital equipment.  

This may be the only exception to the “rule of less” that has been applied to imaging reimbursements since the federal Deficit Reduction Act (DRA) took effect in 2007. Cutbacks in reimbursement have at the very least slowed the growth of medical imaging procedures and led to a decline in the purchase of new imaging equipment, just as the increased reimbursement for digital mammography led to a boom in the purchase of full-field digital systems that today dominate the landscape of women’s health. 

While the federal government has been content to influence the practice of medicine through financial dictates, individual state governments lately have taken a more direct approach. Five states now mandate physicians to inform women with dense breasts that mammography may be of limited value for them. Connecticut, Virginia, Texas, California and New York require physicians to advise patients that complementary imaging studies, such as ultrasound or MRI, may be needed if dense fibroglandular tissues are likely to obscure the mammographic signs of cancer. 

This legislation offers opportunity for radiologists, who might do what the RSNA at its last annual meeting advised members to do: “Be the voice of radiology for your patients.”  They might educate and inform patients about the significance of breast density, as they are doing at the Elizabeth Wende Breast Clinic in Rochester, N.Y. They might also provide complementary testing. It is logical to expect that they do so. But stepping into this breach carries risk. (Editor’s Note: For more information, see “Legislating Women’s Health: A Chance for Radiologists to Step In” by Greg Freiherr at http://bit.ly/YOG3Mh.)

Third-party payers in the first states to adopt such mandated education have typically reimbursed for the ultrasound procedures that may follow, although its not required by law. And while ultrasound coverage may be provided, it is seldom there for the MRI exams that might be indicated for women with dense breasts at high risk of developing cancer. When reimbursement is not available, the laws do not address who should shoulder the costs.

And there are logistical challenges, as well. Few mammography practices have the capacity to perform ultrasound immediately following the determination that a patient has dense breasts. Even fewer can accommodate an MRI exam the same day. Patients found to have dense breasts and prescribed a complementary exam, therefore, may have to return for another appointment or travel to another facility, neither of which may be easy, particularly if they have traveled a long way for their mammogram already.  

Then there are fundamental problems with ultrasound and MRI. Their high sensitivity and lack of specificity lead inevitably to more biopsies and a preponderance of negative findings for procedures that otherwise would not have been performed, as illustrated by early experiences in the first state to enact such legislation, Connecticut.[1]

Consequently, legislative efforts of this type amount to little more than unfunded mandates that impose costs on insurance companies, practitioners and patients. While they may provide an opportunity for radiologists to become more involved with patients, radiologists must be careful in how they respond to this opportunity, as these mandates may expose them to risks that can endanger the very relationships that they foster. 

 At least when the federal government seeks to influence medical practice, it foots the bill…albeit at a cut rate.

Greg Freiherr has reported on developments in radiology since 1983. He runs the consulting service, The Freiherr Group. Read more of his views on his blog at www.itnonline.com.

1. Hooley RJ, Greenberg KL, Stackhouse RM, Geisel JL, Butler RS, Philpotts LE. “Screening U.S. in patients with mammographically dense breasts: initial experience with Connecticut Public Act 09-41.” Radiology. 2012;265:59-69. Abstract: www.medscape.com/medline/abstract/22723501.

Related Content

Clinical Data Supports Use of Xoft System for Endometrial Cancer
News | Brachytherapy Systems | August 03, 2017
Researchers presented clinical data supporting use of the Xoft Axxent Electronic Brachytherapy (eBx) System for the...
The ASPIRE Cristalle FFDM system with DBT combines Fujifilm’s state-of-the-art hexagonal close pattern (HCP) detector design, advanced image processing and image acquisition workflow
News | Women's Health | August 01, 2017
Fujifilm Medical Systems U.S.A., Inc. announced that The Mammography Center of Monterey, an ACR-accredited breast...
Sponsored Content | Videos | Breast Imaging | July 28, 2017
Nancy Cappello, Ph.D., executive director and founder of Are You Dense Inc. and Are You Dense Advocacy, explains how
Radiotherapy Prior to Surgery Reduces Secondary Tumor Risk in Early-Stage Breast Cancer Patients
News | Radiation Therapy | July 24, 2017
Moffitt Cancer Center researchers launched a first-of-its-kind study comparing the long-term benefits of radiation...
Kubtec Launches New Website For Digital Imaging and Irradiation Products
News | Digital Radiography (DR) | July 20, 2017
Kubtec announced the launch a new website focused on the applications of digital X-ray imaging and irradiation for...
Volpara Solutions to Showcase Volpara Enterprise DDP Software at AHRA 2017
News | Mammography | July 11, 2017
Volpara Solutions Inc. will showcase its new Volpara Enterprise DDP software at the Association for Medical Imaging...
Fujifilm Showcases Digital Radiography, Mammography Innovations at AHRA 2017
News | Digital Radiography (DR) | July 06, 2017
Fujifilm Medical Systems U.S.A. Inc. will present its comprehensive portfolio of digital radiography (DR) and...
Feature | Breast Density | July 05, 2017 | By Nancy M. Cappello, Ph.D.
Two decades of research on the masking risk of dense breast tissue by mammography screening is indisputable. As the...
Solis Mammography Ranks No. 19 in Dallas Business Journal’s Middle Market 50
News | Mammography | June 30, 2017
June 30, 2017 — Solis Mammography was named the 19th fastest-growing, middle-market company in North Texas by the
GE Healthcare Announces First U.S. Installation of Senographe Pristina Mammography System
News | Mammography | June 29, 2017
GE Healthcare has collaborated with Boca Raton Regional Hospital (Boca Raton, Fla.) to bring a more comfortable...
Overlay Init