At the ACR 2017 Economics Forum, Dana Smetherman, MD, MPH, FACR, a member of the ACR Mammography Commission, delivered an informational barrage to help radiologists beat back the forces that would diminish access to life-saving mammography.
Her presentation was a call to action touting mammography’s positive effect on women’s health. She characterized mammography as one of the greatest success stories of modern medicine. Since the introduction of dedicated mammography systems in the mid-1980s, breast cancer mortality decreased 37 percent. Nine of 10 breast cancer patients are now still living five years after initial diagnosis.
“This is not just a victory for our patients and our clinical colleagues; this is a victory for radiology and the American College of Radiology,” she said. “They have fought tirelessly to have access to high quality mammography for all the women of our country.”
In 2016, U.S. radiologists interpreted over 39 million mammograms using about 17,000 mammography systems at more than 8,700 ACR-Accredited facilities. “Though breast cancer still kills six American women every hour, the mortality rate would be worse without broad access and public acceptance of mammography,” she said. A study from the Harvard teaching hospitals found that 70 percent of their breast cancer deaths arose from the 20 percent of women who did not receive regular screening mammography before their diagnoses.
“Despite Its importance, mammography is under attack from potential reimbursement cuts, misguided screening guidelines, the slow acceptance of improved imaging technology and Congress’ possible retreat from support for essential health insurance benefits,” she said.
Medicare reimbursement was stable from 2003 to 2016 when the professional component (PC) for screening and unilateral diagnostic breast imaging was 0.7 relative value units (RVUs). They were 0.87 RVUs for bilateral diagnostic mammography, with an addition PC RVU of 0.06 for CAD.
“With input from the ACR economics staff, the professional component of screening mammography was increased in 2017 to 0.76 RVUs, but the technical component, which Congress raised in 2000 to account for introduction of digital mammography, was again subject last year to Medicare’s standard methodology. To its credit, the Centers for Medicare and Medicaid set aside a potential 50 percent cut in technical component RVUs, but it plans to revisit the issue in 2018,” Smetherman said.
The College’s longstanding disagreement with the U.S Preventive Services Task Force (USPSTF) about the appropriate starting age and intervals between screening mammograms continues to raise concern. The ACR supports annual screening mammography from age 40 to 84. USPSTF began recommending screening every other year from age 50 to 74 in 2009, but the federal Protecting Access to Lifesaving Screening (PALS) Act placed the guideline on hold. Smetherman noted the moratorium was then added to spending bills in 2015 and again in 2017, but that later measure will expire at the end of this year.
“The difference between the two guidelines can be measured in women’s lives,” Smetherman said. Data drawn from the medical literature indicates 12 of every 1,000 lives would be saved with 65% compliance with the ACR guideline. Five fewer lives per 1,000 would be saved assuming the same compliance rate if the USPSTF guideline was applied.
“If we run those numbers, roughly 65,000 women — a population equal to Palo Alto, CA — would die they had mammograms from 50 to 74 every other year,” she said.
Private insurers have hampered the breast cancer fight because of their unwillingness to recognize the diagnostic power of digital breast tomosynthesis (DBT). It received a Category 1 CPT code through ACR efforts for Medicare patients in 2015.Clinical trials show DBT finds more cancers and generates six percent fewer patient recalls than digital mammography. The reimbursement rate for DBT may be $37 higher that digital mammography, but it ultimately saves the insurer $8 per patient or $200,000 per year for the average Medicaid program.
Still, commercials insurers have been reluctant to accept DBT. In response, Illinois and Pennsylvania have mandated DBT insurance coverage. Five states are considering similar legislation.
“Congressional efforts to repeal and replace the Affordable Care Act (ACA) add another layer of uncertainty,” Smetherman said. “While mandatory insurance coverage in the ACA contributed to increased screening mammography guideline compliance at all economic levels, Republican replacement legislation would let the states decide if insurers must offer such essential benefits.”
“The time may come when we may need to all rise and defend access to mammography,” she said.