“Screening saves lives” is an adage that radiologists frequently espouse. Often, however, patients forego potentially lifesaving screenings, like mammography, because of access issues — including cost, time spent away from work, and lack of childcare. So when opportunities arise to help solve some of these issues through legislation and outreach, radiology advocates (or “radvocates,” as they call themselves) rise to the cause.
Such was the case for Amy K. Patel, MD, medical director of the Women’s Imaging Center at Liberty Hospital and assistant professor of radiology at the University of Missouri Kansas City School of Medicine, when she learned that the Missouri state legislature would be considering a bill to mandate insurance coverage of 3D mammography during its 2018 session. At the time, Medicaid and Medicare covered 3D breast tomosynthesis mammography in Missouri, but not all private insurers did — leaving patients to pay out of pocket for this advanced screening.
“Missouri has access-to-care issues, and many patients can’t afford to pay for this procedure out of pocket,” Patel says. “It’s concerning that patients can’t access this lifesaving procedure because 3D mammography is proving to find more cancers when they are much smaller compared to 2D mammography, which can result in less invasive treatment for the patient. It also makes lesions more conspicuous to our eye compared to 2D mammography and benefits patients with dense breasts, which can obscure lesions and make them more difficult to see on a static 2D mammography image.”
Recognizing the opportunity to improve care for Missouri women, Patel and other members of the Missouri Radiological Society worked with legislators on a bill that would require insurance companies to cover 3D mammography in accordance with the ACR’s national screening guidelines
, which say that average-risk women should be screened annually starting at age 40. They then conducted outreach to help generate legislative support for the bill.
In April of 2018, the radiologists’ work paid off when the Missouri legislature unanimously approved the bill. Now, women throughout Missouri have access to annual 3D mammography screening beginning at age 40, with no out-of-pocket costs. “This bill improves access to care, as private insurers in the state of Missouri are now required to cover both 2D and 3D mammography annually beginning at age 40. Under previous legislation — which had not been amended since the early 1990s — insurers were only required to cover 2D mammography every other year beginning at age 50. So many more women will be covered under this new legislation and not have to pay out of pocket,” Patel says.
Patel’s involvement in the Missouri measure was a natural fit. She has been interested in advocacy since her residency, when the Kansas Radiological Society and her mentor, John Lohnes, MD, encouraged her to get involved in the ACR, which ultimately connected her to advocacy work. “During my first ACR meeting as a first-year radiology resident, I was hooked. I knew that it was crucial to get involved in this governing body of my profession, and I knew that getting involved early was imperative,” Patel says. “Dr. Lohnes also introduced me to Dr. Geraldine McGinty, who is also one of my beloved mentors and who I attribute much of my career success thus far.”
With her mentors’ support, Patel applied to and received the 2015 ACR Rutherford-Lavanty Fellowship for Government Relations
, which allows residents to work alongside ACR government relations staff to learn about state and federal legislative and regulatory processes. The fellowship also teaches residents about ACR’s advocacy work and governmental factors that play important roles in shaping radiology.“ Combining my love of politics with the realization that I could be a part of the process to advocate for patients was a win-win in my eyes,” Patel says.
From there, Patel became increasingly involved with other advocacy groups, such as the Radiology Advocacy Network (RAN)
. In 2017, when she took a breast imaging position in Massachusetts, Patel joined the Massachusetts Radiological Society, which afforded her the opportunity to leverage her advocacy skills as part of the mammography committee — work that would prove beneficial when she moved to Missouri.
While Patel was in Massachusetts, state Sen. Joan B. Lovely (D) introduced a bill that mandated insurance coverage for 3D mammography, as well as other supplemental screenings. To help garner support for that bill, Patel and other radiologists testified at the Massachusetts statehouse, sharing their expert insights about the benefits of 3D mammography. (As of the time this Imaging 3.0 case study was published, this bill was still being legislated.)
Meanwhile in Missouri, legislative affairs were heating up, and the Missouri Radiological Society and the Missouri State Medical Association (MSMA) were poised to partner on advocacy efforts. “The Missouri Radiological Society and the MSMA are relatively small organizations, so we always work together,” explains Karen Goodhope, MD, FACR, immediate past president of the Missouri Radiological Society. “The MSMA often needs our support, expertise, and backup on laws that relate to radiation safety and radiology. In turn, they lobby on our behalf.”
In December of 2017, the Missouri Radiological Society received word that state Rep. Dean Plocher (R) was introducing H.B. 1252
, mandating insurance coverage of 3D mammography. Insurance companies would be required to reimburse physicians administering 3D mammography for women receiving a baseline mammography at age 35, biannual mammography for women ages 40 to 49, and annual mammograms beginning at age 50. Insurers would also be required to cover 3D mammography if a physician recommended it for a patient who did not fall into these categories and was at-risk due to a history of family breast cancer.
“I was grateful for the chance to introduce this lifesaving, cost-saving bill,” Plocher told the Missouri Times.1
“The success rates for breast tomosynthesis (3D) versus traditional X-rays are encouraging, and I believe this legislation will truly act to improve healthcare for women and men and serve as a lifesaving measure.”
Before Plocher could introduce the bill, however, members of the Missouri Radiological Society wanted to work on its wording. “When we first reviewed the bill, the suggested intervals for mammography did not align with what radiologists would recommend
,” says Goodhope, adding that rather than the ACR’s guideline of annual mammograms starting at age 40, the bill included different screening intervals based on various ages (for example, biannual exams for high-risk patients ages 40 to 50, then starting annually later).
“Without our intervention, the bill would have been completely uninformed and not aligned with established guidelines from the radiology specialty. As physicians, we must be paying attention to things like this for our patients, because while legislators may mean well, they’re usually laypeople from a medical standpoint and don’t have the specialized knowledge needed to serve the best interest of patients,” Goodhope says.
Communicating with Representatives
While working in Boston, Patel accepted the medical director position at Liberty Hospital in Missouri through Alliance Radiology. The move was a return home for Patel, who completed her fellowship at Washington University in St. Louis, attended medical school at the University of Missouri-Kansas City School of Medicine, and was born and raised in rural Northwest Missouri. “By the time I decided to take the job in Missouri, the Missouri Radiological Society knew I was relocating,” Patel says. “They also knew I had been working on the mammography bill in Massachusetts.” Patel reached out to Goodhope and offered to help edit the Missouri bill and to testify at the statehouse in support of the legislation.
Together, Patel and the Missouri Radiological Society crafted a letter that the MSMA general counsel and director of government affairs, Jeff Howell, sent to representative Plocher. The letter stated that both the ACR and the Society of Breast Imaging recommended that annual mammography screening begin at 40 and provided data to support the guideline. Plocher agreed with their suggested changes and amended the bill.
In the meantime, Patel and Goodhope both reached out to state senate representatives to garner support for the bill. Goodhope sent an email to her state senator introducing herself as the president of the Missouri Radiological Society and explaining why she supported H.B. 1252.
Patel called Rep. Marsha Haefner (R), a senior state representative who had the authority to generate support from other representatives and with whom Patel had a personal connection through mutual friends. During the phone conversation, Patel explained why she supported the bill and offered to send Haefner a handout that she could share with her legislative colleagues about why radiologists recommend mammography at 40.
Patel says that this type of outreach to elected officials is critical to successful advocacy. She notes that beginning a relationship is as simple as sending an email to a legislator and his or her legislative assistant. From there, she says, radiologists should continue to keep in touch with the officials’ legislative assistants. “Over time, you’re more likely to get access to the elected official themselves, and then you can develop that relationship further,” she says. “The more you cultivate relationships with people in your local legislative offices, the more likely you are to garner support, because your representative will view you not just as a constituent or a doctor but as a partner.”
Moving Beyond Passage
In Missouri, once legislation has been introduced, representatives often discuss and vote on it with little notice. For testimonies, the Missouri Radiological Society often calls on a general radiologist who lives in Jefferson City, Missouri’s capital, and therefore can get to the statehouse on short notice, Goodhope says.
In the case of H.B. 1252, the legislators discussed the bill in April of 2018, unbeknownst to the Missouri Radiological Society. While Patel did not get a chance to testify, both the house and senate unanimously approved the bill. “I found out about the legislation passing when I received the weekly MSMA legislative update. We are almost always notified about these bills ahead of time by the MSMA and our lawyer. I was delighted it passed so quickly,” says Goodhope.
Although the bill passed, Patel’s work wasn’t done: It was time to educate the public about the legislation and its impact on patient care. “If the public doesn’t know about the bill, or if they don’t understand it, they can’t take advantage of it,” says Patel, noting that radiologists should take the lead to disseminate information to both the public and to other physicians about new imaging-related legislation. “The last thing you want is someone who is not knowledgeable about radiology publicly commenting on the legislation,” she says.
Such was the case with Missouri’s 3D mammography bill — Patel noticed articles in which breast surgeons were commenting on the new law without any input from radiologists. “Breast surgeons do incredible work, but they may not be privy to the inner workings of mammography. It was important for me to get out and explain why 3D mammography is technologically superior for patient care and share that the majority of Missouri women can now take advantage of it because they don’t have to shoulder the cost. Previously, many women were not able to afford it,” Patel adds.
Spreading the Word
Patel contacted her hospital’s marketing and public relations department about spreading the word to patients about the legislation. “I told them that I wanted to do everything I could, whether it was the news or speaking engagements. I accepted every opportunity they offered, and I’m still accepting,” says Patel, who has appeared on televised news segments
, interviews on the radio
, and in various newspaper articles
H.B. 1252 took effect in January of 2019. Although it is too early to assess the legislation’s impact, Patel says she’s received an overwhelmingly positive response from patients. “We had a patient come in who had seen me on the news. She asked to meet with me and when she did, she was in tears — she had wished for legislation like this for a long time,” Patel says.
In addition to informing the general public, Patel has also arranged for her state legislators to visit her and her team at Liberty Hospital. The visits give legislators a firsthand chance to see the impact of the legislation that they helped pass. This is important, Patel says, because it helps them better understand patient needs and encourages them to work more closely with physicians. “Most elected officials think radiologists still look at films on a view box,” Patel notes. “Without seeing the work we do every day, how can legislators understand that radiologists are imaging experts?”
Patel worked with The Liberty Hospital Foundation, the hospital’s charitable foundation that often assists with women’s health needs, and the hospital’s marketing and public relations department to invite the legislators to visit her group. RADPAC can also help radiologists arrange site visits with their legislators. As long as it works with their schedules, elected officials are usually receptive to these visits, Patel says. “One of my state senators visited for about 20 minutes the other day, and we have already discussed future legislative efforts,” Patel explains. “Even short site visits can result in big changes and important coverage for our patients.”
Continuing the Effort
With H.B. 1252 now law, Patel is committed to continuing her advocacy work, and she encourages other radiologists to get involved, as well. “Advocacy is a huge value that radiologists can provide in the care of our patients, and as healthcare transitions to value, it’s important that we’re seen doing this work,” Patel says.
For radiologists interested in joining advocacy efforts, Patel recommends that they begin by reaching out to their state radiological societies or ask the ACR for help with state contacts. Those wishing to get involved at the national level should contact RADPAC or the ACR Government Relations team
, Patel suggests. Both have resources to help radiologists get started with advocacy, understand the issues, and make contacts, she says.
Patel invites all radiologists to join the cause. “Political advocacy is everywhere. We’re looking for radvocates across the country,” says Patel. “We know healthcare is competitive; we know insurance providers are pushing back on reimbursements. But we can’t change anything unless radiologists take initiative and get involved.”