Why It Can Take a Year to Get a Mammogram in the U.S.

By Abby Christopher, AlterNet
Posted on December 4, 2008, Printed on November 30, 2009
http://www.alternet.org/story/108717/

Depending on where you live, the wait to get a routine breast screening could be as long as a year. And even if you're not facing delays today, if current trends continue, you might well be in the near future.

In Los Angeles, a routine mammogram appointment might not be available for four months; some medical clinics in New York City cite nine-month wait times; in Florida, delays are consistently six to nine months; and in parts of Rhode Island, you can expect to wait a year.

Why? Because many radiologists don't want to read mammograms.

"There is no public or private agency measuring or ensuring that women have reliable access to mammograms," says Robert Smith, Ph.D., director of cancer screening for the American Cancer Society.

While it's tough to pin down hard numbers -- how many radiologists read mammograms, the number of cases they read every week and where they practice -- one point that everyone, from radiologists to researchers, can agree on is that supply simply isn't meeting the growing demand for mammograms, as baby boomers age and 1.2 million women hit 40 every year.

Most radiologists don't choose mammography as a subspecialty for a number of reasons -- the repetitive nature of the job, narrow focus, the stress of missing a diagnosis -- but two are cited most often: money loss and malpractice.

"Missed or delayed diagnosis of breast cancer remains the leading cause of medical malpractice litigation in the nation today, while at the same time reimbursement for mammographic examinations remains embarrassingly low,"  explains Dr. Leonard Berlin, chairman of the department of radiology at Rush North Shore Medical Center in Skokie, Ill., and Rush Medical College in Chicago.

The shortage of breast-imaging specialists has forced general practice radiologists eager to avoid mammography to read routine screenings. Most practices rely on contracts with hospitals and physician-referral networks that, in many cases, require practices to offer mammograms. Some radiologists may be lured into mammography by various incentives offered to the practitioner who reads the most screenings. But more often, practices simply divvy up mammogram readings among staff.

"Junior staff get assigned to read mammograms, and most of them just don't want to do it. Most will try to cycle out and pursue other subspecialties like MR (magnetic resonance) and CT (computerized tomography)," says Dr. Barbara Sharp, an advocate for improved access and a breast-imaging specialist at Mori, Bean & Brooks Radiology, a general radiology practice in Jacksonville, Fla.

Cost of Mammography & Radiology

Many radiologists consider it bad business to offer routine breast screenings.

The number of facilities offering mammograms has dropped from 9,114 in 2004 to 8,832 in 2006, according to the FDA. Last year's Government Accountability Office report on mammogram access stated that "mammography facility officials most often cited financial considerations as the reason their facility closed."

Among the general practice facilities that do make mammography available (often to fulfill contractual obligations), many are reducing the number of appointments offered, favoring other imaging services that bring in more revenue.

"Mammography is a loss-leader. Right now, mammography is being subsidized by other examinations," said Dr. Ellen Mendelson, director of breast imaging and professor of radiology at Northwestern University in Chicago

In 2007, President Bush signed a hastily drafted cost-cutting measure called the Deficit Reduction Act, which cut Medicare reimbursements for MRIs and CT scans by as much as 40 percent, making it even harder for practices to absorb the losses mammograms generate since other imaging services are starting to bring in less money.

Because Medicare reimbursement rates are dropping for all imaging services, radiology practices are more inclined to cut back on or eliminate mammography, the service that brings in the least revenue. Medicare reimburses about $84 per screening mammogram, while the average cost to a facility for a mammogram is $125, according to a report on mammogram access published in July by Rep. Anthony Weiner (D-NY).

Even though most Americans use private health insurance, Medicare reimbursement rates are a marker for what private carriers will pay. When there are changes in Medicare reimbursement rates, it has a ripple effect on private payers' rates.

Weiner tried, but failed, to pass legislation earlier this year, which would have increased reimbursement rates for radiologists who offer routine screenings. Long wait times (as long as nine months in New York) for mammograms could be remedied by better reimbursement rates, according to Weiner. However, there is considerable pressure to cut Medicare costs, and this is the second time since 2002 that Weiner's efforts have been shot down.

Malpractice: It's Not Just a Fear

The fear of malpractice is well founded according to several state chapters of the American College of Radiology and one of the leading physician insurance carriers, the Physicians Insurance Association of America. Missed breast cancer diagnoses ranked No. 1 in malpractice suits filed and No. 2 overall in paid settlements and judgments, according to a 2002 PIAA report. Judgments and damages awarded to women whose breast cancers were missed were as high as $5.7 million in 2006.

The American Medical Association has designated certain "crisis states" where malpractice insurance premiums and number of suits filed are particularly high, leading to compromised health care access.

Anecdotal evidence suggests that medical malpractice is affecting access to care in areas where rates are highest. For example, in Florida, where annual rates are as much as $215,000 per physician, the state is having a difficult time recruiting new doctors and keeping the licensed ones practicing. Over 14 percent of licensed radiologists have plans to leave the state or stop practicing. (There has also been a significant increase in the number of doctors in Florida and other states practicing "bare," meaning they carry no malpractice insurance. Physicians who practice without insurance must plainly disclose this to their patients and to state medical boards.)

Certain cities within the crisis states -- Philadelphia and New York City, for instance -- are notorious for finding for the plaintiff in medical malpractice suits, according to Walter Olson, who specializes in malpractice at the Manhattan Institute. This could be one reason why, in some parts of a state, it is easier to schedule a routine mammogram than others.

Malpractice exposure can effect where a radiologist chooses to practice. Some smaller practices have closed shop and joined larger radiology groups to be protected under their malpractice insurance. And border crossing has become an escape hatch for some doctors worried about malpractice exposure.

"Some radiologists who read mammograms practice across state lines to avoid medical malpractice laws in certain states. Illinois and Pennsylvania are hard states to practice in, but Indiana and Ohio aren't. So, doctors will go to nearby states where malpractice isn't as much of a threat," said Northwestern University's Mendelson.

Discouraging Border Crossing To Preserve Health Care Access

Some states are trying to discourage doctors from border crossing by providing modest incentives. For example, starting in 2005, the New Jersey Department of Banking and Insurance recognized doctors in subspecialties that "are most threatened by medical malpractice." Radiologists who read mammograms are among three subspecialties (the others are neurosurgery and obstetrics) that can apply for very modest annual subsidies.  In 2006, each breast-imaging specialist who successfully applied for the subsidies received about $5,700. And one of the largest malpractice insurance providers in New Jersey has announced it is increasing premiums for radiologists who read mammograms by 15 percent, more than other radiologists.

Doctors in the AMA's so-called crisis states have been especially active in fighting for tort reform that would place caps on malpractice judgments and settlements. AMA chapters throughout the country have attempted to change the ways in which judges advise juries before they deliberate malpractice cases. Earlier this year, bipartisan legislation was introduced that, if passed, would establish a federal fund to help establish health courts, an alternative approach to the ways in which malpractice cases are tried today. Each state awarded a grant would have some freedom to experiment with how to set up a health court to resolve malpractice disputes. One concern about medical malpractice today is that lay juries and judges without medical backgrounds are making the final decisions. Health courts could attempt to assemble individuals who are both objective and knowledgeable about the medical condition under dispute.

A handful of states, most recently Texas, have had some success reforming malpractice laws. In Texas, where tort-reform legislation passed in 2003, malpractice judgments for pain and suffering are capped at $750,000.

But in spite of Texas' model of success, changing medical malpractice law, subsidies for subspecialists and tort reform do not change the biggest factor driving medical malpractice lawsuits: communication breakdowns between doctors and patients.

Why Patients Sue

In many cases, women sue because some breast cancers are not detected early. Once a woman gets a later-stage diagnosis, she may ask why the cancer wasn't found sooner, in one of her annual screening mammograms. And certainly some missed diagnoses should have been caught earlier and are the result of a radiologist's negligence. But the breast isn't an easy area to screen, and mammography is not 100 percent accurate. In fact, studies estimate the error rate in mammogram screenings can range from 15 to 30 percent.

Breast cancers, commonly detected as masses and calcifications, can be tricky to spot in screenings. Some types of breast cancer resemble normal tissue nearly perfectly. Instead of forming a dense mass, they form clouds of tissue that are indistinguishable from normal breast tissue. If there is a distinct change between screenings, radiologists can find them.  But if it is the patient's first mammogram, radiologists might miss the abnormality.

Mammograms are also harder to read in some breasts than others. Generally, the denser the breast tissue, the more difficult it is to see masses. Mammographers use four densities to characterize breasts: fatty; scattered fibroglandular; heterogeneous; and very dense.

"Fatty and scattered fibroglandular are much easier to read, and heterogeneous and very dense are the hardest," according to Dr. Loretta Lawrence at the Breast Imaging Center of North Shore University Hospital, Great Neck, N.Y. "To find cancer in the densest breasts -- very dense or heterogeneous -- you're looking for a white dot in white dense tissue."

Some radiologists compare looking for cancers in dense breasts to searching for a grain of salt or sand -- one that may not even exist -- in a snowstorm.

Women under 50 typically have denser breasts, but, Lawrence says, "I've seen women at 80 with dense breasts, so you can't assume. We don't know how dense your breasts are until we see your mammogram."

Calcifications can also be a headache for mammographers. They are divided into two categories: macrocalcifications and microcalcifications. Macrocalcifications are benign, large calcium deposits that are more common in women 50 and older. However, microcalcifications, much smaller calcium deposits, may or may not be cancerous. They are trickier to detect and interpret, and therefore very often the root cause of medical malpractice suits.

According to the American Cancer Society, an area of microcalcification that is seen on a mammogram does not always mean that cancer is present. Microcalcifications may appear alone or in clusters. Their shape and layout help the radiologist judge how likely it is that cancer is present.

Still, it's hard for women to accept all that uncertainty, especially when we've been urged to believe just the opposite -- that screenings are foolproof. We've been overwhelmed by the familiar refrain, "mammograms save lives." That sort of ad campaign or simple slogan scares us into the exam room. The implication is: Get your mammogram, and you're covered. It's human nature to want it to be that easy.

"It's great that screening campaigns have raised awareness," says Dr. Berlin of Rush North Shore Medical Center and Rush Medical College. But in the course of getting through to us, the "campaigns may have unwittingly raised expectations," he says. And in some cases, this has led to serious misunderstandings. Sure, regular screenings save lives. The National Cancer Institute and the American Cancer Society, among many others, urge us to get screened annually once we hit 40.  But ask any radiologist who reads mammograms, and they'll tell you straight up, they most certainly are not infallible.

The introduction of digital mammograms has helped make finding certain breast cancers easier, even in dense breasts. But at $400,000, digital mammography is expensive, and the FDA estimates that the new screening technology is only offered at 20 percent of breast-imaging facilities in the United States.

For now, breast cancer survivor Becky Olson recommends that we keep our expectations in check. "Is it an exact science? No. Is mammography still the best screening tool we have for breast cancer? I believe it is."

Number of Women Getting Screened in Decline

Early detection of breast cancer has saved lives, but a National Cancer Institute study published last year showed a decline in the number of women getting screened, and that has radiologists and oncologists worried.

The fear is that women who put off getting their mammograms might be diagnosed with later-stage breast cancer, making them much more difficult to treat. The reasons women are backing off of routine screening aren't yet known, but long wait times could be partly to blame.

According to the NCI study, "It could be the end result of a cascade of events -- cost-cutting by insurers leading to lower reimbursements for doctors who perform mammograms, leading to fewer doctors getting specialized in reading the tests, leading to less availability and longer appointment delays for the patient."

It is widely accepted that delays in routine screenings can have serious consequences.

"You're putting yourself a greater risk the longer the interval between mammograms," according to Dr. Carl D'Orsi, director of breast imaging at Emory University in Atlanta. "Let's say you have to wait six months for an appointment, six months later than your last annual, you could lose six months of early detection if you have a fast-growing tumor."

Olson, who heads up a cancer support group in Oregon called Breast Friends, knows just how fast some cancers can grow. In August 2003, she got the all clear after having her annual screening. Ten months later, while doing a self-exam in the shower, she found a large, deep lump. It was stage-three breast cancer. "Some tumors are very fast-growing," she says. Even without delays, "There are 12 months between mammograms. ... A lot can happen in 12 months."  Or even 10.

But access does not show any sign of improving around the country. According to the Institute of Medicine, "the problem is that radiologists choose other fields. If there are not enough radiologists to do all the work available, which work would you choose to do? Would you choose a field in which professional liability is high, reimbursement is low and regulation is significant, or would you choose something else?"

Abby Christopher is a freelance health and health policy writer based in Portland, Oregon.

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