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

By Abby Christopher, AlterNet. Posted December 4, 2008.

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.

See more stories tagged with: health, breast cancer, medical malpractice, mammograms, breast cancer detection

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

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