In part one of his blog, Gerald Kolb laid out the history of the USPSTF guidelines for mammography and shared referral patterns from recent studies of the guidelines. In this second and final part, he makes the case for advocacy and personalized care in order to maintain mammography volume and department revenue.
Here’s a question I get a lot: how do imaging providers proactively work to overcome the challenge of revenue losses as patients begin to comply with the new USPSTF recommendations? I believe the answer is advocacy and individualization.
Advocacy
To maintain volume, radiology departments need to make the case for screening. The American College of Radiology and Society of Breast Imaging have position papers on the importance of screening younger women, but those are seldom read by busy primary care physicians or by patients.
I believe advocacy needs to be done at a “grass roots” level by local breast radiologists. Who better to discuss the need to screen younger women than the radiologist whose signature is on the reports?
Advocacy is an evangelical activity. Not the religious kind of evangelism, but living one’s life with the conviction that you can personally make the difference in the lives of others. Of course, the more visible advocacy activities are often physician interviews with local media, but individual, one-on-one discussions with peers about the importance of screening are of equal importance.
I’m not just talking about radiologists here—perhaps the most effective advocates for early mammography are women, and who better to send a positive message than those who deliver mammograms on a daily basis—the technologist herself. Also, don’t forget the power of your patients. Service excellence becomes an imperative if copays and deductibles are required of patients. Women must be treated with kindness and respect from scheduling through billing.
Encourage women who are happy with your service to “like” you on Facebook and to remind their friends to get an annual mammogram. Social media has made patient satisfaction an absolute priority in women’s care because of the way it leverages opinion—both positive and negative.
A very effective advocacy technique is for the technologist to take a moment to thank the patient for taking the time to take care of herself—reminding her that mammography is one of the most important things a woman can do for her health.
Finally, schedule a woman’s mammogram for the next year before she leaves the center. You will get her into your reminder system and improve the opportunity to keep your patients on an annual screening cycle.
Personalized Care
No two women are the same, yet we have traditionally treated all women the same with respect to screening for breast cancer.
We now have good evidence that, while the majority of women are still well served by mammography alone, women who are at high risk of breast cancer should begin screening at age 30 and supplement annual mammography with annual breast MRI.[i] The evidence is also clear that dense breast tissue both increases the risk of breast cancer, and also the risk that a cancer will be missed on screening mammography.
Approximately 40-50 percent of women will be affected by either being at high risk or by having high breast density. Each of these women would benefit from an individualized breast-screening program. Breast MRI is complex, as use of the technology generally requires pre-certification, but a breast MRI program is effectively the product of having a comprehensive risk analysis system.
No risk analysis system is complete unless it is designed to work proactively with primary care, as even under the existing screening recommendations, the initial contact with screening eligible women comes at age 40. Building a collaborative program for risk assessment with primary care also provides an advocacy opportunity with physicians who occupy the front of the referral chain for breast imaging.
Most of the women who require supplementary imaging will, however, be women whose dense breast tissue reduces the sensitivity of their mammograms. Because the number of eligible women can approach 50 percent of those receiving mammograms, the only way that this group of patients can be effectively treated is by incorporating supplemental imaging on the same day as the patient’s mammogram. This is a departure from the typical process where batch reading of screening exams is utilized, but it is entirely possible and is in use in many centers across the nation.
Individualization of screening will result both in more screening procedures than would otherwise be the consequence of the proposed mammography regulations and, by virtue of the detection of more cancers, the downstream diagnostic and therapeutic procedures that result from that activity.
Combined with an aggressive advocacy program, they form a two-pronged response that both promote women’s care and protect revenues of breast imaging centers.
Hear more from Gerald Kolb in a recording of his Cassling webinar, "Breast Screening in 2017 - A Practical Guide."
[i] Saslow D, Boetes C, Burke W, et al. American Cancer Society guidelines for breast screening with MRI as an adjunct to mammography. CA Cancer J Clin. 2007;57:75-89.
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