A 40-year-old woman walked into Elizabeth Wende Breast Care in upstate New York for her yearly screening mammogram.
A 40-year-old woman walked into Elizabeth Wende Breast Care in upstate New York for her yearly screening mammogram. Although a radiologist found a nodule, the patient declined follow-up because her insurance wouldn't cover it, and she couldn't afford to pay the cost on her own.
“What do you do with that? Is there anything you can do?” said EWBC attending radiologist Dr. Stamatia Destounis.
Three weeks after the center called the insurance company, filled out forms, wrote a letter, and asked the insurance company director to review the case, the patient finally received the care she needed. The situation is indicative of the kind of environment mammographers are living in today.
The recession is affecting not only the housing, retail, and unemployment markets, but healthcare as well. What was once considered routine, preventive, and necessary is now being delayed or abandoned altogether due to money pressures.
In February the Centers for Disease Control and Prevention released a study of epidemiological data from 2000 to 2006 showing the number of women getting mammograms dropping in 34 states by as much as 5.3% (AJR 2009;192:352-360). It's easy to imagine in the current economic climate the numbers have dropped even further.
It's too soon to compile an in-depth report on how the recession is affecting mammography. But anecdotally, many mammographers are noticing a drop in patient volume. Private centers seem to be hit harder than academic centers, although a lot depends on geography. Wealthier communities will obviously be less affected than poorer ones. In the public versus private sphere, academic centers seem to be holding fairly steady or experiencing a slight increase due to the sliding-scale payment option they offer patients.
At EWBC in Rochester, NY, fewer and fewer patients are returning for their yearly screening mammograms, according to Destounis.
In the 1980s and '90s, the return rate held steady at around 95%, but recently the number has dropped to 88%, Destounis said.
When she broadened her search to include every other year, she also found patients had a tendency to skip their mammogram one year and come back the next. Instead of coming in yearly, patients have started pushing their screening mammograms to 18 months or longer. It may be because the patient wants to wait and see if she reaches her deductible, the copayment is too high, or she can't afford it, Destounis said.
Another private imaging center, Weinstein Imaging Associates of Pittsburgh, has found the percentage of women coming in for a screening mammogram has decreased a few percentage points compared with the first six months of last year.
“I do see a steady decline of women coming in for their screening mammogram,” said Dr. Marcela Bohm-Velez, president of Weinstein Imaging Associates.
And the patients who do come in are much more concerned about cost than they ever were before, she said.
“Every time I recommend additional imaging, such as breast ultrasound or MRI, one of the first things the patient asks is, ‘Will the insurance pay for that?' They're very conscientious about what will be covered by insurance,” she said.
Even the big hospitals are noticing the effects of the recession.
Hoag Memorial Hospital in Newport Beach, CA, performs approximately 40,000 screening mammograms a year. In the past, the practice had been growing 10% annually, according to Dr. Gary Levine, Hoag's medical director of breast imaging.
“This year, although we're seeing growth, it's a minor growth, on the order of 2% to 3%. We think this doesn't reflect saturation of the market, but instead reflects the economy,” he said.
The curtailed growth at Hoag could also be less significant than in other places because it's in a relatively well-to-do area, according to Levine.
“I think some of the changes that are present elsewhere may not be felt as greatly in Newport Beach. But I think there is a trend for patients to put off medical care, just like they would put off replacing their car or upgrading something else in their life. Unfortunately, when it comes to healthcare, that can be dangerous,” he said.
Some academic institutions are feeling the pinch as well.
At Northwestern University the decline isn't so noticeable-but it's there, according to Dr. Ellen Mendelson, a professor and the director of breast imaging at Northwestern.
“We have had in the past an accessibility issue in terms of our numbers of breast imagers available to do all of the studies that have been requested. But we think there has been some decline, and it's related to the economy,” she said.
Approximately six months ago Northwestern was backed up trying to provide reasonably prompt appointment times for screening and diagnostic mammograms-so backed up they had to turn patients away. That's not as much of an issue anymore, according to Mendelson.
“Our patient calendars have no openings, but I think there is a concern about the economy. There has been a definite increase in the number of patients who have gone to arrange for financial assistance,” she said.
Some universities are holding steady in their patient volumes, but that could be due to geography and the patient population.
Patient volume at the University of California, San Diego has remained the same over the last six months. But that could be because of the types of patients the facility serves, according to Dr. Chris Comstock, UCSD's director of breast imaging.
“Most of the patients we see, there's a mix of Medicare and third-party payers. Most of the screening fees are covered, so I wouldn't expect a change,” he said.
Patients who have lost their jobs and insurance and who must pay out of pocket would most likely be the ones to postpone their screening mammograms. But UCSD doesn't see many of those patients, he said.
“We're about 7% of the San Diego market in terms of screening. Is our 7% at the highest risk? Probably not,” he said.
Some institutions, like the University of Virginia, are seeing a slight increase in screening mammography rates.
“This may be because we are a public institution with sliding-scale fees adjusted to income, as well as [available] philanthropic funds for screening mammography,” said Dr. Jennifer Harvey, director of breast imaging at UVA in Charlottesville.
At Northwestern, more and more patients are calling patient representatives to work out financial assistance plans. Requests have jumped from one or two a year to six or seven a month, which is significant, according to Mendelson.
“There are repercussions from the loss of jobs, like the immediate truncation of health insurance. I think in the past if you talked to people, you would find they had some transitional time before they lost all their benefits, but now it's immediate. ‘Goodbye, take your stuff,' and along with it you have no more benefits, including health insurance,” she said.
Other centers, such as EWBC, are experiencing a dramatic uptick in the number of calls to the billing center, along the lines of 200%.
“We're becoming sort of like counselors over the phone. Before the procedure is even done, the patient wants to know how much it's going to cost,” Destounis said.
So many patients are asking about costs even before they schedule an appointment, the phone room now has a list of how much each test costs, she said.
“The front desk, the phone room, the billing department-everyone has become more savvy about how much the procedures are so they can answer the patient truthfully. It is a different time and a different environment,” she said.
In the past when a patient came to the breast center, the office would bill her for whatever the insurance wouldn't cover. Now, facilities can't afford to do that.
“We have patients, they'll come in for a test, they won't pay us anything because they say they don't have the money right then and they'll ask to be billed. And then they'll never come back to us again. They don't pay their bills. We just can't afford to stay open in this environment if we keep doing that,” Destounis said.
The new paradigm involves finding out who the patient's insurance provider is even before she walks through the door. Then EWBC calls the company and asks what the copay is. When the patient arrives for her procedure, EWBC collects the payment immediately.
“Even though a lot of the actual billing is streamlined and electronic, we have not been able to reduce our billing staff because they're doing a lot of legwork upfront. But doing all this legwork upfront has helped us in improving collecting at the time of the service,” Destounis said.
Because patients are putting off their screening mammograms, there has also been an increase in diagnostic workups.
At EWBC, the ratio used to be 80% screening, 20% diagnostic. Now the ratio has shifted to 70% screening and 30% diagnostic.
“The problem is screenings are less time-intensive than the diagnostics. You have to do excess reviews, obtain a history, conduct a physical exam. The diagnostic patient takes a lot more time to take care of than a patient who comes in for a routine mammogram,” she said.
Patients also seem to ignore their screening mammogram until they have a problem, according to Destounis.
“They may have waited three years to have a screening mammogram and now they have a lump and they want a diagnostic mammogram tomorrow. They blew off their screening appointment because it wasn't important, but now they think something's wrong with them, now it's an emergency,” she said.
If women continue to postpone their screening mammograms, the end result could be more late-stage cancers, according to numerous radiologists.
“We have come such a long way. The majority of cancers we diagnose today at our practice are early-stage. And they're treatable. If these women do not have annual mammograms, I think in a couple of years we're going to start seeing later stages of breast cancer,” Bohm-Velez said.
Mammography finds cancers early and so can save lives; early cancers are more treatable. But the current trend of finding cancers early may be reversed if women stop coming in for their screenings.
“Our trend over the last five to 10 years has been detecting smaller and smaller cancers. A quarter of the cancers we find are still in situ, they haven't become invasive cancers at all yet,” Levine said.
Even the invasive cancers are smaller and much less expensive to treat, according to Levine.
“If patients avoid screening, that trend is going to be reversed. We'll find more advanced cancers, cancers found through inspection, [by] feeling them, rather than detecting them through imaging. And the more advanced cancers have a much worse prognosis and are much more expensive to treat,” he said.
On average it can cost $30,000 to treat a small, localized breast cancer, while it costs on average $400,000 to treat advanced-stage breast cancer, according to Levine.
“So even though an individual may think, ‘I can't afford my screening mammogram right now,' it's much less expensive for that patient to have the screening mammogram because if they develop breast cancer down the line, it's so expensive to treat that advanced cancer,” he said.
All physicians are still encouraging patients to come in for their screening mammograms despite concerns over cost because it's good for their health and relatively inexpensive.
“In the long run, it may save their lives [and] save them money. That's really the story,” Levine said.