Breast MRI: A Technology Trap?

In the early ‘90s Congress mandated mammography for payment by Medicare, and the requirement of coverage gradually came to apply to most health insurers. Few will remember today, but crucial testimony in this process came from Richard Bird, MD, a Carolina breast radiologist who had developed the workflow system to allow the delivery of a mammogram at a price of $35. Congress would never have mandated coverage, had the economics not been satisfactorily addressed.

In April of 2007 the American Cancer Society issued recommendations for the use of adjuvant breast MRI for screening certain classes of high-risk patients. Specifically excluded from those recommendations were women with dense breast tissue, and the reason was that the weight of the evidence was not yet great enough to support MRI for this use. It's clear, however, that evidence in support of this use is mounting, but therein lays a very big Catch-22.

Even though a very small percentage of women can be classified at very high risk within the meaning of the ACR recommendations, pushback from third-party payers has been immediate and strong. Onerous precertification processes, lack of uniformity in acceptance criteria, limitation to one MRI per year (biopsy?), and routine denial for lack of medical necessity are plaguing the provider community. Breast MRI is becoming a real challenge from the reimbursement side.

Imagine what will happen when MRI is found to have specific value for patients with dense tissue. By various estimates the number with dense breast tissue ranges from 8 to 40 percent of the screening population, depending upon which density criteria one includes (extremely and/or heterogeneously dense). The financial impact would be on the order of $2.5 to $12 billion in additional screening expense. While the technology may be valuable, the simple fact is that cost increases of this magnitude are not acceptable. Consider the fact that, at Medicare rates, 30 million women can be given a digital screening mammogram, including CAD, for under $4.5 billion.

What should we do? The ultimate risk of expansion of the recommendation for breast MRI would be a dramatic repricing of the study to levels that are closer to the level of payment for a diagnostic mammogram. It should be obvious that this alternative would not be an economic possibility for the technology, especially as it now exists.

The answer to this quandary may be found in a new way of looking at technology that I will explore in my next blog--stay tuned.