Unnatural Selection: A Health Care Imperative
In my last blog I briefly discussed the growing reimbursement challenge of breast MRI, positing a catch-22 between the recommended use of breast MRI, and reimbursement for the study. This blog will suggest an alternative approach that will provide the patient with the real benefit of MRI--without the expense.
The major challenge of breast MRI lies in the fact that it has been accepted as the gold standard in breast diagnostics without a great deal of reality testing. Please don't take this as a disavowal of the evidence establishing the benefits of breast MRI. On the contrary, I fully recognize the benefits of breast MRI. My quarrel is with the selection of MRI as the only alternative to mammography for adjuvant imaging of the breast.
In any health care paradigm, physicians have a responsibility to choose the imaging technology that is most appropriate for the patient, given the relative risk of disease, the relative "quality" of different available technologies, and the cost of those technologies. Just because MRI will "work," doesn't mean that's why it should be selected.
Let's look at a real life example, a patient whose only known risk factor is dense breast tissue, and whose mammogram, though difficult to interpret, is objectively normal. Adjuvant breast ultrasound is certainly far less expensive than MRI, and should provide both sensitivity and specificity, when used with the mammogram, that will compare favorably with an adjuvant MRI. If the ultrasound was ambiguous, an MRI might be ordered, however breast specific gamma imaging is an alternative, and lower cost, modality that will yield approximately the same results.
In the title I refer to "Unnatural Selection," because the natural tendency is--in my opinion--to move too quickly to the "ultimate" imaging modality, rather than select modalities, and the progression from one modality to another, based on personal preference (rather than the dictates of patient care). This is the easy pathway, but it's not intellectually honest. And, it doesn't address the matter of health care expenditure increases that are outstripping both the inflation rate and the ability of this nation to meet its health care costs. The latter must be the responsibility of each of us, or our power to make these important decisions will be taken from us.