ACR leaves mammography fee decisions up to Congress

The American College of Radiology has halted efforts to move payment for screening mammography out of congressional control and into Medicare's relative value scale (RVS).

Congress mandated reimbursement for screening mammography by Medicare and private insurers as part of the Mammography Quality Standards Act of 1994. That law requires that Congress, not Medicare, set payment for the procedure. But in recent years, reimbursement has lagged far behind technical and professional costs to provide the service.

For example, standard two-view bilateral screening exams, which account for 70% of all breast imaging, are reimbursed at $66.81. Of that amount, $46.11 covers labor, equipment, supplies, and overhead. The remaining $20.70 goes to the mammographer for interpretation. The payment has increased only 7% since 1996.

The ACR had been working on the assumption that it might have a better chance at achieving incremental pay increases if the procedure was folded into the RVS. Screening mammography is the only Medicare-approved medical procedure that is not covered by the AMA's RVS process, according to Dr. William Thorwarth, chairman of the ACR Commission on Economics.

"We have had a real concern with relative values for breast imaging across the board," Thorwarth said. "We thought if we could get screening mammography incorporated into the RVS system, its value might be reconsidered and payment adjusted. But getting into that process can be unpredictable, and it's not known how long it might take—or what might happen once it was accepted."

Given the uncertainty about how payment for diagnostic mammography might change under Medicare's ambulatory payment classification program just going into effect, ACR executives decided they might have better luck lobbying Congress directly. Under the new payment system, which began to phase in Aug. 1, reimbursement for the technical aspect of diagnostic mammography is being ratcheted down and will now be reimbursed at a rate 26% lower than the entire payment for screening exams, Thorwarth said.

"It's unbelievable," he said, "especially since diagnostics take so much more tech time and room time, and all the labor and procedural costs are higher. Yet it's been assigned a lower value. We're concerned that will reduce access to diagnostic mammography, particularly for Medicare beneficiaries."

Since Congress felt strongly enough about screening mammography to enact a law protecting it, threats to access could support radiology's case for an upward pay adjustment.

"We're likely to be more effective in changing the reimbursement situation by working with Congress, not in this session but possibly in the next," Thorwarth said. "We will push to have screening mammography's value reconsidered, because Congress is aware of women's health needs and this is certainly a critical one."

Watch for an in-depth look at the mammography payment problem in the September issue of Diagnostic Imaging magazine. The article, "Small change for big medicine: The crisis in breast imaging services," explains how the quality of mammography in the U.S. is threatened by low reimbursement.