There is a reality radiologists have faced for several years: Mammography, performed and interpreted by experts, can not survive. It is a technology besieged by conglomerate forces that will drive it into extinction, with many other important procedures and technologies to follow. Radiologists see four major reasons for this destructive phenomenon: HMO’s, government regulations, special interest groups ( THE MAMMACTIVISTS) and trial lawyers.
President Clinton’s overblown health care crisis and ill-conceived reform project of the early ‘90’s catalyzed the conversion of fee-based private health insurance into the HMO chimera we now face. Positioned as middlemen – with profits their sole motivation-- HMO’s are driving down reimbursements to the point where it is no longer economically possible for reputable physicians to do mammography and balance the books.
MAMMACTIVISTS -- special interest groups fanatically focused on breast cancer -- have railroaded thousands of pages of Federal regulations and compliance requisites through Congress affecting every aspect of mammography. These disease-specific laws are enforced by regular inspections and audits; this, despite the fact that mammography is one of the most straightforward procedures in radiology and is little more complex than a chest X-ray. No such regulations exist for neurosurgery, heart transplant, treatment of pediatric malignancy, or any other medical procedure. These laws have increased operating costs of women’s centers significantly, yet neither the HMO’s nor the government recognizes this exigency with increased compensation. Micromanaging individual diseases with laws leads, at best, to inefficiency and inflated costs.
A mammogram is an inherently limited study with relatively low sensitivity and specificity. Unfortunately, the public does not understand these limitations because the exam has been oversold as a diagnostic modality (We are told this is for the public’s “own good”). As a result, people have a difficult time understanding why breast abnormalities are “missed” or “misinterpreted” during routine mammography. Personal injury lawyers ruthlessly take advantage of this dilemma by scavenging mammograms involved in breast cancer cases. They prey on this ignorance by holding radiologists to impossible standards bolstered with retrospective analyses of mammograms done by venal physicians in their stable of “experts”. As a result, mammography is the single highest liability risk for radiologists (and the second highest risk in all of medicine). For a $15 reading fee, radiologists can face multi-million dollar lawsuits.
In their practices, the few radiologists left who interpret mammograms are seriously considering abandoning the procedure. Some argue that radiologists have an ethical obligation to do the procedure. This may be so, but radiologists cannot be the sole bearers of this obligation. If the businessmen, the politicians, the lobbyists, and the lawyers cannot share in this ethical challenge then radiologists will increasingly refuse to shoulder the burden alone.