1. Addressing the Workforce Shortage in Breast Imaging Barbara Monsees, M.D. St. Louis, MO

2. Breast Cancer

Common disease

Public health problem of growing magnitude (as the population ages)

No health behavior known to either cause or prevent the disease

Early detection plays a pivotal role in control of this disease

• more favorable stage distribution &

• decrease in breast cancer death rate

3. ACS Breast Cancer Screening Guidelines May 2003

Yearly screening mammograms starting at age 40, continuing as long as in good health

High risk women should discuss screening

• Beginning earlier

• More frequently

• Using US or MRI, in addition to mammography

4. Mammography Screening is Widely Accepted by American Women

Tolerant of recalls & biopsies for benign disease

Eager for new or additional screening techniques for breast cancer, especially for high risk women

5. Long wait times reported in the media Long waits are not acceptable to women or public health officials 6. Like it or not:

There is no better screening technique on the horizon

Mammography screening will remain the mainstay of breast cancer control for the forseeable future

If we arent proactive, organized and methodical, we will lose the ground that we have gained against this disease

7. Breast Imaging Workforce Shortage

Growing target population

Additional workload, same workforce

• Image guided needle biopsies

• Increased use of US and MR

• Other technologies?

Workforce instability

• Fewer entrants to the field

• Individuals retiring

• Poor reimbursement

• Medicolegal liability

8. There is no organized network for mammography screening in the U.S.

Quality has improved but is still quite variable

Usual market forces will not solve this problem, because there are too many disincentives to offering the service

9. Projected Trends in the Size of the Population of U.S. Women by Age Cohort Each year, the size of the population of U.S. women of mammography screening age increases by 1.25 million. Source: U.S. Census, Series P-25 10. Yearly mammography volumes in millions(60% compliance) 11. Breast Cancer, 1973-2000 SEER Age-Adjusted Rates,9 Registries White ALL Black Black White Incidence Mortality 12. Disparities in U.S. Breast Cancer Mortality ReductionSEER Age Adjusted Rates 1990-2000 White Black Hispanic Asian American Indian 13. US Mammography Use by Age & Poverty Status CA Cancer J Clin 2003;53:342-55 40-49 years 50-64 years 65 years & older 14. GAO Report

U.S. General Accounting Office

April, 2002

(GAO-02-532)

The work for the report performed from June 2001 through March 2002.

15.

Mammos increased 15% (35 to 40 million)

Facilities decreased 5%

Machines increased 11%

RTs(able to perform mammos)increased 21%

increase in mammography equipment and personnel has been sufficient to meet the increase in demand

General TrendsGAO Report GAO-02-532 16.

State and local officials frequently raised concerns about the adequacy of the Medicare reimbursement rate.Many radiology practices state that recent modest increases in reimbursement dont cover the actual costs of practice.

GAO-02-532 17.

Most availability problems in certain metropolitan areas

• Increase in demand, capacity declined

• High demand at some facilities

• • Reputation

• • Referral patterns

• • Large workload due to public assistance programs

• • Restrictions due to insurance coverage

GAO-02-532 18. GAO on Personnel last few years show a substantial decline in the number of new entrants to the fields Personnel includes radiologists and radiologic technologists GAO-02-532 19. Mammography Technologists

Job physically challenging

• Bend, lift, reach, on feet all day

Work closely with anxious patients

Expected to do large volume per day

More paperwork and QC

20.

Data limited regarding the number currently interpreting mammograms

FDA database unable to determine the total number of radiologists who are qualified under MQSA and currently interpreting

How many radiologists interpret mammograms? 21. How many radiologists interpret mammograms? How many are specialists?

2002/2003, ACR sent member record update requests to 16,147 paying members

56% responded (9,048)

54% general radiologists reported doing mammography (4,924)

7% members reported being specialists in mammography (654)

Self-reported info from respondents: 12% of radiologists interpreting mammograms are specialists 22. Society of Breast Imaging

82 Fellows of Society

1457 General members

Membership requires board certification and an interest in Breast Imaging

23. Radiology Fellowship Match, Active Programs June 4, 2003, Appointment Year 2004-05 BI/WI represents only 6% of positions in the match.Only 25% of positions were filled, representing only 3% of filled fellowships. POSITIONS 36(75%) 12(25%) 48 Breast/Womens Imaging 358(47%) 411(53%) 769 All Programs Unfilled Filled# 24.

20 minute telephone survey

4th or 3rd year residents who had completed rotations in BI

Questions addressed:

• Training

• Attitudes about mammography

• Interest in performing BI in the future

Attitudes of Radiology ResidentsRegarding Breast Imaging(BI) Survey: 211 of 224 accredited US programs Bassett et al, Radiology.2003 25. Compare interpreting mammography toCT of the abdomen with contrast 26. Resident responses as % of total Concern about missing a potentially important finding 27. Resident responses as % of total Concern about making appropriate recommendation to referring physicians 28. Resident responses as % of total Concern about malpractice liability 29. Compare interpreting mammography to other types of imaging examinations 30. Resident responses as % of total Rate the stress levels associated with possible misdiagnosis 31. Resident responses as % of total Rate patient stress related to the exam 32. Resident responses as % of total Mammography should be interpreted by breast imaging subspecialists 33. Resident responses as % of total like to spend> 25% of your time interpreting mammograms when in practice 34. Resident responses as % of total If not, what are the reasons? 35. Performance Parameters for Screening and Diagnostic Mammography:Specialist and General Radiologists Sickles et al, Radiology 2002;224:861-869 *Number per 1000 27.0 3.0 36.6 3.4 9.9 7.1 Generalists 43.9 5.3 59.0 6.0 15.8 4.9 Specialists DX SCR DX SCR DX rec bx % SCR recall % Stage 0-1 CA detection rate* CA detection rate* Abnormal rate 36. Expertise reflects complex multifactorial process

Specialist vs General Radiologists

Training, experience, talent

Quality feedback

• Auditing

• Multidisciplinary conferencing

• Double reading

Reading a high volume of films

Specialty breast center

• Has all of the above

CME

37. Evaluation of Proscriptive Health Care Policy Implementation in Screening Mammography

110 radiologists interpreted the same enriched set of screening mammograms (64 CAs/148 mamms)

Participants from randomly sampled facilities

Analyzed implications if the U.S. limited workforce by accuracy

Beam et al, Radiology 2003;229: 534-540 38. Evaluation of Proscriptive Health Care Policy Implementation in Screening Mammography Beam et al, Radiology 2003;229: 534-540 Analyzed implications if the U.S. limited the workforce by accuracy -50% -11,400 Increase 10% -25% -6,000 Increase 5% -10% -2,200 Increase 1% 20,000 Current Service Capacity # Radiologists Accuracy 39. How can we measure interpretive skills & performance?

Self-assessment testing?

Is there a valid test?

Volume requirement?

More CME?

Can audit data be used?

• Numbers too small in low volume practices

• Audit results will vary by institution

• • Nature of practice may vary!

40. Audit data needs to remain non-discoverable

Discoverability a big issue

• Will provide further disincentive to radiologists to interpret mammograms

• Lawsuits already burdensome

41. ACR Practice Cost Survey: Spring 2001 Screening Mammography

37 practices surveyed; 21 responded

Data from 37 different hospital & office sites

• 15 hospitals, 22 offices/freestanding

• 253,000 screening mammograms

• Average number units

• • Hospitals responding = 4.5

• • Offices responding = 2.1

• • Average number units/facility in U.S. = 1.5

42. ACR Practice Cost Survey: Spring 2001Screening Mammography

Costs: Clinical staff, supplies, equipment, indirect costs

Included, but not part of survey:

• ACR accreditation fee (per unit)

• FDA inspection (annual)

Physician work based on 2 methods

43. Screening Mammography Reimbursement vs Costs *ACR survey, Spring 2001 $86.60 *2001 Cost at Office Facility$124.54 *2001 Cost at Hospital Facility $ Medicaid (varies by State) $80.94 Medicare (2004) 44. Operational costs are higher at hospital facilities

Most Medicare patients get their mammograms at hospital facilities

Most teaching facilities are at hospitals

• Trainees see stressed staff & hear tales of economic woes

• Trainees get to choose what field to enter!

45. Providing Professional Mammography Services: Financial Analysis

7 university-based programs: all incurred professional losses due to diagnostic mammograms & breast US

Economic disadvantage to breast centers with a good reputation: higher proportion of difficult diagnostic & outside mammograms and US

Enzmann et al, Radiology 2001;219:467-473 To break even on diagnostic mammos: Revenue must go up 143% RVUs need adjustment by factor of 2.95 46. Providing Professional Mammography Services: Financial Analysis (contd)

Growth in screening is followed by growth in diagnostic mammography

Breast centers with a good reputation will have a higher proportion of diagnostic mammograms and difficult outside mammograms.Both are provided at a financial loss.There are economic disincentives to concentrate high-quality mammography talent.

Enzmann et al, Radiology 2001;219:467-473 47. CAD is reimbursed, but double reading is not! 48. Cost to Facility to Meet MQSA Requirements

Written notification of results to patients, (estimated @ $0.94 per examinee notification

Medical audit: acquire & maintain data, and analyze patient outcomes

Regular quality control tests, including related non-mammography equipment

Annual physicist fees and survey

Accreditation fee

FDA inspection

• $1,749 for one facility & one unit

• $204 for each additional unit

• Follow-up inspection fee = $991

• (States can charge an additional fee)

49. PIAA Breast Cancer Study, Spring 2002:study of 450 current paid cases

#1 condition for which patients file a medical malpractice claim

Radiologists most frequent defendants

2 ndmost expensive condition in terms of indemnity

88% of patients had at least one mammogram

• 80%, 1 stmammo was negative/equivocal

50. 174.8 329 531 733 TOTAL 2.6 375 7 9 Pathology 1.2 144 8 20 Hospital 2.8 236 12 22 Other 8.9 247 36 46 Internal medicine 16.0 309 52 62 FP/GP 20.7 334 62 78 Surgical specialties 9.8 265 37 87 Corporations 49.0 369 133 167 Ob/Gyn 63.7 346 184 242 Radiologists Total indemnity ($millions) Average indemnity ($1000s) Paid Claims # Claims Specialty 51. PIAA: Physician Associated Issues1995 vs 2002 28.7% 35.5% Physical findings failed to impress 35.1% 25.8% Negative mammogram report 37.8% 22.7% Mammogram misread 2002 1995 52. Repercussions from Malpractice Crisis on Mammography Practice

Lawsuits, even unsuccessful ones, are a reason that radiologists will not agree to interpret mammograms

The threat of malpractice causes radiologists to overcall, causing:

• More recalls for evaluation

• More biopsies for benign disease

53. When radiologists practice defensive medicine,more women.

Get unnecessary breast work-ups

Have unnecessary biopsies

And, the cost of medical care increases 54. Do radiologists who interpret mammograms pay higher malpractice premiums?

Asked for quotes with and without mammo

4 companies presented rates to one Connecticut practice

As reported in Hartford Courant, source Alan Kaye, MD, Chair Radiology, Bridgeport Hospital

Rate without mammo:

• 14% less

• No difference

• 29.5% less

• 17% less

55. What is the answer for the future? Remember the mission: minimize the morbidity and mortality from breast cancer We need ways, including incentives, to ensure that sufficient numbers of adequately trained personnel at all levels are recruited and retained to provide quality mammography services 56. MQSA being reviewed by GAO & IOM

Facility closures?Are there access issues?

• Rural? Urban?

• Low income women?

Workforce trends

Which regulations are beneficial?

What additional regulatory requirements should be added to improve quality?

Eliminate requirements that dont positively modify outcomes

57. Possibilities. Development of centers of excellence

Patient care

• More efficient; lower cost

• Higher sensitivity

• Fewer recalls

• Better outcomes

Hubs for training of new highly qualified personnel

Provide incentives for development