Building a Turnkey Women's Imaging Service
Building a profitable breast imaging service entails deploying the right technology for a multimodality approach, effectively triaging high-risk women, and taking great overall care of the CEOs of family health Women’s imaging is smart business: for the over-40 female population, yearly breast-cancer screening is an annuity that, in the right hands, translates into downstream revenue for radiology providers and increased market visibility among women and their families and friends. That’s why some of the country’s leading imaging organizations are investing in women’s health, implementing a range of modalities and an array of marketing and wellness initiatives designed to attract and keep valuable female patients. It all starts with the right mammography equipment, according to Gerald Kolb, chief knowledge officer at Solis Women’s Health, Austin, Tex, a privately owned outpatient imaging company with 13 comprehensive breast centers and 15 mammography centers in six states. “We believe quite strongly that if we discover cancers early, they are, for all intents and purposes, curable,” he says. “The full range of modalities in our comprehensive breast centers includes digital mammography, ultrasound, and stereotactic biopsy capability. The first thing we do when we acquire a center is make it all digital.” Though it is, of course, possible to perform high-quality screening using plain-film mammography, Elsie Levin, MD, medical director of Sagoff Breast Center at Faulkner Hospital, Boston, is a believer in full-field digital mammography. Although her facility completed its digital transition just last year, she says, “There are a tremendous number of advantages to digital mammography. You get greater productivity, and with dense breasts, digital mammography has the edge.” Kathy Schilling, MD, medical director of breast imaging and intervention at the Center for Breast Care of Boca Raton Community Hospital, Boca Raton, Fla, concurs. She says, “Digital mammography is the best way to identify the majority of breast cancers. It’s the best screening tool we have, it’s widely available, and it finds more cancers in patients with dense breasts or patients who are pre- or perimenopausal.” She stresses, however, that the right equipment is nothing without the right staff. “You need digital mammography, but you also need dedicated breast imagers,” she says. Mark Farmer, director of outpatient services at Charlotte Radiology, Charlotte, NC, adds, “You need computer-aided detection to assist the doctors in reading the exams. Besides equipment to perform diagnostic mammograms and biopsies, additional modalities are needed to assist further in your diagnosis, including breast ultrasound and breast MRI.” Kolb notes that there are advantages to digital mammography beyond its diagnostic superiority: The modality also allows Solis Women’s Health to deal with a shortage of qualified imagers. “The fundamental thing that digital mammography brings you is the ability to move images around,” he notes. “We have a very significant investment in PACS and RIS. Now, if I want to open a new center in Phoenix, where we have one comprehensive site and seven screening sites, I can put a new comprehensive center in that market and absorb some of the cost by sending the physician screens from other locations to read.” A Multimodality Approach MRI has always played a role in breast-cancer care, but has only recently gained traction as an additional screening modality. In July 2008, the American Cancer Society (ACS) revised its guidelines on breast-cancer detection to include annual MRI exams for high-risk women. Some, like Levin, view the modality as essential to comprehensive care: Sagoff Breast Center was an early adopter of the technology, installing its first dedicated breast MRI unit in October 1997. “That’s been my baby,” Levin says. She estimates that Sagoff Breast Center performs around 350 screening MRI studies per month. “I do a lot of high-risk screening, so medical oncologists who run clinics in the Boston area send me their patients with a genetic susceptibility and patients with a family history of breast cancer. We have long MRI experience; fortunately, people have been pleased with the service and the interpretation.” Charlotte Radiology also has a dedicated breast MRI unit–and specially trained mammographers to read the images that it produces. “That’s one thing that’s been an important aspect of the care we provide,” Farmer notes. “A lot of programs have a general radiologist reading breast MRI, and we felt we wanted our breast imagers doing that.” Kolb is less enthusiastic about dedicated breast MRI due to economic concerns. “In order for it to be cost effective, reimbursement would have stay above $315 per exam. (See table on page 38 for reimbursement rates.) I see that the reimbursement rate for MRI is probably dropping; every sign coming out of Washington says it is coming down,” he says. “What we may end up with are these twin pressures: one pressure that is driving down reimbursement and one toward overutilization to compensate. I don’t want us to be caught in that.” Kolb explains, “I look at a population of 1,000 screening mammograms. Out of that, I am going to diagnose five cancers, and from referred cancers, I’m going to have another five. In a hypothetical screening volume of 20,000 coming through one of our practices, we are going to have about 200 cancers a year.” He continues, “We will also find the same number of patients who would meet the ACS high-risk definition, which gives me 400 patients per year who unequivocally should have MRI.” In addition, he says, there will be another 600 patients with extremely dense breasts or other diagnostic problems that would warrant using MRI. Obtaining payment for these cases with diagnostic problems has been difficult, according to Kolb. “Our payment history here is no good,” he notes. “We find that payors don’t want to pay for enough categories. When you add all of that together, I’ve got 1,000 MRI studies in a year. I am trying to justify a $2 million capital investment, plus staffing and service on the equipment, and for that, my cost bundle is too high. It makes it a marginal investment, unless I can find a way to get more procedures through, which means aggregating patients from several facilities or sharing a magnet with a hospital.” He adds, “If I have to bring the biggest capital value to my patients, it’s not going to be through MRI. We can find good MRIs without owning our own.” Solis Women’s Health operates a breast center on the campus of All Saints Hospital in Fort Worth, and it refers patients who require breast MRI to one of the hospital’s magnets. Solis Women’s Health reads for the professional fee, and the hospital earns the technical fee. Other breast centers have seen solid returns after implementing dedicated breast MRI. Around 4% of Charlotte Radiology’s diagnostic patients get breast MRI; for Sagoff Breast Center, which receives a particularly high level of referrals for the modality, that figure is closer to 10%. Boca Raton Community Hospital estimates that the percentage of its patient population receiving breast MRI is also around 10%. Practices are also divided on the use of breast ultrasound as a screening modality, though they’re unanimous on its necessity as part of the larger care continuum. “Mammography, ultrasound, and MRI are the trifecta,” Levin says, “but I’m not a big fan of screening breast ultrasound. I think MRI beats it any day. I know, from my experience, that many of the cancers I find by ultrasound after an abnormal MRI are so subtle that I’m not sure you’d pick them up with ultrasound alone, and that makes me nervous.” The team at Boca Raton Community Hospital is more enthusiastic about the modality. Larraine Chrystal, executive director of women’s services at the facility, says, “Thirty percent or so of our patients have ultrasound for dense breasts, or if they have an abnormal MRI. A lot of them are coming to us for a bilateral screening of the breast, and we’re participating in a trial to see if we can get breast ultrasound to be known as a screening tool.” The Cutting Edge Two emerging modalities, breast-specific gamma imaging (BSGI) and positron-emission mammography (PEM), are also beginning to gain a foothold in the field. BSGI uses a gamma camera to look for early-stage tumors with 99mTc-sestamibi, and it has been shown, in some studies,¹,² to have comparable sensitivity and superior specificity to MRI. PEM functionally images breast tumors using an organ-specific PET scanner and FDG contrast. Solis Women’s Health uses BSGI as an alternative to MRI, although it has implemented the modality, so far, in just two of its centers. “At All Saints Hospital, they have BSGI, and we find that a lot of cases that could go on to MRI, we serve with BSGI.” As with breast MRI, Solis Women’s Health receives professional-component reimbursement for BSGI, and the hospital gets the technical fee. Boca Raton Community Hospital negotiates reimbursement with insurers for PEM on a case-by-case basis, and Schilling has seen the modality work as an effective substitute for MRI as well. “We have had patients who cannot tolerate breast MRI approved for PEM by insurance companies,” she says. “That includes patients who have pacemakers or who are claustrophobic. There are a lot of contraindications for breast MRI, and here we have another method to offer patients. I absolutely think it will be commonplace soon, and that’s why we got involved with it early. It solves a lot of the problems created by breast MRI. There are many fewer false positives and false alarms.” As with any new modality, opinion on PEM is sharply divided. “It’s functionally equivalent to BSGI, using a different contrast in a different way,” Kolb says. “They’re roughly equivalent, but the cost of PEM is four times as high. The contrast agent you use is sugar based, and there’s some risk with that; it also has a shorter half-life.” Meanwhile, Matthew Gromet, MD, chief of the breast imaging section at Charlotte Radiology, sees no immediate need to move forward with either modality. “We have not pursued either, but will monitor both,” he says. “When we evaluate a new modality, we try to determine whether it’s going to add benefit for the patient, as far as diagnostic sensitivity and accuracy are concerned. Since we have MRI, ultrasound, and readily accessible biopsy capability, we have not yet evaluated the additional benefits for these modalities.” Levin echoes Gromet’s reluctance. “I have my own breast MRI,” she says. “I don’t have to compete for magnet time with the head, knee, and spine exams. Right now, MRI is our focus, but it will be interesting to see how both techniques develop. Both show promise.” Risky Business Effective triage and handling of the high-risk population are crucial to the success of a women’s health center, and no one knows that better than the team at Sagoff Breast Center, a destination for the high-risk population. “We have a chance to see and talk to our patients, so we look at their mammograms, we see if they have dense breast tissue, we look at their family history, and we talk about supplementing the annual mammogram with an MRI,” Levin says. “We get different information from a mammogram than we get from an MRI, and for patients like that, we do mammography and MRI six months apart, so they’re effectively getting screened twice a year.” Schilling finds it useful to have a technologist check a new patient’s forms to make sure that the center is adequately informed of family history and other risk factors. “We make sure it’s filled out properly because we need to know their history as they come in,” she says. A dedicated staff member never hurts. “We also have a breast-health specialist here who does a high-risk evaluation,” Schilling adds. If a Boca Raton Community Hospital patient is calculated to be at high risk, she is referred to the facility’s high-risk clinic, where she is further evaluated to determine what her level of surveillance should be. Charlotte Radiology also gathers information on a patient’s family history of breast cancer and includes this information in the diagnostic report to the referring physician. “We are also exploring a program to gather more detailed information, use the Gail model to calculate lifetime risk, and share that information with the referring doctor,” Farmer notes. “We’re very close to achieving that, and we want to pass that information on to the referring physicians so they can use it to manage their care of these patients better.” Solis Women’s Health is also experimenting with a new program designed to optimize care for high-risk patients. “We’re moving toward a system where each patient’s imaging is individualized, so we want to identify the high-risk patients before they come to us,” Kolb says. “There’s a cohort of patients in the 30–40 age bracket who could benefit from some of the more advanced imaging.” Kolb sees the potential benefit of referring physician outreach. He says, “We need to make it as easy as possible for gynecologists. We need to give them easy questions to ask their patients so we know, going in, if they’re high risk. To a gynecologist or a family doctor or an internist, the breast is only one part of what they’re dealing with; in medicine in the United States, we get superspecialized, and with high-risk patients, you’ve got to be multidisciplinary immediately.” Gromet cautions that whatever the method of risk evaluation, facilities need to be flexible. “We follow the ACS guidelines, with maybe one modification,” he says. “They say that if your lifetime risk is 20% or more, you should get screening MRI. That would generally be determined from a genetic consultation. The modification is that if you’re in the 15%–20% risk range and have extenuating factors, like dense breasts, then we often suggest MRI, because high breast density has not yet been factored into the risk models and therefore needs to be factored in independently.” What Women Want For multisite organizations like Charlotte Radiology and Solis Women’s Health, convenience is a key factor in drawing in patients. “We have 12 breast centers around the Charlotte area, six of which are diagnostic,” Farmer says. “You might have practices with a similar volume to ours with fewer centers, but we’re focused on geographical convenience, and our surveys indicate that that’s a reason we continue to see growth.” Kolb concurs. “We have two different delivery vehicles: the comprehensive breast center that does screening through diagnosis and Solis mammography centers,” he says. “We place our mammography centers in strategic locations where women can get to them easily. We want to put them in locations where they’ll get lots of drive-by traffic. We want women to see a Solis center and be reminded that it’s time to get a mammogram.” Many facilities also offer same-day turnaround on screening mammograms, and Boca Raton Community Hospital takes that a step further. “We offer patients same-day readings, because the reasons mammography is down nationally are access and fear,” Chrystal says. “Patients come here, and if they have the time, we’ll do their mammograms, any additional views, ultrasound, high-risk screening, and self-exam education–and they’ll get same-day results. We navigate patients all the way through the process. Does it make a difference? Absolutely; people feel very confident about staying with us if they have a problem.” Boca Raton Community Hospital also encourages patients to self-refer, and this, according to Chrystal, helps to mitigate the access issue. “A patient who comes in here doesn’t have to name a physician,” she says. “She comes in here on her own, and she is responsible for that piece of her health care.” Though most women’s health facilities have yet to feel the pinch brought on by the economic downturn, many are preparing for a potential decrease in compliance by creating new initiatives. At Sagoff Breast Center, this means raising money to help the underinsured population. “We’re very lucky in that we have a dedicated core of women called the Friends of the Faulkner-Sagoff who do a big fundraiser every year to provide care for women who are underinsured,” Levin says. “If a woman doesn’t have the necessary coverage, we can do her screening mammogram and anything else that may be required–surgery, oncology, and so forth. All the participating physicians and departments are reimbursed to cover costs, so we can take care of women in that situation.” Boca Raton Community Hospital runs a similar program, and Chrystal stresses the importance of getting the message out to the community that women’s health centers have options for women who can’t afford to pay for their care. “You have to open your doors for everyone,” she says, “and that’s what we’re trying to do.” Spreading the Word In the end, investing in women’s imaging is about more than just accommodating the female patient. Because women tend to be the principal health care decision makers in their households, enforcing rapid turnaround times and investing in cutting-edge technology can translate into additional business for the hospital or radiology practice associated with a successful women’s imaging center. Shawna Plate, manager for breast-health marketing and practice relations at Charlotte Radiology, notes that cross-marketing initiatives for other female-centered imaging modalities can yield powerful returns. “We see 85,000 patients a year through our screening and diagnostic programs, and we’ll often cross-promote our vein and vascular services,” she says. “We also perform bone-density screenings in our breast centers, so we promote that a patient can get her bone-density screening along with her mammogram. Other procedures, like uterine-fibroid embolization, we promote through educational information at all our sites.” Farmer notes that because four of Charlotte Radiology’s breast centers are located next to four of its imaging centers, “If a patient has a great experience at one of our breast centers and sees an imaging center located right next to it, there’s a strong likelihood that she’ll go to that imaging center when she needs something else.” Chrystal agrees, saying, “With any mammography center, I’m going to tell you that downstream revenues from women’s friends and families always need to be examined. If you don’t think women make decisions on health care, you are wrong. If a woman has a wonderful experience, she’s going to come back, with her whole family, whenever anyone needs imaging.” Additional Reading - Marketing and Wellness Initiatives Medicare Reimbursement Rates