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527
Review
Economic Robert
Issues
in Screening
Article
Mammography
A. Clark1
The issues surrounding screening mammography present apparent conflicts: conflicting guidelines for screening; an oversupply of facilities, yet inadequate access to mammography for some groups of women; increased medicolegal vulnerability as participation in screening is promoted; disparate results from studies of cost-effectiveness; wide variations in delivery modes and practice patterns of facilities, yet an evolution toward a single set price for mammography by payers for screening. This review does not claim to offer solutions to these conflicts, rather it attempts to carry forward a discussion of the issues. With these conflicts, screening mammography may be only a microcosm of similar economic issues in general health care delivery. Our health care system has room for variety, if access and quality are improved at an affordable cost. Screening for breast cancer with mammography will not reach its full potential to reduce mortality until many
of these
issues
can be resolved.
Screening for breast cancer with mammography significantly reduces the mortality from the disease in women who are screened [1 2]. Although debate continues over both the
Moreover, national politicians and women’s recently issued a “Breast Cancer Challenge”
medical
community,
demanding
success
health advocates to the American
in the fight against
breast cancer by the year 2000; this challenge in toto by NCI director Samuel Broder [6].
challenges
by the year 2000 that all women
over
the age of 40 get regular mammograms and to ensure all mammograms are of the highest quality.
that
These
to ensure
was accepted Included were
national
guidelines
have evolved
during
a time of
rising health care expenditures and an intense scrutiny of the economics of health care. Realization of these goals will have a marked economic impact on the women paying for the services, on the providers of mammography and related
services,
and on society
as a whole dealing with containment
of health care expenditures. The purpose of this review of screening mammography, economic terms.
is to consider the current status focusing on pertinent issues in
,
age at which
screening a widespread
screening, raphy is a basic,
should begin and the frequency of consensus is that routine mammog-
essential
element
of health
care
women [3, 4]. Three of the most widely disseminated guidelines for screening mammography are summarized in Table 1 The National Cancer Institute (NCI) has set cancer control goals for the year 2000 that include participation of 80% of .
all eligible
women
in regular
mammographic
Received August 9, 1991 ; accepted after revision I Department of Radiology, H. Lee Moffitt Cancer FL 33682-8425. AJR 158:527-534,
March
1992 0361-803X/92/1583-0527
screening
October Center
Overview
of Health
Care Expenditures
for adult
[5].
In the past decade,
States that
in 1 990
Roentgen
health
billion, a 2.5-fold capita
14, 1991. and Research Institute, Wiversity C American
health
care expenditures
in the United
have risen more than 10% each year; it is estimated
Ray Society
basis,
care
increase
annual
expenditures
amounted
to $653
from the level of 1980 [7]. On a per
health
care
expenditures
in the
last
of South Florida, 12902 Magnolia Ave., P. 0. Box 280179, Tampa,
528
CLARK
TABLE
1: Guidelines
for Screening Issuing
March
1992
Mammography
Group
Recommendations
United States Preventive Services Task Force American College of Physicians
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AJR:158,
Annual or biannual mammography, ages 50-74 Annual mammography, age 50 and older; mammography age 50 based
American Cancer Society, American Academy of Family Physicians, American Association of Women Radiologists, American College of Radiology, American Medical Society, American Society of Internal Medicine, American Society for Therapeutic Radiology and Oncology, College of American Pathologists, National Cancer Institute, National Medical Association, and American Osteopathic
Baseline
of woman by age 40; annual
mammography
mography,
under
on risk factors
ages 40-49;
or biannual
annual mammography,
mam-
age 50 and
older
College of Radiology
decade rose from $1 059 to $2525. This increase in the per capita expense has been attributed to several factors, including “excess” inflation in the medical care sector, increased
demand for screening mammography is the total number of women who purchase screening services yearly. The full brunt of the economic impact of screening mam-
use, advances
mography has not been realized so far, as only 25-40% of eligible women receive regular screening mammography [1115]. A variety of factors contribute to these low figures and may be considered patient related or physician related [151 8]. Barriers that keep women from receiving screening indude high cost; limited availability of services; limited access
increasing
in costly
number
high-technology
of elderly
services,
and an
in the population.
In 1965, before the institution of Medicare and Medicaid, health care expenditures were 5.9% of the gross national product (GNP). In 1990, spending on health care amounted to 1 1 .9% of the GNP; it has been estimated that in 1991, national health care spending would rise to $71 7 billion, or 1 2.5% of the GNP [7]. The United States currently spends
to services;
of mammograms;
lack of knowledge
about
more of its GNP for health care than any other industrialized
lack of physician
referral.
cite several
country in the world; Canada Britain spends 6% [7].
not referring women for screening mammography: high cost, skepticism about its effectiveness, unclear or conflicting guidelines, a lack of confidence in local mammographic expertise, and a sense that asymptomatic women will not accept screening.
spends
9%, Japan
spends
7%,
The national “economic burden” for cancer care in 1990 in the United States has been estimated at $1 04 billion, divided between $35 billion in direct costs and $69 billion in morbidity and mortality costs [8]. The total national expenditures for all cancer screening services in 1 990 (mammography, Pap tests, and colorectal screening) were estimated to be $2-3 billion [8]. About 47 million American women over age 40 are now eligible
for screening
for routine
mammography
mammography
[9]. The average
in the United States
charge
is more than
$1 00 [9]. If all women over age 40 were to receive annual mammograms at this charge, total mammography expenditures would be nearly $5 billion per year, or almost 1 % of the
total national
health care expenditures
for 1990 and about
25% of the total annual expenditures for diagnostic [1 0]. For each woman, the expense for mammography
represent
almost
4% of the average
annual
imaging would
per capita
penditure for health care. It is clear that implementing grams for more widespread screening mammography
have significant effects on future health care costs. ety, these costs may not be easily borne; therefore, to limit expenditures without reducing effectiveness rently
being
Demand-Side
expro-
will For socimethods are cur-
sought.
Analysis
Demand-side analysis is the consideration of economic factors that contribute to the development of aggregate (total) demand for a product or service. The annual aggregate
fear of cancer,
cancer treatment, Clinicians
or the radiation effectiveness;
and
reasons
for
Attempts to overcome these barriers and increase use have yielded mixed results [1 8-23]. Women with an underlying concern for health-related matters and women with strong family
histories
efforts
of breast
to increase
uneducated
cancer
participation
women,
and older
spond to such interventions mend
screening
are more
to
Poor women,
women
are less likely to rePhysicians may recommore often for women who
[1 9-21
mammography
likely to respond
in screening. ].
are younger and better educated [21]; physicians are more likely to refer women for screening mammography when the physicians’ own offices are well organized and when mammography
services
are easily
23]. One of the most important participation in screening physician [1 8, 21]. Thus, physicians and physicians’
scheduled
and available
determinants
[21-
of a woman’s
is the referral from her primary access of women to primary-care mammography referral practices
are critical points in the use of screening.
Relationships
Among
Access,
Quality,
and Cost
Access to screening services cannot be entirely separated from other issues, such as quality and cost. For example, a
primary
care physician
may not refer women
for screening
the physician thinks that the local charges for mammography are too high or that the local quality of services is poor [15, 1 6]. Similarly, a woman may resist mammography for reasons
if
March
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AJA:158,
ECONOMIC
1992
ISSUES
IN SCREENING
of cost or quality. Although the interrelationship is important, it is easier to discuss these issues separately. The adequacy of access to mammographic services for women is a complex and controversial topic. The access of many Americans to health care is limited; it is estimated that nearly 40 million Americans, or at least 1 5% of the population, do not have health care insurance [24, 25]. Methods to make screening mammography available to all women, including poor women, are only one aspect of an ongoing debate over how to provide access to health care for everyone in the United States. It is becoming clear, however, that lack of access to screening and other medical services contributes to an increased mortality from cancer in poor women [26,
27]. A compendium care coverage
of proposed
als for providing
cancer
determine
types
of screening. comes
to universal health [28], and proposand detection services to
screening
the medically indigent have Most proposals for universal
as one of three types: insurance by employers, workers and the poor; private insurance; or (3) ment [30]. The type of
solutions
been published
has recently
similarly been summarized [29]. health care can be categorized
(1) compulsory provision of private with the government insuring non(2) tax credits for the purchase of all insurance provided by the governsystem that eventually evolves may
of effective
interventions
For example,
if universal
employer
based,
be more effective
workplace
in promoting
to improve
health
screening
the use
insurance programs
use and improving
bemay
access.
if health care coverage is driven by tax credits, the offer of tax incentives to providers of screening for the medically indigent or credits given directly to women who purchase screening examinations may increase the use of screening [31 ]. However, any comprehensive approach to
Alternatively,
these
problems
will require
major
delivery and payment methods. Documentation of the quality
an important
changes
in health
of mammography
part of providing
this service.
has become
In 1987,
the
(ACR) began a program to practices [32, 33]; the pro-
American College accredit individual
of Radiology mammography
gram is becoming
a de facto standard
This voluntary program involves cations, equipment, mammograms,
care
of quality
assurance.
peer review of staff qualifidoses of radiation to the
breast, and quality control programs. Facilities that meet all the criteria of the program are awarded a 3-year accreditation and a listing on the American Cancer Society (ACS) referral list of approved clan or woman
mammographic to find qualified
centers. facilities
One way for a cliniis to obtain a listing
from the local ACS chapter or the ACR. As of June 1991, more than 3000 mammography facilities had been accredited [34]; however, this is less than one third of the estimated 1 0,000 facilities nationwide [9]. Over 30 states have laws requiring reimbursement for screening mammography, but only nine have enacted quality assurance legislation [35, 36]. At least two (Michigan and Florida) have passed laws requiring the equivalent of ACR accreditation for centers that perform mammography. Federal legislation to establish national standards for quality in mammography is expected [35, 36]. Moreover, Medicare began reimbursement for screening mammography in 1991 ; guide-
MAMMOGRAPHY
529
lines issued by the Health Care Financing Agency imply that ACR accreditation or its equivalent will be required for reimbursement
by Medicare
[34].
Determinants of Price: Demand and Supply
Comparison
of Aggregate
Estimates of aggregate demand vary, depending on which guidelines for screening mammography are used (Table 1). The lowest estimate of aggregate demand for mammography (1
5 million
procedures
annually)
results
from
the guidelines
of
the United States Preventive Services Task Force. The highest estimate of aggregate demand (47 million procedures annually) comes from the joint ACS/NCI/ACR guidelines. A recent report [9] assessed this supply-and-demand compari-
son. The authors
began with a practical
capability
examinations
of 6000
mammography
per year and estimated,
unit given
the aforementioned calculations for aggregate demand, that the number of mammography units required to provide mammography
services
the demand raphy
varied
figures
units exist
from
2566
to 7892,
used. Approximately
in the United
States.
depending
10,000
The authors
on
mammogconcluded
that there is currently an oversupply of mammography units and that this excess supply has several adverse economic effects. First, it implies that these resources are being used inefficiently.
Second,
units necessitates
the underuse
of existing
that these units charge
mammography
a high price, more
than $1 00 per procedure, to cover costs; this may impede the desired public health trend to reduce charges for screen-
ing mammography
and thereby
increase
ersupply of units operating at low capacity of quality assurance and record keeping.
use. Third, the ovincreases the cost
However, overall comparisons of aggregate supply do not assess the regional distribution
demand and of mammog-
raphy machines. In a similar analysis of supply-and-demand relationships for screening mammography in four counties in Florida, an oversupply of machines was found in urban coun-
ties, and an undersupply was found in rural counties [37]. This apparent reduced access to mammography facilities for rural women probably reflects the women’s overall reduced access
to health
care [38].
In rural
areas,
the lack of a large
population base reduces incentives for rural radiologists to provide screening services, particularly at low cost. Conversely, in urban areas, the perceived need to remain “competitive”
may force
radiologists
to provide
screening
services,
even when more than enough units are already available for the population. A potential solution, as yet untried, might be cooperative provision of low-cost peting radiology practices.
screening
services
by corn-
Standard economic theory holds that supply will accurately match demand in a free market [39]. However, for many reasons, medical care is not a free-market situation; demand for medical services may actually increase as supply increases, rather than the reverse [40]. For the past several decades, the cost of diagnostic mammography has been
reimbursed
by medical
at a cost-based
rate,
insurance with
carriers,
the costs
and other payers,
determined
at low-use
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530
CLARK
AJR:158,
March
1992
rates. The current average charge of more than $1 00 for mammography was set during this period and has become
sumed to be 40 examinations per day (or per 8-hr shift, or per technologist per day), or 1 0,000 examinations per year.
an “allowable” charge. This price, charged to third-party payers, now acts as a “price floor” resulting in both high prices and oversupply [39].
Practical
capability
demand
always
Recent
changes
in the reimbursement
policies
of Medicare
and commercial insurers for the cost of screening mammography (as distinguished from diagnostic or consultative mammography)
may
alter
this
situation.
Medicare
has
set
its
reimbursement rate for screening mammography in 1 991 at $55 per examination; other insurance carriers and payers may follow this lead. If the new allowable charge for screening mammography becomes $55, it will affect the supply of services. For example, if this charge does not cover the costs of certain facilities, those facilities may lose money or go out of business. Moreover, if this charge is lower than the costs of most facilities, an undersupply of units may result. This would be analogous to the situation of a “price ceiling” [39]. As long as mammography charges are set by payers, rather than a free market, the supply and demand for screening will never match. Therefore, it is important that both the providers of screening mammography recognize the effects of price
and the payers of the costs setting. The differences in cost
structure and overhead of various types of facilities markedly affect the ability of some facilities to operate at lower fixed prices.
may be less: Inefficiencies exist;
use of mobile
in staffing
mammography
and
units
is
less efficient than that of standard units because of setup and travel time; the population may be too small in rural areas to provide an adequate number of examinations each day. For planning purposes, a practical capacity of 6000-8000 examinations annually may be a more realistic goal. However, screening mammography can be provided profitably at
charges
of less than $60 at practical
examinations
per year,
capacities
of 6000-8000
and as low as $30-45
per examina-
tion, when operated
at maximum
critical
the
to recognize
capacity
reciprocal
[43]. Clearly,
relationship
volume if costs are to be reduced. However, not all facilities may be able to duplicate reported cost structures [44]. The largest difference cost structures
be overhead free-standing
among
screening
allocation. facility
does
and
these in the
mammographyfacilities
When mammography that
it is
of cost
screening
may
is provided examinations
in a only
(and not consultative or diagnostic examinations), without a radiologist in attendance, and with no other assessment of overhead charges, the efficiencies of high volume can be achieved and the costs reduced. However, larger overhead costs are incurred if screening mammography is performed in a hospital or clinic, in combination with consultative studies
or with a radiologist in attendance. High-volume, low-cost mammography screening would require a change in both the Supply-Side
practice
Analysis
Supply-side
analysis
addresses
the determinants
duction function. For screening mammography, production should be considered: performing
of pro-
two facets of the examination
and interpreting the study. Several recent articles [41 -43] have evaluated the efficiency of performing screening mammography in high volume. These reports have emphasized techniques to increase throughput of examinations and maximize the use of a mammography
machine
and facility.
Because
mammography
ser-
vice is characterized by high fixed costs (e.g., equipment and salaries) and negligible variable costs (e.g., film), the unit examination cost is minimized as throughput is maximized, and the marginal cost of each additional examination performed (until capacity is reached) is negligible. In other words, the marginal
profit
of each
additional
until capacity is reached. Several techniques have been screening efficiency and reduce costs: examinations only, batch processing day, loading of films on mechanical
examination developed
increases to
improve
dedication to screening of films once or twice a viewers for batch inter-
pretations, simplified and standardized reporting either manually or by computer, and standardized
of results follow-up
and quality assurance [41-43]. Mass screening has been proposed as the only feasible approach to offering screening at low cost [43]. Less often stated is the possibility that increased efficiencies will result in greater
capacity
profits
in addition
of a dedicated
to lower
mammography
prices.
The
maximum
unit is generally
as-
patterns
of many
mammography
facilities
and
the
expectations of many women receiving mammography. However, evidence exists that this can be accomplished [41-43]. Numerous indirect costs exist that may vary widely from facility
to facility.
These
include
those
for physical
overhead
(e.g., rent, heat, electricity, maintenance), medicolegal age, quality assurance, marketing, and opportunity
covercosts.
Medicolegal costs for the provider of screening mammography can be calculated initially as the annual malpractice in-
surance premium of the radiologist. Medicolegal costs may increase markedly as the use of screening mammography increases. Failure to diagnose breast cancer has become one of the most common reasons for malpractice litigation in the United
States
[45].
Until recently,
the defendants
in most
of
these suits have been primary care physicians, as the common standard for diagnosis was clinical detection. Some think that as use of screening mammography increases, the vulnerability of radiologists to malpractice claims for failure to detect early breast cancer will increase also. This topic has been addressed recently from several perspectives [45-50]. Radiologists should be aware of the areas of vulnerability
in the
practice
of mammography
and of the
current
standards of practice with which their own practices will be compared. Continuing education is recommended, as well as an awareness of the subtle, secondary mammographic signs of breast cancer. Documentation of quality assurance through the use of practice audits has been emphasized as an important part of preventive defense of vulnerability [50-52]. Similarly, the practice of nonoperative management (short-term mammographic
follow-up)
of women
with
mammographic
AJA:158, March
ECONOMIC
1992
abnormalities
with
a standard
of practice
low malignant
ISSUES
risk has been
IN SCREENING
assessed
as
[46, 47, 53].
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Because documentation of quality assurance is such an essential part of screening mammography, its costs should be accurately assessed. However, no studies have yet eval-
uated the costs of a comprehensive quality assurance program. The components of a practice audit have been well outlined [51 52], but the accumulation of follow-up informa,
tion on women who have difficult and time-consuming.
received mammography can A cost-effective approach
be to
quality assurance requires an efficient and effective information system [51 54, 55]. Although this type of program can be done manually, for most practices of moderate volume, a computerized tracking system will be necessary [51 54-56]; hardware, software, and personnel therefore are relevant ,
,
costs
for
tracking mograms
a basic may
require
annually
(the largest
nine mammograms
per radiologist
per day. At a
per day would
be
,
preted in high volume for a professional fee of $5-i 0 per examination. The equivalent daily fees for screening then would be 36 examinations at $1 0 per study, a total of $360. Not all radiologists interpret mammograms, so it is likely that
mammograms procedures
will be interpreted increases.
per radiol-
In a screening
situation,
it is feasible for one radiologist to interpret 40-200 examinations per day. Even with professional fees of $1 0 per study, daily fees in high-volume conditions could range from $400 to $2000. Technologic advances could increase the interpretation productivity of a radiologist even further. The use of “prereaders” (e.g., physician assistants or nurse-cliniclans) or computer image analysis to detect normal examinations in screening populations has been proposed
systems
may obviate a radiologist’s site or the transfer of these approaches are such methods could drastically in-
physical presence at a mammography films for interpretation [63]. Although
currently
investigational,
previous
cost
on the
training
interpretation,
in
basis
of comparisons
or expertise,
and
the
availability
relative
fees
of difficulty,
of the studies
for
interpretation.
for Until
recently, many radiologists may have determined that the opportunity costs for low-cost screening mammography were very high; that is, the forgone imaging studies, particularly
fees for interpretation newer cross-sectional
of other imaging
studies, were higher than the fees for interpretation of screening mammograms. This may be a negative incentive for radiologists
to participate
in low-cost
screening
programs.
Conversely, primary care physicians may view the opportunity costs of interpreting screening mammograms differently; the alternative
explain
office
practice
in part the recent
mograms
aggregate-
$360. Bird and McLelland [41 57] and Sickles et al. [42, 51] have suggested that screening mammograms can be inter-
Teleradiology
be equivalent
opportunity
fees for nine mammograms
[60-62].
might
calls,
were obtained
of the
of 40 mammograms
mam-
per year or about
as use
interpretations
time for telephone
total examination charge of $1 00, the professional interpretation fee would be about 40%, or $40 per examination. The
ogist
alternative that must be given up to produce a service. Opportunity cost in this setting is the cost to the interpreter of mammograms to provide the service, as calculated on the basis of the income forgone from the next best alternative opportunity. A general radiologist might measure the opportunity cost of interpreting mammograms as the professional fees that could be derived from interpreting another type of examination in an equivalent amount of time; for example,
who have abnormal
Additionally,
demand estimate), and all radiologists were involved in interpretation, each radiologist would have to interpret 2350 mam-
more screening
mammography is that of opportunity cost [64]. cost can be defined as the value of the next best
of women
program.
,
mograms
screening Opportunity
considerable
assurance
mailings, or electronic communications. The costs of quality assurance are also proportional to the efforts made to track the outcomes of women who have normal mammograms. Although false-negative rates (“missed” breast cancers) cannot be determined without tracking such outcomes, few largevolume screening programs systematically track these women [51 57]. Another facet of supply-side analysis is the production function of mammographic interpretation. An estimated 10,000 mammography facilities are providing studies at an average examination charge of more than $1 00 [9]. An estimated 20,000 board-certified radiologists are potentially available to interpret mammograms [1 0, 58, 59]. If 47 million mammograms
crease the efficiency of interpretation. As productivity increases, an economic benefit could be realized as either lower examination charges or increased interpretation profit. An important concept in the analysis of the economics of
workload to interpretations of 10 CT or MR examinations. Each radiologist would arrive at his or her own calculation of
quality
the outcomes
531
MAMMOGRAPHY
by primary
fees may be much
increase
care physicians
lower.
in interpretation [65].
Potential
This may
of mamchanges
in the practice of radiology may lower the opportunity costs for radiologists. These changes include decreasing reimbursement rates for other types of examinations, increased training in mammography for residents and practicing physicians, greater efficiencies in mammographic interpretation (as noted before), and future rationing of high-technology imaging services resulting in relatively fewer studies for interpretation.
Cost-effectiveness Confusion
analysis [66-69].
and
Analysis misconceptions
about
cost-effectiveness
are widespread, especially among clinical physicians Such analysis has several levels: cost-outcome de-
scription, cost minimization, and cost utility [66-71].
cost-effectiveness,
cost-benefit,
All health care evaluations have at least two major cornponents: costs and outcomes. Outcomes are variable and may include detection of disease, survival, quality of life, and response to treatment. The choice of an outcome for measurement depends on the purpose of the evaluation, the specific programs studied, and the type of evaluation being conducted [71]. Cost determination depends on the perspec-
tive of the evaluation, the purpose, and the time frame of the study. For example, if costs are evaluated from the point of view of a screening mammography facility, only costs (not
532
CLARK
charges) related to performance and interpretation of the screening examination would be included. If a more compre-
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hensive
societal
point
of view
is taken,
costs
would
include
charges for screening mammography plus incurred charges for all screening-induced procedures and expenses. If differences exist in treating screening-detected cancers as compared with clinically detected cancers, such costs might also be included in an evaluation. Cost-effectiveness
analysis
defines
outcomes
in natural
such as cancers detected, survival rates, years of life gained, or tumor response to treatment. In order to compare two programs, their outcomes must be measured in equivalent units. The costs of each program may then be deterunits,
mined,
and the incremental
or additional
cost of one program
relative to the other is compared with the incremental change in outcome for that program relative to the other; the results are expressed as a ratio [70, 71 ]. For example, one recent study found that screening mammography performed every 2 years in asymptomatic
year of life gained clinical
care
less costly program screening
[72].
women
when When
one
than another,
is more costly mammography
over age 50 cost $4850
compared
per
with a policy of routine
program
the choice
is more
effective
is obvious.
When
and
one
and more effective than another (e.g., vs usual clinical care), its value is
less obvious without such a cost-effectiveness analysis [73]. Cost-benefit analysis defines the outcomes of programs in monetary units (such as dollars); programs are compared by subtracting the incremental costs from the incremental benefits and calculating a net cost for one program over another. This technique is not straightforward, because natural units, such as years of life gained, must be valued in dollars. Wide disagreements exist among health professionals, actuaries, economists,
and lawyers
over
the monetary
value
of a year
of life. The few reported studies of screening mammography have focused on either cost identification or cost-effectiveness [7280]. The outcomes of screening mammography have been defined by several large screening trials in the United States, Sweden, the Netherlands, the United Kingdom, and Canada [1 2]. Cost identification and definition of the outcome are nec-
March 1992
AJR:158,
tiveness
analyses
therefore
vary
widely.
For
example,
the
reported cost per year of life gained because of screening vanes from $1 333 to $44,000 [70, 72-80]; the reported cost per cancer found varies from $7000 to $25,000. In order
to put these
costs
in perspective,
they
must
be
compared with the costs of other health outcomes. For example, the cost-effectiveness of adjuvant chemotherapy in women with node-negative breast cancer has been recently reported
at $1 5,400
per quality-adjusted
year
of life gained
(QALY) in 45-year-old women and $1 8,800 per QALY in 60year-old women [81]. Other types of care with costs per QALY ranging from $1 0,000 to $25,000 include hemodialysis for end-stage renal disease, treatment of three-vessel coronary artery disease, bone-marrow transplantation for acute lymphocytic
leukemia,
and
treatment
of
hypertension
[82-85]. Practical use of cost-effectiveness studies is currently difficult. Calculated cost-effectiveness values are useful only in creating a rank-order list for setting funding priorities across programs that are competing for scarce resources [69]. Each individual calculation has little meaning by itself; it must be compared with values associated with other programs. However, few programs can be accurately compared, because each uses unique methods in its evaluation. Moreover, mdividual clinicians dealing use for such analyses.
with individual patients may have little Individual physicians are generally not
concerned with the overall net health benefit derived from a fixed budget [69]; they are concerned with the welfare of their patients. Many physicians recoil at the choices implied from population-based
studies
on
the
rationing
of
scarce
re-
sources. For future cost-effectiveness studies to be translated to widespread clinical practice, standards of practice patterns and cost-effectiveness methods must be defined and documented. Only then can mass screening programs claim to meet a specific cost-effectiveness value. For these reasons, audits
of practice
in documenting
patterns
future
will probably
cost-effectiveness
play an integral
of screening
part
mam-
mography.
,
essary
at all levels
charges charges
for
the
of analysis.
Cost
screening
mammograms
for screening-induced mammograms, sonography, physical examination, and mammogram is important,
identification
the
incurred
procedures such as additional fine-needle aspiration cytology, biopsies. Although the cost per it does not reflect total cost per
cancer detected
[74, 75, 78]. Variations
may
either
be related
includes
plus
to differences
in cost identification in underlying
cost
as-
sumptions and their measurement or to differences in practice patterns of screening programs. For example, if the recall rate for additional mammography (or the biopsy rate) of one program is different from that of another program, the costs identified for each will patterns and costs exist Europe and the United in health care use and
be different. Differences in practice within the United States and between States for several reasons: variations expenditures, reimbursement differ-
ences, differences in expectations of women and physicians, malpractice trends, and local practice standards; cost-effec-
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27. Freeman HP, Wasfie TJ. Cancerofthe breast in poor black women. Cancer 1989;63:2562-2569 28. Caring for the uninsured and underinsured. JAMA 1991;265:2437-2624
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IC, Danner D. Legal pitfalls in the diagnosis and management Hematol Oncol Clin North Am 1989;3:823-842 46. Spratt JS, Spratt SW. Medical and legal implications of screening and follow-up procedures for breast cancer. Cancer 1990;66: 1351 -1 362 47. Winchester DP. Evaluation and management of breast abnormalities. of breast
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WN. Galvin HB, Ominsky SH, Sollitto AA. Mamrnohow to operate successfully at low cost. Radiology
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Evens AG. Diagnostic imaging in cancer care: the role of cost/benefit analysis. Cancer 1991;67:1245-1252 71 . Goodwin PJ. Economic evaluations of cancer care-incorporating qualityof-life issues. In: Osoba D, ad. Effect of cancer on quality of life. Boca Raton, FL: CRC Press, 1991:125-136 72. Van der Mass PJ, de Koning HJ. van Ineveld BM, et al. The costeffectiveness of breast cancer screening. Int J Cancer 1989;43: 1055-
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76. Moskowitz M. Cost-benefit determinations in screening mammography. Cancer 1987;60[supplj: 1680-1683 77. Gravelle HSE, Simpson PA, Chamberlain J. Breast cancer screening and health service costs. J Health Economics 1982;1 :185-207 78. Cyrlak D. Induced costs of low-cost screening mammography. Radiology 1988;168:661 -663 Eddy DM. Screening
March
FW
AC,
for mild to
527
Review
Economic Robert
Issues
in Screening
Article
Mammography
A. Clark1
The issues surrounding screening mammography present apparent conflicts: conflicting guidelines for screening; an oversupply of facilities, yet inadequate access to mammography for some groups of women; increased medicolegal vulnerability as participation in screening is promoted; disparate results from studies of cost-effectiveness; wide variations in delivery modes and practice patterns of facilities, yet an evolution toward a single set price for mammography by payers for screening. This review does not claim to offer solutions to these conflicts, rather it attempts to carry forward a discussion of the issues. With these conflicts, screening mammography may be only a microcosm of similar economic issues in general health care delivery. Our health care system has room for variety, if access and quality are improved at an affordable cost. Screening for breast cancer with mammography will not reach its full potential to reduce mortality until many
of these
issues
can be resolved.
Screening for breast cancer with mammography significantly reduces the mortality from the disease in women who are screened [1 2]. Although debate continues over both the
Moreover, national politicians and women’s recently issued a “Breast Cancer Challenge”
medical
community,
demanding
success
health advocates to the American
in the fight against
breast cancer by the year 2000; this challenge in toto by NCI director Samuel Broder [6].
challenges
by the year 2000 that all women
over
the age of 40 get regular mammograms and to ensure all mammograms are of the highest quality.
that
These
to ensure
was accepted Included were
national
guidelines
have evolved
during
a time of
rising health care expenditures and an intense scrutiny of the economics of health care. Realization of these goals will have a marked economic impact on the women paying for the services, on the providers of mammography and related
services,
and on society
as a whole dealing with containment
of health care expenditures. The purpose of this review of screening mammography, economic terms.
is to consider the current status focusing on pertinent issues in
,
age at which
screening a widespread
screening, raphy is a basic,
should begin and the frequency of consensus is that routine mammog-
essential
element
of health
care
women [3, 4]. Three of the most widely disseminated guidelines for screening mammography are summarized in Table 1 The National Cancer Institute (NCI) has set cancer control goals for the year 2000 that include participation of 80% of .
all eligible
women
in regular
mammographic
Received August 9, 1991 ; accepted after revision I Department of Radiology, H. Lee Moffitt Cancer FL 33682-8425. AJR 158:527-534,
March
1992 0361-803X/92/1583-0527
screening
October Center
Overview
of Health
Care Expenditures
for adult
[5].
In the past decade,
States that
in 1 990
Roentgen
health
billion, a 2.5-fold capita
14, 1991. and Research Institute, Wiversity C American
health
care expenditures
in the United
have risen more than 10% each year; it is estimated
Ray Society
basis,
care
increase
annual
expenditures
amounted
to $653
from the level of 1980 [7]. On a per
health
care
expenditures
in the
last
of South Florida, 12902 Magnolia Ave., P. 0. Box 280179, Tampa,
528
CLARK
TABLE
1: Guidelines
for Screening Issuing
March
1992
Mammography
Group
Recommendations
United States Preventive Services Task Force American College of Physicians
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AJR:158,
Annual or biannual mammography, ages 50-74 Annual mammography, age 50 and older; mammography age 50 based
American Cancer Society, American Academy of Family Physicians, American Association of Women Radiologists, American College of Radiology, American Medical Society, American Society of Internal Medicine, American Society for Therapeutic Radiology and Oncology, College of American Pathologists, National Cancer Institute, National Medical Association, and American Osteopathic
Baseline
of woman by age 40; annual
mammography
mography,
under
on risk factors
ages 40-49;
or biannual
annual mammography,
mam-
age 50 and
older
College of Radiology
decade rose from $1 059 to $2525. This increase in the per capita expense has been attributed to several factors, including “excess” inflation in the medical care sector, increased
demand for screening mammography is the total number of women who purchase screening services yearly. The full brunt of the economic impact of screening mam-
use, advances
mography has not been realized so far, as only 25-40% of eligible women receive regular screening mammography [1115]. A variety of factors contribute to these low figures and may be considered patient related or physician related [151 8]. Barriers that keep women from receiving screening indude high cost; limited availability of services; limited access
increasing
in costly
number
high-technology
of elderly
services,
and an
in the population.
In 1965, before the institution of Medicare and Medicaid, health care expenditures were 5.9% of the gross national product (GNP). In 1990, spending on health care amounted to 1 1 .9% of the GNP; it has been estimated that in 1991, national health care spending would rise to $71 7 billion, or 1 2.5% of the GNP [7]. The United States currently spends
to services;
of mammograms;
lack of knowledge
about
more of its GNP for health care than any other industrialized
lack of physician
referral.
cite several
country in the world; Canada Britain spends 6% [7].
not referring women for screening mammography: high cost, skepticism about its effectiveness, unclear or conflicting guidelines, a lack of confidence in local mammographic expertise, and a sense that asymptomatic women will not accept screening.
spends
9%, Japan
spends
7%,
The national “economic burden” for cancer care in 1990 in the United States has been estimated at $1 04 billion, divided between $35 billion in direct costs and $69 billion in morbidity and mortality costs [8]. The total national expenditures for all cancer screening services in 1 990 (mammography, Pap tests, and colorectal screening) were estimated to be $2-3 billion [8]. About 47 million American women over age 40 are now eligible
for screening
for routine
mammography
mammography
[9]. The average
in the United States
charge
is more than
$1 00 [9]. If all women over age 40 were to receive annual mammograms at this charge, total mammography expenditures would be nearly $5 billion per year, or almost 1 % of the
total national
health care expenditures
for 1990 and about
25% of the total annual expenditures for diagnostic [1 0]. For each woman, the expense for mammography
represent
almost
4% of the average
annual
imaging would
per capita
penditure for health care. It is clear that implementing grams for more widespread screening mammography
have significant effects on future health care costs. ety, these costs may not be easily borne; therefore, to limit expenditures without reducing effectiveness rently
being
Demand-Side
expro-
will For socimethods are cur-
sought.
Analysis
Demand-side analysis is the consideration of economic factors that contribute to the development of aggregate (total) demand for a product or service. The annual aggregate
fear of cancer,
cancer treatment, Clinicians
or the radiation effectiveness;
and
reasons
for
Attempts to overcome these barriers and increase use have yielded mixed results [1 8-23]. Women with an underlying concern for health-related matters and women with strong family
histories
efforts
of breast
to increase
uneducated
cancer
participation
women,
and older
spond to such interventions mend
screening
are more
to
Poor women,
women
are less likely to rePhysicians may recommore often for women who
[1 9-21
mammography
likely to respond
in screening. ].
are younger and better educated [21]; physicians are more likely to refer women for screening mammography when the physicians’ own offices are well organized and when mammography
services
are easily
23]. One of the most important participation in screening physician [1 8, 21]. Thus, physicians and physicians’
scheduled
and available
determinants
[21-
of a woman’s
is the referral from her primary access of women to primary-care mammography referral practices
are critical points in the use of screening.
Relationships
Among
Access,
Quality,
and Cost
Access to screening services cannot be entirely separated from other issues, such as quality and cost. For example, a
primary
care physician
may not refer women
for screening
the physician thinks that the local charges for mammography are too high or that the local quality of services is poor [15, 1 6]. Similarly, a woman may resist mammography for reasons
if
March
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AJA:158,
ECONOMIC
1992
ISSUES
IN SCREENING
of cost or quality. Although the interrelationship is important, it is easier to discuss these issues separately. The adequacy of access to mammographic services for women is a complex and controversial topic. The access of many Americans to health care is limited; it is estimated that nearly 40 million Americans, or at least 1 5% of the population, do not have health care insurance [24, 25]. Methods to make screening mammography available to all women, including poor women, are only one aspect of an ongoing debate over how to provide access to health care for everyone in the United States. It is becoming clear, however, that lack of access to screening and other medical services contributes to an increased mortality from cancer in poor women [26,
27]. A compendium care coverage
of proposed
als for providing
cancer
determine
types
of screening. comes
to universal health [28], and proposand detection services to
screening
the medically indigent have Most proposals for universal
as one of three types: insurance by employers, workers and the poor; private insurance; or (3) ment [30]. The type of
solutions
been published
has recently
similarly been summarized [29]. health care can be categorized
(1) compulsory provision of private with the government insuring non(2) tax credits for the purchase of all insurance provided by the governsystem that eventually evolves may
of effective
interventions
For example,
if universal
employer
based,
be more effective
workplace
in promoting
to improve
health
screening
the use
insurance programs
use and improving
bemay
access.
if health care coverage is driven by tax credits, the offer of tax incentives to providers of screening for the medically indigent or credits given directly to women who purchase screening examinations may increase the use of screening [31 ]. However, any comprehensive approach to
Alternatively,
these
problems
will require
major
delivery and payment methods. Documentation of the quality
an important
changes
in health
of mammography
part of providing
this service.
has become
In 1987,
the
(ACR) began a program to practices [32, 33]; the pro-
American College accredit individual
of Radiology mammography
gram is becoming
a de facto standard
This voluntary program involves cations, equipment, mammograms,
care
of quality
assurance.
peer review of staff qualifidoses of radiation to the
breast, and quality control programs. Facilities that meet all the criteria of the program are awarded a 3-year accreditation and a listing on the American Cancer Society (ACS) referral list of approved clan or woman
mammographic to find qualified
centers. facilities
One way for a cliniis to obtain a listing
from the local ACS chapter or the ACR. As of June 1991, more than 3000 mammography facilities had been accredited [34]; however, this is less than one third of the estimated 1 0,000 facilities nationwide [9]. Over 30 states have laws requiring reimbursement for screening mammography, but only nine have enacted quality assurance legislation [35, 36]. At least two (Michigan and Florida) have passed laws requiring the equivalent of ACR accreditation for centers that perform mammography. Federal legislation to establish national standards for quality in mammography is expected [35, 36]. Moreover, Medicare began reimbursement for screening mammography in 1991 ; guide-
MAMMOGRAPHY
529
lines issued by the Health Care Financing Agency imply that ACR accreditation or its equivalent will be required for reimbursement
by Medicare
[34].
Determinants of Price: Demand and Supply
Comparison
of Aggregate
Estimates of aggregate demand vary, depending on which guidelines for screening mammography are used (Table 1). The lowest estimate of aggregate demand for mammography (1
5 million
procedures
annually)
results
from
the guidelines
of
the United States Preventive Services Task Force. The highest estimate of aggregate demand (47 million procedures annually) comes from the joint ACS/NCI/ACR guidelines. A recent report [9] assessed this supply-and-demand compari-
son. The authors
began with a practical
capability
examinations
of 6000
mammography
per year and estimated,
unit given
the aforementioned calculations for aggregate demand, that the number of mammography units required to provide mammography
services
the demand raphy
varied
figures
units exist
from
2566
to 7892,
used. Approximately
in the United
States.
depending
10,000
The authors
on
mammogconcluded
that there is currently an oversupply of mammography units and that this excess supply has several adverse economic effects. First, it implies that these resources are being used inefficiently.
Second,
units necessitates
the underuse
of existing
that these units charge
mammography
a high price, more
than $1 00 per procedure, to cover costs; this may impede the desired public health trend to reduce charges for screen-
ing mammography
and thereby
increase
ersupply of units operating at low capacity of quality assurance and record keeping.
use. Third, the ovincreases the cost
However, overall comparisons of aggregate supply do not assess the regional distribution
demand and of mammog-
raphy machines. In a similar analysis of supply-and-demand relationships for screening mammography in four counties in Florida, an oversupply of machines was found in urban coun-
ties, and an undersupply was found in rural counties [37]. This apparent reduced access to mammography facilities for rural women probably reflects the women’s overall reduced access
to health
care [38].
In rural
areas,
the lack of a large
population base reduces incentives for rural radiologists to provide screening services, particularly at low cost. Conversely, in urban areas, the perceived need to remain “competitive”
may force
radiologists
to provide
screening
services,
even when more than enough units are already available for the population. A potential solution, as yet untried, might be cooperative provision of low-cost peting radiology practices.
screening
services
by corn-
Standard economic theory holds that supply will accurately match demand in a free market [39]. However, for many reasons, medical care is not a free-market situation; demand for medical services may actually increase as supply increases, rather than the reverse [40]. For the past several decades, the cost of diagnostic mammography has been
reimbursed
by medical
at a cost-based
rate,
insurance with
carriers,
the costs
and other payers,
determined
at low-use
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530
CLARK
AJR:158,
March
1992
rates. The current average charge of more than $1 00 for mammography was set during this period and has become
sumed to be 40 examinations per day (or per 8-hr shift, or per technologist per day), or 1 0,000 examinations per year.
an “allowable” charge. This price, charged to third-party payers, now acts as a “price floor” resulting in both high prices and oversupply [39].
Practical
capability
demand
always
Recent
changes
in the reimbursement
policies
of Medicare
and commercial insurers for the cost of screening mammography (as distinguished from diagnostic or consultative mammography)
may
alter
this
situation.
Medicare
has
set
its
reimbursement rate for screening mammography in 1 991 at $55 per examination; other insurance carriers and payers may follow this lead. If the new allowable charge for screening mammography becomes $55, it will affect the supply of services. For example, if this charge does not cover the costs of certain facilities, those facilities may lose money or go out of business. Moreover, if this charge is lower than the costs of most facilities, an undersupply of units may result. This would be analogous to the situation of a “price ceiling” [39]. As long as mammography charges are set by payers, rather than a free market, the supply and demand for screening will never match. Therefore, it is important that both the providers of screening mammography recognize the effects of price
and the payers of the costs setting. The differences in cost
structure and overhead of various types of facilities markedly affect the ability of some facilities to operate at lower fixed prices.
may be less: Inefficiencies exist;
use of mobile
in staffing
mammography
and
units
is
less efficient than that of standard units because of setup and travel time; the population may be too small in rural areas to provide an adequate number of examinations each day. For planning purposes, a practical capacity of 6000-8000 examinations annually may be a more realistic goal. However, screening mammography can be provided profitably at
charges
of less than $60 at practical
examinations
per year,
capacities
of 6000-8000
and as low as $30-45
per examina-
tion, when operated
at maximum
critical
the
to recognize
capacity
reciprocal
[43]. Clearly,
relationship
volume if costs are to be reduced. However, not all facilities may be able to duplicate reported cost structures [44]. The largest difference cost structures
be overhead free-standing
among
screening
allocation. facility
does
and
these in the
mammographyfacilities
When mammography that
it is
of cost
screening
may
is provided examinations
in a only
(and not consultative or diagnostic examinations), without a radiologist in attendance, and with no other assessment of overhead charges, the efficiencies of high volume can be achieved and the costs reduced. However, larger overhead costs are incurred if screening mammography is performed in a hospital or clinic, in combination with consultative studies
or with a radiologist in attendance. High-volume, low-cost mammography screening would require a change in both the Supply-Side
practice
Analysis
Supply-side
analysis
addresses
the determinants
duction function. For screening mammography, production should be considered: performing
of pro-
two facets of the examination
and interpreting the study. Several recent articles [41 -43] have evaluated the efficiency of performing screening mammography in high volume. These reports have emphasized techniques to increase throughput of examinations and maximize the use of a mammography
machine
and facility.
Because
mammography
ser-
vice is characterized by high fixed costs (e.g., equipment and salaries) and negligible variable costs (e.g., film), the unit examination cost is minimized as throughput is maximized, and the marginal cost of each additional examination performed (until capacity is reached) is negligible. In other words, the marginal
profit
of each
additional
until capacity is reached. Several techniques have been screening efficiency and reduce costs: examinations only, batch processing day, loading of films on mechanical
examination developed
increases to
improve
dedication to screening of films once or twice a viewers for batch inter-
pretations, simplified and standardized reporting either manually or by computer, and standardized
of results follow-up
and quality assurance [41-43]. Mass screening has been proposed as the only feasible approach to offering screening at low cost [43]. Less often stated is the possibility that increased efficiencies will result in greater
capacity
profits
in addition
of a dedicated
to lower
mammography
prices.
The
maximum
unit is generally
as-
patterns
of many
mammography
facilities
and
the
expectations of many women receiving mammography. However, evidence exists that this can be accomplished [41-43]. Numerous indirect costs exist that may vary widely from facility
to facility.
These
include
those
for physical
overhead
(e.g., rent, heat, electricity, maintenance), medicolegal age, quality assurance, marketing, and opportunity
covercosts.
Medicolegal costs for the provider of screening mammography can be calculated initially as the annual malpractice in-
surance premium of the radiologist. Medicolegal costs may increase markedly as the use of screening mammography increases. Failure to diagnose breast cancer has become one of the most common reasons for malpractice litigation in the United
States
[45].
Until recently,
the defendants
in most
of
these suits have been primary care physicians, as the common standard for diagnosis was clinical detection. Some think that as use of screening mammography increases, the vulnerability of radiologists to malpractice claims for failure to detect early breast cancer will increase also. This topic has been addressed recently from several perspectives [45-50]. Radiologists should be aware of the areas of vulnerability
in the
practice
of mammography
and of the
current
standards of practice with which their own practices will be compared. Continuing education is recommended, as well as an awareness of the subtle, secondary mammographic signs of breast cancer. Documentation of quality assurance through the use of practice audits has been emphasized as an important part of preventive defense of vulnerability [50-52]. Similarly, the practice of nonoperative management (short-term mammographic
follow-up)
of women
with
mammographic
AJA:158, March
ECONOMIC
1992
abnormalities
with
a standard
of practice
low malignant
ISSUES
risk has been
IN SCREENING
assessed
as
[46, 47, 53].
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Because documentation of quality assurance is such an essential part of screening mammography, its costs should be accurately assessed. However, no studies have yet eval-
uated the costs of a comprehensive quality assurance program. The components of a practice audit have been well outlined [51 52], but the accumulation of follow-up informa,
tion on women who have difficult and time-consuming.
received mammography can A cost-effective approach
be to
quality assurance requires an efficient and effective information system [51 54, 55]. Although this type of program can be done manually, for most practices of moderate volume, a computerized tracking system will be necessary [51 54-56]; hardware, software, and personnel therefore are relevant ,
,
costs
for
tracking mograms
a basic may
require
annually
(the largest
nine mammograms
per radiologist
per day. At a
per day would
be
,
preted in high volume for a professional fee of $5-i 0 per examination. The equivalent daily fees for screening then would be 36 examinations at $1 0 per study, a total of $360. Not all radiologists interpret mammograms, so it is likely that
mammograms procedures
will be interpreted increases.
per radiol-
In a screening
situation,
it is feasible for one radiologist to interpret 40-200 examinations per day. Even with professional fees of $1 0 per study, daily fees in high-volume conditions could range from $400 to $2000. Technologic advances could increase the interpretation productivity of a radiologist even further. The use of “prereaders” (e.g., physician assistants or nurse-cliniclans) or computer image analysis to detect normal examinations in screening populations has been proposed
systems
may obviate a radiologist’s site or the transfer of these approaches are such methods could drastically in-
physical presence at a mammography films for interpretation [63]. Although
currently
investigational,
previous
cost
on the
training
interpretation,
in
basis
of comparisons
or expertise,
and
the
availability
relative
fees
of difficulty,
of the studies
for
interpretation.
for Until
recently, many radiologists may have determined that the opportunity costs for low-cost screening mammography were very high; that is, the forgone imaging studies, particularly
fees for interpretation newer cross-sectional
of other imaging
studies, were higher than the fees for interpretation of screening mammograms. This may be a negative incentive for radiologists
to participate
in low-cost
screening
programs.
Conversely, primary care physicians may view the opportunity costs of interpreting screening mammograms differently; the alternative
explain
office
practice
in part the recent
mograms
aggregate-
$360. Bird and McLelland [41 57] and Sickles et al. [42, 51] have suggested that screening mammograms can be inter-
Teleradiology
be equivalent
opportunity
fees for nine mammograms
[60-62].
might
calls,
were obtained
of the
of 40 mammograms
mam-
per year or about
as use
interpretations
time for telephone
total examination charge of $1 00, the professional interpretation fee would be about 40%, or $40 per examination. The
ogist
alternative that must be given up to produce a service. Opportunity cost in this setting is the cost to the interpreter of mammograms to provide the service, as calculated on the basis of the income forgone from the next best alternative opportunity. A general radiologist might measure the opportunity cost of interpreting mammograms as the professional fees that could be derived from interpreting another type of examination in an equivalent amount of time; for example,
who have abnormal
Additionally,
demand estimate), and all radiologists were involved in interpretation, each radiologist would have to interpret 2350 mam-
more screening
mammography is that of opportunity cost [64]. cost can be defined as the value of the next best
of women
program.
,
mograms
screening Opportunity
considerable
assurance
mailings, or electronic communications. The costs of quality assurance are also proportional to the efforts made to track the outcomes of women who have normal mammograms. Although false-negative rates (“missed” breast cancers) cannot be determined without tracking such outcomes, few largevolume screening programs systematically track these women [51 57]. Another facet of supply-side analysis is the production function of mammographic interpretation. An estimated 10,000 mammography facilities are providing studies at an average examination charge of more than $1 00 [9]. An estimated 20,000 board-certified radiologists are potentially available to interpret mammograms [1 0, 58, 59]. If 47 million mammograms
crease the efficiency of interpretation. As productivity increases, an economic benefit could be realized as either lower examination charges or increased interpretation profit. An important concept in the analysis of the economics of
workload to interpretations of 10 CT or MR examinations. Each radiologist would arrive at his or her own calculation of
quality
the outcomes
531
MAMMOGRAPHY
by primary
fees may be much
increase
care physicians
lower.
in interpretation [65].
Potential
This may
of mamchanges
in the practice of radiology may lower the opportunity costs for radiologists. These changes include decreasing reimbursement rates for other types of examinations, increased training in mammography for residents and practicing physicians, greater efficiencies in mammographic interpretation (as noted before), and future rationing of high-technology imaging services resulting in relatively fewer studies for interpretation.
Cost-effectiveness Confusion
analysis [66-69].
and
Analysis misconceptions
about
cost-effectiveness
are widespread, especially among clinical physicians Such analysis has several levels: cost-outcome de-
scription, cost minimization, and cost utility [66-71].
cost-effectiveness,
cost-benefit,
All health care evaluations have at least two major cornponents: costs and outcomes. Outcomes are variable and may include detection of disease, survival, quality of life, and response to treatment. The choice of an outcome for measurement depends on the purpose of the evaluation, the specific programs studied, and the type of evaluation being conducted [71]. Cost determination depends on the perspec-
tive of the evaluation, the purpose, and the time frame of the study. For example, if costs are evaluated from the point of view of a screening mammography facility, only costs (not
532
CLARK
charges) related to performance and interpretation of the screening examination would be included. If a more compre-
Downloaded from www.ajronline.org by 221.214.176.180 on 10/05/15 from IP address 221.214.176.180. Copyright ARRS. For personal use only; all rights reserved
hensive
societal
point
of view
is taken,
costs
would
include
charges for screening mammography plus incurred charges for all screening-induced procedures and expenses. If differences exist in treating screening-detected cancers as compared with clinically detected cancers, such costs might also be included in an evaluation. Cost-effectiveness
analysis
defines
outcomes
in natural
such as cancers detected, survival rates, years of life gained, or tumor response to treatment. In order to compare two programs, their outcomes must be measured in equivalent units. The costs of each program may then be deterunits,
mined,
and the incremental
or additional
cost of one program
relative to the other is compared with the incremental change in outcome for that program relative to the other; the results are expressed as a ratio [70, 71 ]. For example, one recent study found that screening mammography performed every 2 years in asymptomatic
year of life gained clinical
care
less costly program screening
[72].
women
when When
one
than another,
is more costly mammography
over age 50 cost $4850
compared
per
with a policy of routine
program
the choice
is more
effective
is obvious.
When
and
one
and more effective than another (e.g., vs usual clinical care), its value is
less obvious without such a cost-effectiveness analysis [73]. Cost-benefit analysis defines the outcomes of programs in monetary units (such as dollars); programs are compared by subtracting the incremental costs from the incremental benefits and calculating a net cost for one program over another. This technique is not straightforward, because natural units, such as years of life gained, must be valued in dollars. Wide disagreements exist among health professionals, actuaries, economists,
and lawyers
over
the monetary
value
of a year
of life. The few reported studies of screening mammography have focused on either cost identification or cost-effectiveness [7280]. The outcomes of screening mammography have been defined by several large screening trials in the United States, Sweden, the Netherlands, the United Kingdom, and Canada [1 2]. Cost identification and definition of the outcome are nec-
March 1992
AJR:158,
tiveness
analyses
therefore
vary
widely.
For
example,
the
reported cost per year of life gained because of screening vanes from $1 333 to $44,000 [70, 72-80]; the reported cost per cancer found varies from $7000 to $25,000. In order
to put these
costs
in perspective,
they
must
be
compared with the costs of other health outcomes. For example, the cost-effectiveness of adjuvant chemotherapy in women with node-negative breast cancer has been recently reported
at $1 5,400
per quality-adjusted
year
of life gained
(QALY) in 45-year-old women and $1 8,800 per QALY in 60year-old women [81]. Other types of care with costs per QALY ranging from $1 0,000 to $25,000 include hemodialysis for end-stage renal disease, treatment of three-vessel coronary artery disease, bone-marrow transplantation for acute lymphocytic
leukemia,
and
treatment
of
hypertension
[82-85]. Practical use of cost-effectiveness studies is currently difficult. Calculated cost-effectiveness values are useful only in creating a rank-order list for setting funding priorities across programs that are competing for scarce resources [69]. Each individual calculation has little meaning by itself; it must be compared with values associated with other programs. However, few programs can be accurately compared, because each uses unique methods in its evaluation. Moreover, mdividual clinicians dealing use for such analyses.
with individual patients may have little Individual physicians are generally not
concerned with the overall net health benefit derived from a fixed budget [69]; they are concerned with the welfare of their patients. Many physicians recoil at the choices implied from population-based
studies
on
the
rationing
of
scarce
re-
sources. For future cost-effectiveness studies to be translated to widespread clinical practice, standards of practice patterns and cost-effectiveness methods must be defined and documented. Only then can mass screening programs claim to meet a specific cost-effectiveness value. For these reasons, audits
of practice
in documenting
patterns
future
will probably
cost-effectiveness
play an integral
of screening
part
mam-
mography.
,
essary
at all levels
charges charges
for
the
of analysis.
Cost
screening
mammograms
for screening-induced mammograms, sonography, physical examination, and mammogram is important,
identification
the
incurred
procedures such as additional fine-needle aspiration cytology, biopsies. Although the cost per it does not reflect total cost per
cancer detected
[74, 75, 78]. Variations
may
either
be related
includes
plus
to differences
in cost identification in underlying
cost
as-
sumptions and their measurement or to differences in practice patterns of screening programs. For example, if the recall rate for additional mammography (or the biopsy rate) of one program is different from that of another program, the costs identified for each will patterns and costs exist Europe and the United in health care use and
be different. Differences in practice within the United States and between States for several reasons: variations expenditures, reimbursement differ-
ences, differences in expectations of women and physicians, malpractice trends, and local practice standards; cost-effec-
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