SUMMARY: How should you choose a mammogram facility? The best answer for that comes from an expert. Some questions were asked by community members during our recent crowdsourcing partnership with WNYC. Here’s a thoughtful, detailed explanation from Dr. Geraldine McGinty, MD, MBA, FACR, a radiologist who specializes in breast imaging.
By Geraldine McGinty, MD, MBA, FACR
How should I choose a mammogram facility?
Full coverage of annual screening mammography with no co-pay for women 40 and older is a very welcome provision of the Affordable Care Act. There are, however, aspects to screening for breast cancer that raise some important questions for women as they choose where to be screened.
First, a little background information:
Screening mammograms (routine mammograms, not those performed if you have a lump or any other problem or a history of breast cancer) are typically interpreted by the radiologist after they are performed. About 10% of women screened can expect to be called back for additional testing (either additional diagnostic mammogram pictures or ultrasound). That doesn’t mean there was anything wrong with the initial mammogram, just that because of overlapping shadows or a change since the previous mammogram, more information is needed.
That 10% number is considered “best practice.” Radiologists have their “recall rates” tracked, among other statistics of their performance. Both higher and lower recall rates are potential opportunities for the radiologist to improve his or her practice, but need to be considered in the context of other performance benchmarks.
If a woman has to return for additional “diagnostic” mammogram pictures or an ultrasound those exams are not included in the “no co-pay” ruling. Many insurance plans now have higher deductibles, so women who are called back may find themselves paying the entire cost of the diagnostic mammogram or ultrasound if they have not met their deductible even though the service is technically “covered” by their insurance company. The cost of that diagnostic mammogram or ultrasound can vary widely. Often hospital radiology departments charge higher prices than radiologists’ offices in the community.
So how should you choose where to go for your mammogram? Here are some questions you might ask and my best attempt to answer them.
1. I don’t understand why they don’t read my mammogram while I’m there. That way I wouldn’t have to take a second day off work and pay for the “diagnostic” examination.
An extremely important part of the mammography examination is the interpretation by the radiologist. You want this to be as effective as possible. Studies have shown (http://www.ncbi.nlm.nih.gov/pubmed/16120936) that on average your radiologist does a better job (fewer recalls while detecting the same number of breast cancers) when reading a batch of mammograms together without interruptions.
If you are called back, the facility should clearly specify what type of imaging you will be having and what it will cost given your insurance. You should ask for and expect a convenient appointment and to get your results before you leave. If you subsequently turn out to need a biopsy, you should expect to speak with the radiologist who is recommending it.
That said, there are facilities where you can go and have the mammogram interpreted while you wait. In New York City (where I practice) many of these facilities do not participate with or accept insurance. If you choose this type of facility, it’s important to clarify the exact service you will be getting and paying for.
2. Why does a mammogram cost more at the outpatient department of my local hospital than in an imaging center?
The difference in price has to do with what is called the “technical component” payment or the payment that you or your insurance company makes for the performance of the mammogram. This payment takes into account the cost of the machine and the salary of the technologist, as well as the general costs of running the facility.
The payment for the radiologist’s interpretation of your mammogram is about the same in either setting. Hospitals bear additional costs because they have to be open 24-7, they have to provide care to the poor and uninsured who show up in the Emergency Department, and they have to train the doctors of the future.
3. So which is better? How do I pick a facility?
All facilities that perform mammography are required to be certified by the Food and Drug Administration, and be accredited by the American College of Radiology or an equivalent (for AK, IA, TX). You can therefore be reassured that the equipment performs at a certain standard and is regularly serviced, that the personnel performing and interpreting the examination have undergone appropriate training and continuing education and that the images taken at the facility have been inspected and found to meet quality standards.
4. So if all facilities meet these standards, how should you select a facility?
The important thing is to get your mammogram. For every horror story that you hear about someone who had a mammogram which missed their cancer, there are many more stories of women whose cancers were not diagnosed until at an advanced stage because they didn’t get a mammogram at all.
We know that we are more likely to keep appointments if they are not scheduled too far in advance and are at a convenient location so those are important primary considerations.
One thing that I consider important is the number of mammograms read by the radiologist. Simply put, more is generally better.
The minimum number of mammograms that a radiologist must read to remain qualified by the F.D.A. is 480 per year. As a fellowship-trained breast imager, I typically read many more than that, as well as a mix of screening and diagnostic mammograms, and that experience improves my reading skills.
Now, you can have too much of a good thing. I wouldn’t want my mammogram read by a severely overworked radiologist who didn’t have time to concentrate.
5. Is a higher priced facility better?
Not necessarily. I would look for a facility where the doctors reading are able to focus on mammography even if they don’t do that exclusively. Fellowship training in breast imaging can be a plus but not an absolute requirement. Many excellent and very experienced radiologists finished their training before specialty training in breast imaging existed.
6. Are there any negatives I should look out for?
I would think twice about going to a facility that is not prepared to explain what service you are having and what your expected out-of-pocket cost will be. You should always have the opportunity to speak to the radiologist interpreting your mammogram, even if that happens after you had the mammogram taken.
7. What if I have had a negative experience at a mammogram facility?
Call the facility and ask to speak to the radiologist. Tell them your concerns. If you’re still worried, ask your doctor to call them. If you’re still not happy, please contact the ACR Director, Breast Imaging Accreditation Programs, American College of Radiology, 1891 Preston White Drive, Reston, VA 20191-4397, firstname.lastname@example.org.
Editor’s note: Recent reports on mammogram recommendations
A long-term mammogram study recently made headlines in The New York Times and elsewhere, casting doubt on the value of mammograms. The study found that the death rates from breast cancer and all causes were the same in women who got mammograms and those who did not, and that there were some downsides to frequent screenings, according to the report in The New York Times.
McGinty said this is not a new study, but a report on new data added to an older Canadian trial which featured poor study design, flawed patient selection and bad mammogram quality.
McGinty said the recommendations of the American College of Radiology regarding guidelines for who should receive mammograms had not changed, and that the group still recommends annual mammograms for women over 40. The ACR response to the Canadian study is here on the ACR web site.
This is part of our WNYC “price of a mammogram” series. Other posts are here.
2. The overview: How much does a mammogram cost? Prices, payments vary widely, our survey with WNYC finds.
3. We don’t offer medical advice, but we wanted to tell you about the guidelines. When is a mammogram not a mammogram?
4. How much does a mammogram cost? Your tales of bills: $0 to $2,786.95.
5. Women’s health resources. No one should ever have to go without a mammogram or other women’s health issues. Reproductive health belongs to us. Here are some resources, and some thoughts about women’s health.
6. Acts of healing, and of overcharging: Contributors talk about their mammograms.
7. How much does a mammogram cost? The takeaway.
8. How should you choose a mammogram facility? Dr. Geraldine McGinty explains.