A small part of me is glad that my inquiries a while back to get a job at Northwestern University in Chicago came to nothing when I read stuff like this on, of all places, Julie Deardorff's blog:
Next appointment? Sept. 21, 2009
It now takes 10 months to get an appointment for a regular screening mammogram at Northwestern Memorial Hospital, which runs the largest single-site breast center in Illinois. And if that causes you any stress or inconvenience, Northwestern officials are sorry.
"The growing national shortage of radiologists who have advanced training in reading mammograms has had a significant impact on us," Dean Harrison, president and chief executive officer of Northwestern Memorial HealthCare, said in a three-quarter page apology in the Chicago Tribune.
Doctors usually recommend that women over age 40 get a mammogram every year.
But the people who read the images--breast imaging radiologists--are scarce in part because screening mammography is not historically a high-paying specialty, has been poorly reimbursed and is prone to litigation relative to other imaging procedures, said Dr. Ellen Mendelson, section chief of Northwestern's breast and women's imaging department. Consequently, radiologists have turned to other sub-specialties.
This is the worst I've heard. The worst it ever got at one institution I worked at was a two or three month's wait, and where I work now it's less than a month. However, in certain parts of the country, what's happening at Northwestern is not far off in many places if things don't change.
The reason is that reimbursement for routine screening mammography sucks big time. Indeed, most facilities either barely break even on the procedure, and some lose money. They keep doing them because they make it up for biopsies, but liability insurance for mammography facilities and radiologists who read mammography is becoming increasingly onerous. After all, the leading reason for medical malpractice suits against physicians is delay in breast cancer diagnosis, and guess who bears the brunt of these lawsuits? Primary care physicians, gynecologists, and radiologists who do mammography, that's who. Consequently, finding mammographers to staff breast centers is a serious problem. It's a problem where I work, and at the facilities where virtually all of my friends and acquaintances who treat breast cancer work. Couple that risk with the low reimbursement for mammography, and it's no wonder that radiologists no longer find breast imaging to be an attractive specialty.
Many mammography facilities are like that at Northwestern; they're on the edge, making patients wait months for mammography, and all it would take is the loss of a few personnel to tip them over the edge. The wait might not balloon to ten months, but it wouldn't be pretty.
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Here in Vancouver (Canada) you can get an appointment within a few days, no problem.
That's right, people... FEAR the delays that 'socialist' medicine will bring you... wait a minute...
Interestingly in canada, the recommendation is every 2 years after age 50, not every year from 40 onward. ( that screening outside that is "inconclusive."
Hmm. http://www.hc-sc.gc.ca/hl-vs/iyh-vsv/med/mammog-eng.php#when
Canada's setup seems to be the same as Australia - once per two years targeting the 50+ group (though 40+ can get screened for free as well if they desire).
I guess the 'once per year' could be due to the radiologists/medical facilities being s**t scared of geting sued, so they schedule more screens to improve their odds of detecting anything strange before the lawyers come a-knocking.
Another possibility could be a greater prevalance of self examination in Oz/Canuckistan thus the centres can be a bit more relaxed. It's just speculation though
Things probably are not going to get any better soon. The few remaining Radiologists come under increased pressure to take up the slack by government and administrators, increased stress means they could miss things, then they get bombbarded with more lawsuits and finally say "Screw this" and take up a job working at 'The Gap' selling jeans for more money and less stress. Thus the remaining have even more stress and work...
A nasty feedback loop begins, and no one considering a medical career will even consider it as a choice.
Much of the problem is driven by the abysmally low rates that Medicare pays for mammography, which is compounded by the private insurance plans that use the shamefully low Medicare rates as the standard by which they make payments. In other words, your glib little comment is very much off-base.
What is the excuse for ridiculous delays for pelvic exams with PCPs? At my last doctor, when I needed to schedule my yearly exam, they told me they didn't have another appointment for 6 months. And I don't think that's unusual--many of my friends have the same problem.
Mammography obviously has some additional factors going against it, but I think a big problem is lack of sufficient compensation for preventive care in general--not just mammograms. A lot of doctors won't even let you schedule a physical within 6 months anymore--all of their appointments are reserved for acute cases.
The lab called; your sarcasmometer is overdue for recalibration.
Wasn't he mocking the critics of government-run care even though government price controls, along with the predatory legal environment, drive this mammography fail bus?
That's right, people... FEAR the delays that 'socialist' medicine will bring you... wait a minute...
No kidding.
I was diagnosed with uterine fibroids back in 2002. I wanted to have UAE done as it would allow me to keep my ovaries (I like my bones too much to want to go into early menopause) and would have far less recovery time than a hysterectomy; I had already ruled out hormone therapies as they would only have a temporary effect (and would weaken my bones). But guess what? BCBS wouldn't cover UAE at the time (and coverage to this day isn't automatic, from what I've found), and I couldn't swing the fifteen grand the local hospital charged for it. Now my fibroids are too big to be effectively dealt with by any means save hysterectomy. Luckily none of them are growing outside the uterine wall, so my main side effects are looking knocked up and needing iron pills.
If I'd been in France, the cost would have been minimal and I could have it done almost immediately after diagnosis.
Joseph C.: They have those eeeevil "government price controls" in Canada and most European nations, too. Yet they're not having ten-month waits for mammograms, last I checked. In fact, it was big news in the UK in 2004 when a Welsh woman didn't get a free mammogram within ten days.
If you think that people don't wait for procedures in Canada, you need to investigate the matter more thoroughly. What about the abysmally low amount of MRI machines in Canada and the Canucks that have to hop into the US to speed up the process of getting a scan?
Joseph C., I AM in canada, as is Richard. We do wait, but never 10 months for a basic X ray screening scan.
We don't have as many MRI's as they're not the end all be all of medical diagnostic imaging, and they're not used for every last little thing. Perhaps you've watched too much House or ER, MRI is not a miracle. Why people persist in using MRI as the baseline for whether health care service is good, or not, I don't understand.
Orthopedics is the primary reason people do hop the line, and they're certainly free to. We have an aging, and active population, which inevitably leads to knee surgeries and hip surgeries, and those have the longest wait lists of most specialties.
Health care isn't first come-first served. Sometimes, people get bumped and delayed due to an emergency that day in the OR, or what have you. Sucking Chest Wound trumps broken wrist.
We've always gotten fast, exceptional care. True, there's some areas where there's delays, but I know more people in the US going without, for years, for lack of access, money, insurance. We might have some delays, but at least we don't have a mountain of insurance to wrangle with. Kind of a nice touch at 4 am when you find yourself in the ER.
And lets not forget, there are americans who sneak up here for "free" or cheaper care too. Goes both ways.
Tell that to the poor bastard who has to drive hours and shell out $1000 even though he's been paying into the Canadian system for his/her entire life.
As someone kindly pointed out already, I was being sarcastic.
I'm suggesting that the free market is not what should be determining the costs and the speed of service that you're seeing in medicine; particularly in preventative medicine. A wait of 10 months can be the difference between a simple surgery and death.
The views from outside of the Canadian single-payer system (aka Socialist, Communist, or Government run as you might think of it) are often surprisingly wrong. As you appear to believe that MRI is the metric by which medicine be evaluated, I would suggest that you don't understand the Canadian system in the slightest. MRI does not stand for "Magically Removing Injury"...
I wrote a draft to explain a couple of the fallacies I was encountering prior to the US election; maybe you might find it informative; http://foo.ca/wp/2008/10/18/a-bit-about-health-care-a-draft/
Joseph:
If there is a real emergency medical need for an MRI or another therapy and you're in the middle of Northern BC unable to make it to a center that has the facilities you need, you might just find yourself on a helicopter to a city with the facilities.
I would imagine that the same thing would happen if you're in deepest darkest Kansas, hundreds of miles from a city.
The difference being that the Canadian system would pay for the ride, and the guy in Kansas might find himself selling the house to pay for the ambulance ride and the treatment after his insurer rules it a pre-existing condition.
Straw man. I never said any such thing. I was just pointing out the problems with getting doctor ordered scans in Canada in response to a statement about it being easier to get mammograms up there.
But the free market isn't determining the reimbursement rates for mammograms in the US, CMS is. And with apparently poor results.
Also from Canada.
You know, what I've been reading here in the last few months has been quite surprising for me. I hear people in Canada complain all the time about waiting to see a GP. I hear them longing for a private system like in the states, in the hopes of declogging the system. And what do I hear from the states ? About same problems we have. Waiting lists to be attributed to a family doctor or a gyne. And, what's more, you have to pay for that.
In the meantime, I've had some friends and family become gravely sick. Guess what ? My friend, after being diagnosed with ovarian cancer, was put in surgery during the very same week. Same for my uncle's prostate cancer, diagnosed thanks to PSA and a zealous doctor. Put in therapy (lupron + radiotherapy) in the same week. My mom goes to the hospital with chest pain ? Sees a pneumologist and a cardiologist within the hour.
So what about our socialist health care ? I'd say it's quite fine indeed. I can go to whatever hospital I want to (that happens frequently since I happen to work in one hospital research center and live near another. I've had a couple mishaps in the lab and on those occasions I've gone to the research hospital's ER). I can get a second opinion whenever I want. Sure, maybe I'll wait a couple hours to get a prescription for antibiotics for my sore throat, and probably much more if I'm stupid enough to go to the ER for that. Oh, and I'll probably wait for months to get a MRI for my knee. Or to see a dermatologist. Except if I want botox injections, in which case they'll receive me same day, because I have to pay out of pocket for that. Actually, whatever private healthcare we have (which is mostly elective plastic surgery) has stolen away doctors from the system and made waiting lists longer instead of shorter.
Now when I hear politicians try to gradually wreck our health care system with the "private hospital will make waiting shorter screed", and people agree with that, I want to strangle both.
Stolen? Aren't doctors like everyone else in Canada: free to work wherever they want?
The wait is usually about a month for me. Less if all I want is a pelvic exam (rather than a full physical), more if my doctor happens to have some vacation time planned and I don't want to see one of the others. ;-) But mileage varies. It depends heavily on how many doctors there are at your clinic, and their patient loads.
Of course they are. They can choose to apply to jobs everywhere they want, which includes private clinics, academic research institutions and pharmaceutical companies.
Dermatologists are going away from treating really sick patients to elective plastic surgery because it pays more. Actually, there are even some cases of GP's, wanting to make quick bucks, who leave the system to get into plastic surgery, with sometimes disastrous consequences, since it's nowhere their area of expertise. Yes, they get sued. But that doesn't make the waiting list to get a family GP or a dermatologist shorter.
The magic of private, "free market" medicine.
What about the abysmally low amount of MRI machines in Canada and the Canucks that have to hop into the US to speed up the process of getting a scan?
True.. a decade ago. Not so much anymore.
Tell that to the poor bastard who has to drive hours and shell out $1000 even though he's been paying into the Canadian system for his/her entire life.
Even in the 1990s, when there were less MRIs than needed, going stateside was an OPTION, not a necessity. You could wait a little longer and still get one here. I know, because I needed an MRI during the "drought". I was willing to wait a month and let more serious cases go before me.
There are more than twice as many MRIs here now, I hazard that the waiting times are shorter.
The baselines on quality of healthcare are infant mortality and life expectancy. In both those areas all other Western nations with "socialized" care has the US beat.
If I could return to the original point: the delay in receiving and mammogram and the shortage of radiologists.
I think that the question that needs to be asked is: do we need a radiologist to read a screening mammogram? Does reading a screening mammogram require a full medical degree plus specialisation as a rediologist?
I don't think so. When you think about it, radiologists have to be retrained in order to read a screening mammogram. This is because they are trained to recognised disease in people where there is a high probability that disease exists. People with symptoms; patients.
With screening mamaograms, the probability of diease is low. The people being screened are not patients.
Radiologists therefore have to be retrained so that they know what a "normal" breast image looks like.
Given this, why not simply exclude radiologists from the task and let them get on with doctoring and instead take people without a medical degree and train them to read a screening mammogram.
They would be cheaper to train and cheaper to employ.
Here in the UK I hear a lot of griping about the NHS. There are some who have an image of the USA as a source of marvellous, cost-no-object treatment. However, I'm sure that's a view based on ignorance; or rather, watching loads of fancy US hospital series like ER, Gray's Anatomy and House, which give very little attention to the problems of the US system.
I think it's almost inevitable that people will complain about their health service. Like a lot of public services you only come into contact with them when things are going wrong.
Kieran asked, "...do we need a radiologist to read a screening mammogram? Does reading a screening mammogram require a full medical degree plus specialisation as a rediologist?"
I agree that the answer is no. In pathology, cervical smears (PAP smears) are read by cytotechnologists (trained in a two-year degree program). PAP smears with abnormal findings, plus a random 10% of normal smears are read by a pathologist. This process lowers to overall cost of cervical smears and gives the pathologists time to perform other tasks such as examine surgical specimens, read surgical biopsies and fine needle aspirates, and oversee labs.
I recently called to schedule my yearly mammo and was told the first available appointment was not until the end of January. This is an unacceptable time frame to wait, but most especially when one lives in a huge metropolis, such as I, and is scheduling with a very large university-based hospital. My feelings go out to those who reside in rural areas and have an even much longer wait.
So what is the reimbursement for mammography, and how far is it from the market clearing rate?
In my area the professional fee (for reading, not for taking the x-ray itself) from Medicare is $31.90.
Remember this requires a physician with a 5 year fellowship and 1 year extra training in breast imaging.
Not to say its not a lot of money on an hourly basis -- but when the same person can be reading CT scans or MRIs, its not very much.
Just a datum.
At RSNA, in 1984 or '85, I recall Mike Moskowitz* calling for a flat $25 fee to read mammos. His position was that radiologists should consider it their moral duty to read them at cost.
The mutterings in the audience were instructive.
fusilier
James 2:24
* then Chief of Radiology at Cincinnati Brigham & Women's Hospital and a Personal Hero of mine
OK, thanks. A few other questions:
1) What does that work out to on an hourly basis?
2) What is the opportunity costs when weighed against the fee for a CT scan?
I'm not trying to lead anybody down a debate hole here. I'm just a bit of an economics wonk who finds this problem interesting.
Given what you just said, it seems to me that our problem is that the resources used to do highly profitable treatment (and I use "treatment" very broadly) are the same resources that are used to do relatively unprofitable (but arguably even more important--at least in the aggregate) screening. Letting the prices float to the market clearing price would make screening roughly as expensive as treatment and cause the number of screenings to drop massively (at least, if the difference between them is as large as I think you're saying it is).
So the question is, would letting the market clear produce an optimal health outcome overall? I suspect that the number of women getting mammograms put off by the 10-month wait would be smaller than the number of women put off by the price difference at the market clearing price. So are we better off letting the price jump, or are we better off looking at ways to decouple the two sets of prices?
I'm not a doctor, but if it can be done relatively safely, I like the idea of special screening technicians.
I just came across this and all I can really say is "Really?"
I live in downstate Illinois, the part that isn't Chicago, and women have been waiting 6 months or longer to get screening mammograms for several YEARS. I'm a radiology technologist, so I've seen it far too much for far too long. Furthermore, when I scheduled my annual screen with my gyn in October 2007, the earliest they could get me in was Jan. 2009. And it's not just my gyn, but everyone's. There is a healthcare crisis in this nation in so many ways.....
Last spring, when I asked to schedule my mammogram, the reply was "how about Wednesday?" which kind of surprised me. My patients get cranky if they have to wait a couple of weeks for a mammogram. Screening colonoscopies may take as long as 6 weeks. I wonder why the regional difference?
And, I would love to train to assist in any way I could. However, my facility isn't offering assistance for schooling at this time (or most other times). When you're making $40,000-$50,000 a year, with a mortgage and a family.....you get it.
That's funny because we live out in Chicago's west suburbs (Fox Valley Aurora/Elgin area) and my wife just had one done Thursday which she had scheduled but one week, week and a half earlier. Of course the potential times weren't great (7:30am or 6+pm), but it wasn't more than 2 weeks delay.
This illustrates something very important: The profit motive does not always lead to wise decisions or the best situation. Sometimes, the profit motive leads to an untenable situation or even a self-destructive situation. It is not perfect.
Personally, I am canadian. Our system is certainly not perfect, but I think it's a hell of a lot better than the american one. The numbers tell the tale: Canadians have better care, and pay less for it. The american healthcare system is one of the most(if not the most) expensive in the world, and ranks as fairly mediocre in quality.
Further, I cannot clear from my mind the cases I have seen in person. My father having a TIA, going to the hospital, spending the night, getting an MRI. Took an ambulance, too. He left without spending a penny. A fellow who worked at the welding trade school I attended had two stents. Easily more than 100k worth of work in the US, and he did not pay one cent either. Right now, I have a friend in the hospital for psychiatric problems. He will, as well, leave the hospital without having paid a penny.
Of course, the cost of this care is spread over a large area, and people who have never met them will pay for their care. This may seem unfair to those who are not used to it. Why should I, a healthy person, pay for the care of someone I don't even know? The answer is a simple, practical one: Because someday, you might get sick. When you do, you will be treated and cared for. You might not be able to work because of your sickness. You won't lose your house because of medical bills. You won't have to go through bankruptcy. You will not have to choose between your home, and your life.
Isn't that worth it? Isn't that worth the higher taxes? I can tell you my answer: Hell Yes.
"2) What is the opportunity costs when weighed against the fee for a CT scan?"
You would cause more cancer than you detected because of the much larger radiation dose (the radiation risk is one of the reasons mammograms are not offered to the under 50s in the UK) and you still need someone to interpret the CT.
Sorry above not exactly clear. You would cause some cancers on a population level by doing CT screening, more than with a mammo. But not more than you would detect. Still it is a much bigger radiation dose, with associated risks. Apologies for hyperbole.
I was actually thinking in terms of financial cost to a radiologist. The radiologist, when deciding whether to spend the next hour reading CT scans or mammograms, has to take the fees into account. What's the difference between the fees that causes the disincentive to read mammograms?
Right, with you now. Not really used to thinking of healthcare like that this side of the pond. I guess this illustrates the difficulty of running screening programs for profit.
I think there is research showing that women present later with breast cancer in the US than in Europe. Could this kind of thing be part of the reason for that?
Hey, instead of waiting ten months for a mammogram, women should find their cancers like I did: by feeling a lump in their breast themselves!
Of course, this wasn't because I had to wait, it was because my insurance company never pays for screening mamos under the age of 40, and with no family history, no one had ever suggested I have one anyway.
If your doctor knows that you'll have to wait ten months, why not set the appointment ten months before your due for your screening? Isn't there data that yearly screening might be overkill for the general population anyway?
Sorry, but as a woman diagnosed with BC in her 30s, I find it hard to get worked up over a 70 year old woman who gets screened every year having to face a delay of a few months. Are those few months really going to make a difference in her prognosis? Given that most of what's picked up is very early stage or non-invasive, is a few month delay really such a big deal?
I have Blue Cross PPO - a very good insurance supposedly. But I just decided not to ever have my yearly MRI again, even though my remaining breast is too dense to accurately screen with mammogram, because my copay is $3,500 and I can't afford it!
So I no longer have any screening, and I'm at high risk for recurrance. Sorry but a ten month delay for an accurate low cost screening modality sounds fine to me.
Kieran asked, "...do we need a radiologist to read a screening mammogram? Does reading a screening mammogram require a full medical degree plus specialisation as a rediologist?"
This idea has merit in a perfect world. However, we live in a world where the only way for a patient to seek redress when they perceive that have been wronged is for them to sue the physician. In a perfect world, if a patient was harmed from a mammographic miss, then they would be compensated without the need for a trial, lawyers, and recriminations all around. Even excellent Radiologists and all physicians will make errors.
However, we live in the United States. Miss a cancer (or miss something that at expert witness will say you "missed")and have your malpractice carrier pay up!!
So, since it costs about double (in malpractice) to read mammo where I live (read 15K-25K more/year)....see how many low cost readers without MD behind their name you can find to take ALL of the liability and for very little pay.
Good luck!
Since we
there is also a shortage of qualified biomedical equipment techs (the folks who maintain/repair the equipment)- especially in the midwest, from what i've heard.
what would happen if the equipment were to break down and a field rep had to come from the other end of the state? even more backlog for every hour the equipment is down.
wait a minute - just how is that any worse than the care i get here in the U.S., after paying all those insurance premiums lo these many years?
unless you mean, here in the U.S., the insurance company might decide to just flat out refuse to pay and dare me to sue them.
I'm still trying to dig into the numbers a bit. If I'm reading "double" correctly, that implies that the cost to carry insurance to read mammograms is as high as $50K per year in your area. Is that correct? What does that work out to per mammogram?