Ed Kouri, MD, (left) and Matt Gromet, JD, MD, take a closer look at a mammogram.

Breast cancer screening programs in hospitals and outpatient imaging centers are more often than not awash in a sea of red ink. On the one hand, they are forced to work within the framework of a federally mandated reimbursement schedule that has not kept pace with real world costs. And, on the other, they are being squeezed by the steadily rising cost of trying to maintain a quality mammography program featuring the gold standard for excellence: second reads. Not only does every new generation of hardware carry a higher price tag, but radiologists subspecializing in mammography are hard to find. Further, the salaries of competent technologists are soaring, and many want to avoid mammography because of its repetitive nature.

As a consequence, many health care facilities faced with the choice of having to lower their mammography standards or increase their investment in a losing department are ready to throw in the towel and opt out of early detection programs for breast cancer.

Proving an exception to the rule that mammography is a money loser is Charlotte Radiology, a professional practice with more than 50 radiologists serving a population of more than 1 million in the greater Charlotte, NC, metropolitan area.

Charlotte Radiology has developed an outpatient business model for mammography that takes it out of the mainstream and treats it as a discrete enterprise dedicated to providing a soup-to-nuts solution, from screening through core biopsies. Its model not only separates screening from diagnosis, it builds screening volume by encouraging patient self-referral, streamlines patient examinations and film reading, and keeps a tight rein on overhead. The practice, employing a total of 190 persons, currently operates seven outpatient breast cancer screening centers (an eighth will open in August) equipped with state-of-the-art low-dose mammography units, and four separate breast diagnostic centers equipped to perform a full range of comprehensive examinations, including stereotactic breast biopsies.

This year it expects to perform an estimated 50,000 screening examinations, and will double read every one of them to assure the highest possible level of accuracy and sensitivity. Its follow-up protocols assure extraordinarily high compliance among the 10% of patients it typically recalls for a diagnostic examination. The breast cancer diagnosis centers annually handle 10,000 to 15,000 procedures.

But perhaps the most startling aspect of this smoothly functioning business within a business is that it charges just $75 per screening examination, slightly above the $69 reimbursement figure approved by Medicare, and it is solidly in the black. One reason for that enviable status is that "we have made it clear to managed care plans that although they may discount other services, they cannot discount mammography," explains Matt Gromet, MD, JD, one of seven mammography subspecialists in the practice. "Fortunately, most plans have accepted our program."

Though reluctant to share exactly how much Charlotte Radiology makes doing breast screening, administrator Mark Jensen says: "Suffice it to say, we are making a profit in mammography. On screening we are able to make a profit because of the model we use and our ability to deal with volume. We open freestanding centers of 800 to 1,200 square feet in nonmedical concentrated suburban areas. There we pay substantially lower rents than we would in a hospital. Our direct expenses in a screening model-separated from diagnostic mammography-are a lot lower. Our indirect expenses also are low because of centralized scheduling, file storage, and interpretation. As a result, we can break even a lot lower than anybody else can break even.

"If we think we could initially attract 8 to 10 patients a day in a suburb or small town, we'll seriously look at opening an office," Jensen says. However, rising costs and low reimbursement are presenting challenges going forward. Several area hospitals have determined that they can no longer provide mammography service, and have worked with Charlotte Radiology to divert patients to outpatient facilities owned by the group but located on the hospital campuses.

Developed over 15 years

Charlotte Radiology, which also owns and operates a large outpatient MRI and diagnostic imaging center with four MRI and CT scanners, was founded in 1967 and is one of the largest radiology groups in the Southeast, performing some 500,000 procedures a year as a preferred provider for more than 20 insurance plans.The group not only provides exclusive radiology coverage at the Carolinas Medical Center, University Hospital, Mercy Hospital, and Mercy Hospital South, but also provides 24-hour coverage of outlying community hospital emergency departments by broadband teleradiology.

The practice started its breast screening program in 1985 and has had 15 years to hone it into a highly productive specialty. Over time it has developed a reputation in the community for fast, no-waiting patient examinations that typically take 10-15 minutes. It has cut costs by minimizing paperwork with preprinted forms, and by assigning helpers to the radiologists so they are able, in less than an hour, to review 45 to 50 patient screens, most accompanied by prior films. This is how Charlotte Radiology provides its quality service at minimal cost:

Marketing. Charlotte Radiology focuses on health fairs, referring physicians, churches, and community outreach to bring in new patients and build brand recognition. It sponsors breast cancer walks, works with the local chamber of commerce, and stays in touch with the media. It does no TV advertising.

The practice has an aggressive direct mail reminder program. Up to three reminder cards are mailed to past patients. "Sending out the second and third reminders has a significant compliance effect in getting the patients back in, and the cost is negligible," Jensen says.The group also aggressively surveys its patients. These surveys provide valuable feedback to enhance the patient-friendly atmosphere.

Scheduling. There is a central office and a single phone number for appointments. Central scheduling helps route patients to centers that have available capacity. There are no secretaries in the scanning centers. Most screening patients self-refer; a doctor's name is requested so he or she can be sent a report, but the majority of patients receive their mammogram without their physician's knowledge until they receive their report.

Procedures. Patient appointments are presented on a computer monitor in each office. Newer offices have a single, certified female technologist; larger, long-established offices have up to three. Each site has ample dressing rooms. Four films are taken of each patient, but those with implants get eight exposures. Typically the patients are in and out in less than 20 minutes; in the larger centers they can be moved through in 10 minutes. "We try to balance patient throughput and the patient's experience so they don't feel like they are being rushed through," Jensen says. Efforts have been made to minimize any paperwork and clerical duties.

A quality assurance specialist visits each center regularly to review testing of the daily and weekly film strips, and works with vendors to make sure quality is maintained.

Processing. Before the patient's examination, prior films are forwarded from the central file room to the screening center. The technologist reviews these films during the examination and compares them to the current film to make sure that they are obtaining the most complete and comprehensive image. After the examination, the prior and current films are sent to one of the central reading sites, where the latter are hung by a film hanger along with the priors in preparation for the radiologist interpretation.

If a patient is new, Charlotte Radiology goes to considerable length to obtain priors, including having a courier pick them up from other locations in the Charlotte area. For the first 4 months of 2001, the average daily number of breast cancer screening examinations was 188. When the program started with a single screening center in the mid80s, the goal was to build up to 40 examinations a day.

Reading Films. Private offices are leased by Charlotte Radiology where its radiologists can read screening mammograms without distractions. The protocol is for a helper to sit next to one of the practice's mammography-specialized radiologists-who function as first readers. The helper hangs the films on a multi-viewer, reads the name of the patient and pertinent demographic information to the radiologist, and does the clerical work. This enables the radiologist to spend 100% of his or her time looking at the film. "For most cases the radiologist can simply say one word-negative-and move to the next case," Gromet says. However, if the patient is recalled, the radiologist puts a finger on the film image where there is an abnormality, and the helper marks the location on a little diagram on the patient form.

After the films have been read and the paperwork organized by the helper, the whole process is repeated with a different radiologist. For the blind second reads, the group uses a broader pool of radiologists who maintain mammography credentials while subspecializing in other areas, Gromet explains.

The film and reports are returned to the file center. Using bar code technology, the forms are scanned and the negatives automatically generate "everything is fine" letters to patients and their physicians.

Recalls. The recall list is turned over to the schedulers who contact patients by phone. "Nobody likes to get what they consider bad news in a letter," Gromet explains. "And sending a recall letter does not necessarily get a patient back. She may decide to ignore it, or go directly to a surgeon, or go elsewhere. We try to not let anyone slip through the cracks. In a recent year we had 97% compliance with our patients who were asked to come back for additional work. If you decide you want to have a high compliance rate you have to invest in the resources."

Billing. This is handled in-house utilizing a software package from a vendor that also is assisting on scheduling and patient demographics.

Diligent Tracking of Results

To track the success of its double read program, Charlotte Radiology spends "a few dollars per mammogram" on outsourced data management. Its specially created program records the accuracy rates of both first and second readers. "With most commercial software, if a second reader finds a cancer missed by the first reader, both get credit for catching it," Gromet notes. "But with our software, if I call a case negative and a second reader sees something that turns out to be a cancer, I don't get credit for finding the cancer, I get recorded for missing a cancer, and the second reader alone gets credit for finding the cancer." Each radiologist gets an annual printout of all the cancers seen and missed.

"False negatives can occur anytime up to 1 year after the initial reading," Gromet explains. That means there is a time lag of about 18 months to complete an accurate annual audit. "Our 1998 sensitivity was 88%, which is pretty much the national average. However, that figure reflects the fact that we diligently search our tumor registry for false negatives and wait for a full year to expire before completing our audit. If a program is not able to spend the time and money to find all of its false negatives, then its sensitivity will be falsely elevated."

Gromet, who is also an attorney, believes double reads also provide some extra protection against malpractice suits. By missing fewer cancers, there are fewer potential plaintiffs, he notes. "If we are to be sued for missing a cancer, we could show our data, and point out the fact that the cancer was missed by two independent readers. We feel that would be a strong defense, showing that we have done everything that we could reasonably do."

Although it regularly looks at digital mammography and computer aided detection (CAD), Charlotte Radiology has no plans to change a successful business model at this time.

"We took another look at digital when the new reimbursement memorandum on digital came out late in 2000 increasing reimbursement by 50% for bilateral mammograms done digitally," Jensen says. "It just didn't make sense for us to jump in strictly for reimbursement reasons. Our physicians believe there are still questions about appropriateness from a medical perspective. We just didn't feel it was right for us at this time. Plus there are regulatory issue that need to be resolved."

"Not only does a digital mammograph cost 5 times as much as a conventional machine," Gromet adds, "but people who are using them are still printing out images on film because there are problems with image display and review that need further improvement."

Jensen believes that CAD could make more sense in a different market. "It may be appropriate in some rural areas where there is no ability to have two reads and it would improve the comfort level of radiologists without subspecialty expertise." But he points out there is nothing in the literature that would indicate that one radiologist and an expensive computer are better than two trained radiologists independently reading examinations.

DeXA Now Offered

While Charlotte Radiology continues to expand its freestanding breast cancer screening clinics in size and number, it also is starting to broaden its outpatient services by offering bone density measurements.

Now available at three sites, DEXA is a 15-20 minute screening procedure that requires a physician referral.

"Patients are requesting DEXA and the fact that they can have both examinations done at the same site in less than 1 hour is very attractive to them," Jensen says. "We can coordinate the schedules so they are done back to back."

Despite its success as a provider of cost-effective screening examinations, Charlotte Radiology expects its future profitability to be continually challenged by rising underlying costs, and the ability to find both qualified radiologists who specialize in mammography and technologists with a "patient service attitude," according to Jensen.

The practice is currently experimenting at one site with a senior technologist acting as a second reader. She was trained and certified following 6 months as a third reader to track her accuracy. "We think this approach will prove to be high-quality, cost-effective, and allow a more widespread adoption of double-reading in other practices," Gromet says.

There has been speculation about the Charlotte Radiology screening model being transitioned to other practices. "We are exploring how this model might be expanded or franchised," Jensen notes.

Gromet believes the Charlotte model could be transitioned to other outpatient radiology practices with freestanding imaging centers. "But we don't think it translates well to a hospital environment," he says. "We have found that for us an outpatient medical office model works well. The rents are not the same as in a hospital, the parking is convenient, and the patient can come in and out quickly. We control the staff. It is less bureaucratic.

"In a hospital environment the overhead is enormous. Those who have van programs generally speaking have higher overheads and a number of logistical problems. It is hard to maintain volume in a van after you have gone to your first 30 to 40 high volume sites. It is a rare van program that has the patient follow-up and compliance that it should, because it is very hard to keep track of patients when you are on the road all the time."

"We are very proud of what we have accomplished," Jensen says. "But we also were fortunate that in our community we started early in screening mammography, and have built a reputation so that we are able to leverage some of that volume to make a profit in today's environment."

Richard B. Elsberry is a contributing writer for Decisions in Imaging Economics.