Standing, from left, Marcela Bohm-Velez, MD, Mary Lou Bradley, and (seated) Barbara Weinstein, MD, Weinstein Imaging Associates, Shadyside, Pa.

Breast imaging facilities are closing down by the hundreds due to inadequate reimbursement, the number of physicians choosing mammography as a specialty is dropping dramatically, and the shortage of qualified mammographers is a rising problem nationwide.1 Yet there are practices that have persevered in this subspecialty and even have made it something of a crusade. At Weinstein Imaging Associates, in Pittsburgh, vice-president Marcela Bohm-Velez, MD, explains: "Every mammogram is a patient."

The practice concentrated solely on diagnostic ultrasound when it opened the doors of its first location in 1980. As the overwhelming majority of the practice's patients were female, adding mammography was only natural over time. In the 1990s, bone densitometry was added as well, and those are still the only three modalities offered at the clinic. The clientele has remained largely female, with fewer than 1% of patients being male.

"We certainly don't bar men from coming in the door, but almost all of our patients are women," says president Barbara Weinstein, MD, FACR, who has been with the practice 13 years. "Obviously, if we are focusing on women, we are excluding a good portion of the population as potential customers, but there truly is a need for these resources for women."

There is also a need for mammography-friendly practices, according to Bohm-Velez. "There are so many issues that are not being addressed by other radiologists in this realm because either they are not interested or they are too busy," Bohm-Velez says. "In most practices, those doing mammography are treated like second-class citizens. Our practice is an exception."

Today, fully half of Weinstein Imaging Associates' business is in providing mammograms. Dual energy x-ray absorptiometry (DEXA), which has grown significantly in the past 2 years, contributes another 10%, and another 30% is in ultrasound or 3D ultrasound. A few interventional procedures, such as ultrasound-guided or stereotactic needle core biopsies, sonohysterograms, transvaginal cyst aspirations, and occasional fine-needle aspirations of the thyroid have been added over time to help offset the problems with mammography reimbursement.

"In adding such services, we wanted to accommodate the patient and diversify ourselves at the same time," says business manager Mary Lou Bradley, who has been with Weinstein Imaging Associates for 22 years. "Doing stereotactic biopsies has helped our business a lot. Bone densitometry is another modality important to our patients because of concerns about osteoporosis."

Weinstein Imaging Associates serves its clients out of three offices: in North Hills, South Hills, and Shadyside, Pa. All offer the same modalities, although the North Hills office also does general x-ray. South Hills is the busiest facility because of its location in a suburban area, and the staff there sees roughly 22,500 patients per year, according to Bradley. Another 12,500 patients are seen in the Oakland office and 10,000 are seen in North Hills. There are four board-certified radiologists on staff, as well as nine mammography technologists and nine ultrasound technologists.

"We don't discriminate, but many of our patients like having a woman doctor," Weinstein says of the decision to have mostly female practitioners on staff. Only one of the staff radiologists is a man. "However, none of us are prima donnas, so if a patient wants a particular staff member to work on their case, that's good. It means the patient has bonded with someone in our practice."

A Patient-focused Practice

The bond that women make with their health care practitioners attracts referrals and thereby helps the practice remain successful, even in the face of dwindling reimbursement and fewer radiologists offering such services.

"Quality and service are our missions, and we have built our reputation on the service we give," Weinstein says. "Here in our private office, the whole family can come in to view a fetal ultrasound, for example, and not upset anything in the practice. The office is geared toward that level of comfort."

The practice is very conscious of its patients' time constraints, and will add people into the schedule at a moment's notice as well as provide services on Saturdays. Weinstein is also careful to have only subspecialists in women's imaging on staff, so that the results are always top quality.

"I find that if we are correct in our interpretation, patients will use us again," Weinstein continues. "For a long time, radiologists were considered these mysterious people who sat in the dark and never talked to people. But here we have always given patients the time of day. We discuss results, we answer questions. Doctors and patients both love that aspect of the work."

Today, if the ultrasound determines that there is a problem with a pregnancy, for example, Weinstein says her staff members are able to explain the situation to the patient and alleviate some of the primary practitioner's load. Patients also are given their imaging results instantly, and that helps out the physicians as well.

"The things we offer here are so different from going to a hospital where the patient has to sit in a cold, dingy hall," Bradley says. "That is very impersonal, whereas we have a nice atmosphere that is warm and comfortable for the patient. As a result, we've kept a majority of the patients who have come here. The only time people jump ship is when we are not part of their insurance plan."

Due to its strong patient-physician relationships, Weinstein Imaging Associates has never perceived a need to spend money on advertising and marketing, relying on its satisfied customer base for referrals. In the next 6 months, the practice does have plans to get a Web site up, but the focus of the site will be on education.

The Crusade

"Education has made women aware of the value of this modality," Weinstein says. "The market wants more, but because the reimbursements are low, those in training are avoiding mammography as a subspecialty because they hear the rumors that it is a losing proposition. Thus, there is a shortage of radiologists doing mammography.

"Likewise, those who run the hospitals see that reimbursements are down and they are not interested in buying more equipment or hiring more technologists and doctors to accommodate the patients," Weinstein says. "This is a huge problem."

"It is sad that not that many radiologists are involved in women's issues, and there are not going to be a lot going into it in the future as long as reimbursement remains as bad as it is," agrees Bohm-Velez, who also serves as a clinical assistant professor at the nearby University of Pittsburgh. "Those leaving their residencies are going into MRI and interventional radiology because that brings in the money. Mammography and ultrasound do not.

"Every day a breast center is closing in the United States," Bohm-Velez continues. "Sure, some places are doing well, but in many of those locations you must pay cash or use a credit card prior to receiving service. Pittsburgh is blue-collar, and this clientele is used to dealing with insurance companies. They will not pay out-of-pocket for a mammogram, and a lot of the country is like that."

In the long run, Bohm-Velez maintains that practices such as Weinstein Imaging Associates will continue to flourish only if women demand that insurance companies increase payments.

"Most breast centers simply can't make it at the current reimbursement level," Weinstein adds. "Reimbursement has continued to go down and if that is what practices are relying on, they can't possibly succeed. Pennsylvania is particularly bad. Within this state, mammography is simply not a financially worthwhile venture.

"Of course, our government doesn't help us by having Medicare reduce reimbursements," she continues. "When there is not another area in the practice making money to even it out, as in a dedicated private practice, then that is especially difficult."

Some practices have elected to continue offering mammography through a joint venture with a hospital, but that is not an option for this fiercely independent practice.

"I have observed compatriots in other fields being bought out by hospitals and insurance companies and I don't know a one who said, 'This is great, I'm glad I did it,'" Weinstein says. "To me, selling out to another company means you lose control of your practice, and I don't want to do that. Another entity can come in and tell us we need to cut costs by using cheap equipment and labor, and it doesn't understand that that is not to be tolerated. We can't lose control. If we do, we can't practice the way we want to. Even though we haven't had business school training, we know what works and what doesn't."

Try Before Buy

Weinstein Imaging Associates thus has been forced over time to make subtle changes to add efficiency to the practice, and is cautious about adding modalities until the value equals the investment.

"We have delayed buying equipment as long as possible, we have lots of loans at the bank, and we are moving into smaller quarters for one of our offices," Weinstein says. "We always try to negotiate the best deal, and constantly look for ways to cut costs without cutting quality. We will not compromise on that aspect. The partners in this practice all agree that when we are so bare bones we need to cut quality, that's when we will close our doors instead."

"I wanted to do stereotactic biopsies right away when I joined the practice 2 years ago, but the reimbursement was so low we would have lost an enormous amount of money," says Bohm-Velez. "In a hospital you can do that and write it off, but it was not the time for us. A year later, however, the reimbursement rules changed and that procedure became profitable for us. We continuously have to see what the reimbursement is and whether we can afford to offer something."

When adding new technology, such as bone densitometry and stereotactic core biopsy, the practice first rents the necessary equipment in order to determine what the market will bear before making a permanent investment.

"We try before we buy, so we can figure out what our break-even point will be," Weinstein says. "Once our case load meets that break-even point, we will buy the equipment. We follow the same procedure for our second facility, then buy it outright for the third because by then we are aware that it is a good investment.

"For the stereotactic core biopsy equipment, obviously we knew we would not do a lot of them. That equipment also is very expensive, and it ties up a room, so we could not justify purchasing it for a long time," Weinstein says. "Then we found a rental company to work with us, and that is what we are doing now. While this is not a big moneymaker, we feel we should do it, and we are more than breaking even on it."

Finding Efficiencies

Maintaining the fiscal solvency of a practice half of whose business is in breast imaging has therefore been a challenge for Weinstein Imaging Associates, to say the least. However, Weinstein says that every time managed care nips away at the practice, it manages to rise to the occasion.

"We have made lots of changes in minor things," Weinstein says. "We created our own database program to do our reports, which added efficiency to our practice. Likewise, our ultrasound patients used to change into gowns, something we recognize as a time-waster. Most patients can cover their clothing with a towel and that reduces the overall appointment time each patient needs. That in turn allows us to see more patients, and to take the equipment we have and get more mileage out of it."

The practice always aims to maximize utilization of its equipment and its staff. Weinstein Imaging Associates also handles its own business needs, and places a priority on having well-informed people to deal with its billing. What has been the biggest challenge in this environment is the fact that sometimes the practice is forced to make tough decisions, such as whether to foot the bill for a procedure or turn a patient away. For example, Weinstein notes that some insurance companies will not pay for two related procedures in the same day, such as a pelvic examination and a transvaginal examination. If a patient comes in for a pelvic ultrasound and there is something on the image that necessitates a transvaginal examination, Weinstein says the practice has two options.

"We can wind up doing it at no cost on that same day for the patient's convenience or we can tell the patient they must come back tomorrow," she says. "I have no idea what this thinking is on the pelvic and transvaginal examinations, but I believe it is to discourage us from doing them. But if an 82-year-old woman comes in with a mass, we would do the second examination for free because it's frankly too cruel to ask her to come back a second day."

Erring on the Side of Caution

Though the practice does keep on top of the latest modalities for its patients' sake, Weinstein Imaging Associates would prefer to err on the conservative side. For example, the practice determined that it is not yet cost-effective to add MRI, a computer-aided detection system (CAD), or digital mammography to the practice, and though doing a second read of mammograms is "the ideal," according to Bohm-Velez, the practice simply cannot afford to do that at this stage either.

"Digital mammography in particular has not proven to be better than conventional mammography, though I think it will down the line," Bohm-Velez believes. "When it does, we will definitely consider it. And while it is fun to play with CAD, the truth is, it is not to the point that it should be before we're ready to add it to our modalities. There needs to be more investigation, and more research centers devoted to it."

The practice's biggest challenge by far has been dealing with all the changes to managed care. "We've had to learn how to bob and weave and survive those changes," Weinstein says. "It's a game, and we have to play it with them to survive. Our victory is being able to compete with the big hospitals successfully. In the mid 1990s, everyone told us to get out of the business. They said we would fold in 5 years, but it has been more than 5 years and we have started a new office and are expanding. A few years ago, in fact, the Allegheny Health System in Pennsylvania went bankrupt, but we are still standing.

"We are very proud of the fact that we had the chutzpah to go against the grain and not compromise our quality and service," Weinstein continues. "This type of care is our product and we are not straying from it, and that fact alone has kept us alive and proud of what we are doing."

Elizabeth Finch is a contributing writer for Decisions in Imaging Economics

References:

1. RSNA spearheads push to make mammography more accessible. RSNA News. May 2001. Available at: http://www.rsna.org/publications/rsnanews/may01/mammography.html. Accessed January 24, 2002.