Robert J. Pizzutiello, Jr, MS

Although most imaging providers considering the acquisition of a new technology conduct some kind of evaluation, their assessment process may be less than adequate unless it involves the radiologists, technologists, information specialists, and office staff who will provide the proposed new service. Without the input and expertise of those in the best position to assess the impact of a new technology, any evaluation of its probable value may be less comprehensive and, ultimately, less helpful.

Facilities investigating conversion from screen-film mammography (SFM) to full-field digital mammography (FFDM) can benefit greatly from a team approach to technology assessment, not only because the breadth of available knowledge will make the evaluation more reliable, but because the teamwork involved in preparing a thorough assessment can carry over into the project's implementation phase, enhancing the ultimate chances of success. In itself, the act of reaching consensus by considering several perspectives simultaneously can increase the team's commitment to the project's success.

TEAM COMPOSITION

A multidisciplinary team should be assembled to evaluate the prospect of changing from SFM to FFDM. Whether the facility is a practice devoted solely to breast imaging or is part of a larger freestanding imaging center or hospital radiology department, the first step in technology assessment is the creation of a team having the broadest possible expertise.

The team should include one or more radiologists, whose role will be to evaluate the clinical impact of FFDM and its probable effects on workflow. A mammography technologist holding a supervisory or senior post will be responsible, as a member of the team, for tracking patient movement through a hypothetical FFDM visit. The technologist will also assess any FFDM-related changes in workflow and technologists' duties that can be expected.

The team's medical physicist will be responsible for the evaluation of the available FFDM technologies, with particular emphasis on image-receptor types, image quality, and radiation dose. The optimal arrangement of film and digital image viewers may also be the responsibility of this team member. It will be especially important to keep ambient light low and to reduce glare. The room's layout may need especially careful attention since both conventional filmboxes and computers other than those used to interpret FFDM images may very likely be used in the same space.

An information-technology specialist should be part of the team, whether this person represents an in-house information department or is retained as an outside consultant. This individual will assess the facility's readiness for FFDM, in network and other information infrastructure terms. FFDM-related picture archiving and communications system (PACS) connectivity, data transfer, and information storage should also be evaluated by the information specialist.

The finance department should be represented by a team member who will assess the capital outlay and ongoing operational and maintenance costs required for conversion from SFM to FFDM. The finance team members should also study the effect of the new technology on revenues, since the ultimate financial success (or failure) of FFDM will be dependent on the balance between income and costs. Likewise, a team member representing the office staff should apply his or her expertise to evaluating the impact of FFDM on patient parking and waiting areas, report turnaround and flow, and patient scheduling.

If the institution is large, a team member from the organization's purchasing department should assist by carefully reviewing proposed contract terms that assure the desired performance outcomes. Other consultants to the evaluation team can include, as appropriate, manufacturer's representatives from the vendors of the FFDM systems under consideration, of laser printers, of PACS, and of other technologies, as needed.

The assembled team should begin its investigation by clarifying the facility's reasons for pursuing FFDM. A list of potential problems (changes) created by SFM technology should be created, as well as a list of benefits expected from FFDM. These lists should concentrate on limitations and advantages in clinical, regulatory, technical, financial, and operational areas. When complete, these lists will provide a structure that allows the team to fill in the necessary blanks while investigating the new technology. Sources of information that may prove useful during this phase of data collection are the Web sites of vendors and academic departments, manufacturers' representatives, meetings and educational courses offered by professional societies, and articles in the medical literature.

COST JUSTIFICATION

Given the challenges faced by mammography providers, profitability is never guaranteed, and many imaging facilities that offer SFM find themselves hovering on the edge of financial losses. This, of course, may lead such institutions to wonder how they could possibly afford to institute FFDM service, given the fact that the initial per-unit cost of equipment acquisition may exceed that for SFM by a factor of three or four. An objective review of the financial aspects of FFDM ownership, conducted so as to minimize the influence of simple desire for the new technology, is in order.

Contacting FFDM vendors is helpful in beginning this financial analysis. They can provide valuable assistance because the development and marketing of FFDM systems have allowed them to gather information from other buyers that may not be available elsewhere. They are, of course, in the business of promoting FFDM sales, but given their bias, their expertise is useful. By applying critical thinking to the evaluation of a vendor's claims, the buyer can verify the assumptions of the manufacturer's analysis. This step, in which the buyer adjusts the vendor's projections to produce realistic estimates based on its own experience, can clarify the financial outcome that the individual practice should expect.

It is certainly encouraging to note that FFDM reimbursement under the Medicare program can be 50% greater than SFM reimbursement, although there may be regional variations in total reimbursement levels. The financial feasibility of FFDM should not be assessed on this basis alone, however.

The table above shows the type of financial analysis that an FFDM vendor might provide to a potential buyer. This analysis assumes that 8,000 mammograms per year will be performed (at a rate of four cases per hour for 250 working days per year). An average Medicare reimbursement of $95 per SFM case is also assumed. Given these assumptions, the gross revenue per year for SFM would be $646,000. For the same set of assumptions, the gross revenue for FFDM with computer-aided diagnosis (CAD) would be $1.07 million; this calculation is based on a 1.5 relative reimbursement factor for FFDM and an additional $15 reimbursement per case for CAD.

Cost analysis involves other factors, of course. The table's example assumes a cost of $5 per SFM patient for film, reducing revenue by $40,000. The capital costs are presumed to be $150,000 for CAD and $400,000 for FFDM, with all equipment amortized over a period of 5 years (at $110,000 per year).

Determining roughly how much the facility in this example could earn by converting from SFM to FFDM involves subtracting the net annual revenue for SFM from the annual income from FFDM with CAD. This yields a difference of $465,000 per year, from which the annual amortized equipment cost of $110,000 is subtracted to yield $355,000 in additional net income. After 5 years, the initial equipment cost for FFDM plus CAD will have been recovered fully. An additional profit of $1.78 million will have been generated.

Naturally, there are several other factors that do not appear in a relatively simple analysis of this kind. Nonetheless, they should be part of a thorough financial evaluation of FFDM. These factors include the mix of screening versus diagnostic studies, reimbursement levels from payors outside Medicare (and the relevant payor mix), debt-service costs, and the expenses associated with equipment service (contractual or otherwise) for SFM and FFDM. Likewise, potential buyers should consider the savings to be gained by eliminating wet film processing, along with the associated costs of capital equipment, supplies, equipment service, and chemical use and disposal. The more a vendor's analysis can be expanded to suit a facility's situation, the more likely it is to predict the financial consequences of implementing FFDM accurately.

It also should be noted that the foregoing example is very conservative in estimating patient throughput at four cases per hour. A 1995 workflow study¹ found FFDM to take an average of 8.5 minutes per patient and SFM to take an average of 12.9 minutes for the same mix of screening and diagnostic procedures. This represents a 34% reduction in examination time for FFDM.

CONCLUSION

It is possible that today's financial climate may cause existing SFM systems to be perceived as too expensive to maintain. An SFM unit is definitely among the least costly pieces of capital equipment in an imaging center, but the reimbursements that accrue to its use are low. The cost of delivering mammography services using SFM may be large by comparison, especially when radiologist and staff productivity levels are taken into account. Any consideration of FFDM acquisition should evaluate the time spent, using SFM, for the technologist to obtain the images, for the support staff to file and keep track of the resulting films, and for the radiologist to interpret the study. In addition to the film and processing costs already analyzed, the wet processor needed for SFM requires space (which may be more or less valuable according to the facility's age and location, but should always be a component of cost analysis). FFDM, evaluated in this light, will probably be expected to increase productivity, possibly reduce expenses, or both.

The imaging facility that fails to form an assessment team to consider a new technology is at the same disadvantage as the center or practice that does not bother to conduct a detailed investigation of a proposed purchase. While happy accidents sometimes occur (where the right technology is acquired for the wrong reasons), more commonly mistakes and disappointments happen that could have been avoided. In pursuing change, radiology providers can obtain poor results if they fail to consider the full impact of that change across the enterprise. Likewise, mistakes can be made when a mammography service is expected to adopt solutions that work in general radiology, with no adaptation for the unique circumstances of mammography. Personal relationships, internal political considerations, external pressures, and capital costs are also likely to drive bad decisions if they are considered in isolation. The optimal change process, instead, relies on a fully informed multidisciplinary team that conducts a thorough technology assessment.

Robert J. Pizzutiello, Jr, MS, is president, Upstate Medical Physics, Victor, NY.

References:

1. Rothenberg LN, Haus AG. Physicists in mammography - a historical perspective. Med Phys. 1995;22:1923-1924.