While we tend to focus on the Washington D.C. legislative scene, many significant initiatives are generated at the state level. In the past few years, popular legislation mandating notification of high breast density in mammography reports has been passed in many states. The impetus is the premise that patients with greater breast density are at higher risk for breast cancer and/or mammography is not as effective in this population. Opponents argue that:
- Such legislation is often an unfunded mandate;
- The mandate puts the referring physician and patient in a difficult position by suggesting additional and often expensive ancillary studies;
- It is inappropriate for governments to arbitrarily regulate how doctors practice medicine.
To date, 19 states have enacted laws that require breast density notification or breast density disclosure. They include: Alabama, Arizona, California, Connecticut, Hawaii, Maryland, Massachusetts, Minnesota, Missouri, North Carolina, New Jersey, Nevada, New York, Oregon, Pennsylvania, Rhode Island, Tennessee, Texas and Virginia. Reviewing the implementations in different states is instructive in illustrating how various jurisdictions prioritize similar issues.
In some states, the legislation includes language which must be inserted into mammography reports. Working with the state medical association, the Arizona Radiological Society was able to modify onerous language that was originally proposed the bill was signed into law. In Utah, the notification is optional. Illinois legislation mandates that insurance carriers reimburse for subsequent ultrasound screening when recommended by a physician. In Maine, legislation was avoided when the physician community voluntarily agreed to include breast density language in mammography reports. Indiana legislation mandates the state health plan to provide coverage for additional exams for women greater than 40 years old who have high breast density. Missouri was the latest state to pass legislation with Governor Jay Nixon signing the bill on July 2.
The momentum in the states has set the stage for possible “dense” federal legislation. Whether you are for or against the concept of “dense” notification, the take home message is that radiologists need to be active at all levels of advocacy: local, state and federal.
Howard B. Fleishon, MD, MMM, FACR