How We Achieved Universal 3D Mammography Coverage in Hawaii — and How You Can, Too

GrosskreutzScott Grosskreutz, MD, diagnostic radiologist and president, Hawaii Radiological Society, contributed this post.

Hawaii’s small size and geographic isolation are part of the state’s charm, but these factors can contribute to slower adoption of newer technology such as digital breast tomosynthesis (DBT). In 2018, less than half of women in Hawaii were covered for DBT —the lowest rate of all 50 states. Our radiologists want to be able to provide the most accurate examination for all our patients, and DBT has been shown to improve breast cancer detection and decrease recall rates.

The Hawaii Radiological Society (HRS) introduced a bill into the state legislature last session, which would have mandated insurance coverage of tomosynthesis. Dr. Kelly Biggs, chair of the American College of Radiology® (ACR®) Breast Imaging Commission’s Government Relations subcommittee, provided supporting material, and Dr. Dana Smetherman, chair of the ACR Breast Imaging Commission, published a commentary with HRS president Dr. Elizabeth Ignacio in Hawaii’s largest newspaper advocating tomosynthesis.

With testimony from dozens of radiologists, patients and referring providers, the bill sailed through the House and Senate chambers on the first three readings without a single no vote, but was effectively tabled when the Conference Committee declined to convene. HRS

We immediately met with legislators who agreed to reintroduce the bill during the next session and reached out to medical directors of third party payers in Hawaii. Together, we established insurance coverage and convinced the state workers’ trust fund board to provide full DBT coverage – meaning that women in Hawaii will soon have 100% coverage for DBT. This universal coverage relieves mammography staff from the fiscal necessity of requesting copays from uninsured patients, enabling them to focus on patient care and productivity.

From our experience we offer the following suggestions:

1) Achieving coverage for DBT is a team effort. The ACR provides great resources and support, including access to experts who can help you develop your strategy for achieving coverage.

2) Share your local DBT experience. Straub Hospital in Honolulu provided a study of two-dimensional (2D) vs three-dimensional (3D) mammography. They found that DBT had almost double the cancer detection rate compared with 2D. What’s more, a large percent of women in Hawaii are of Asian ancestry, who tend to have the densest breast tissue of any ethnic group. It’s important that this demographic-specific information about the benefits of DBT in assessing women with dense breast was shared through our advocacy efforts.

3) If at first you don’t succeed, don’t give up! By immediately arranging sponsors for the bill’s reintroduction, we ensured public attention remained on the issue.

4) The medical directors working for insurance companies are our physician colleagues and share our concern for our patients. Their organizations focus on cost effectiveness and cost containment. We need to respect their concerns and be responsive to their questions. Developing a good working relationship ensures that your advocacy effort will have a fair hearing when future issues arise.

Nationally, 93% of women ages 40 to 74 have coverage for DBT, according to Truven Health Analytics. It’s time to make DBT 100% covered for all women in the US.


Coverage for tomosynthesis by state in 2018


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How Your ACR Board and Council Steering Committee Serve You

McGinty Hi RezGeraldine McGinty, MD, MBA, FACR, chair of the ACR Board of Chancellors, contributed this post.

Your American College of Radiology® (ACR®) Board of Chancellors and Council Steering Committee (CSC), as well as key ACR staff, convened last week to focus on the future of our profession. 700 pages of pre-reading ensured that participants came prepared to share their unique perspectives and experience.

Over four days, the group reviewed detailed financial statements and heard presentations on multiple important topics. Topics of discussion ranged from the impact of proposed changes to reimbursement for Evaluation and Management services that, in a budget neutral Medicare payment system, will result in a significant reduction in reimbursement for radiology and radiation oncology services, to the work that the Commission on Publications and Lifelong Learning is doing to enable evidence-based educational efforts across all the ACR’s work.

We engaged in a scenario planning exercise to prepare for a planned refresh of the ACR’s Strategic Plan in 2020. Scenario planning seeks to help organizations avoid “optimism bias” and become more adaptable in the face of an uncertain future. Potential threats and opportunities identified include innovations in drug and liquid biopsy development that might fundamentally impact the demand for imaging, and integrated diagnostics. The need for ACR to amplify its influence with stakeholders beyond those most familiar to us – like the Centers for Medicare and Medicaid Services and Congress – was also apparent. Importantly, scenario planning is not about trying to predict the future but rather to facilitate strategy that allows organizations to be successful whatever happens.

Time spent together in person for face to face interaction and relationship building is critically important to build trust so that we can undertake difficult decisions together as stewards of our organization. The conversations allow us to understand the diversity of our perspectives and practices.

The interactions between the Board and the CSC reinforce the power of our representative governance structure and enable more effective policy making. Dr. Traci Pritchard, attending her first leadership retreat as a member of the CSC, reflected that she felt proud to be part of a committed group of volunteer leaders that is dedicated to serving the membership and the profession. I could not agree more.

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Together, We Can Close the Gap to Breast Care Disparities

PatelAmyAmy K. Patel, MD, breast radiologist, Alliance Radiology, medical director, Liberty Hospital Women’s Imaging, assistant professor of radiology, University of Missouri-Kansas City School of Medicine, contributed this post.

At the Society of Breast Imaging Annual Meeting this year, breast radiologist expert Michael Linver, MD, FACR poignantly said something which I’ll never forget. We were discussing the topic in the general session about screening patients globally and the disparities that exist. He said, “Although these women do deserve access to mammography screening, what about women in our country who need access such as rural women? We need to be focusing on these women first.”

In many respects, I’ve made improving rural breast health my life mission. I’ve always been a staunch advocate for screening mammography and access, from lobbying on Capitol Hill to challenge U.S. Preventive Services Task Force (USPSTF) recommendations to helping craft legislation to ensure 2D and 3D mammography coverage for women beginning at age 40, to speaking at women’s health events, radio ads, television interviews and public events. In fact, I use social media as a means to disseminate critical screening information to a wide spread of rural patients.

The facts are startling, and frankly disappointing, in the state of Missouri. A study of 28, 536 cases of female breast cancer from 2003-2008 reported to the Missouri Cancer Registry and Research Center demonstrated that women diagnosed with breast cancer living in rural areas, regardless of race, with limited access to care, were more likely to be diagnosed with late-stage breast cancer, with the proportion greatest in African American women (66.7%) (1).

Unfortunately, this is not just exclusive to Missouri, as many states’ rural populations face similar disparities.

I fervently believe we need to take it one step further by committing to improving the quality of care in disparate areas. We need to provide support to technologists at these rural hospitals, from educating the technologists ourselves to ensuring they receive the state-of-the-art equipment they need to advocate support for hospital funding for refresher courses, yearly positioning training and more. These are critical ways which will contribute to closing the gap to health care disparities and improving imaging and access in this country.

As a breast imaging community, it’s simply our duty that we reach these communities and make a concerted effort to close the gap to breast care disparities. We must mobilize and make this population a steadfast priority, regardless of geographic location.

1. Williams F, et al. Rural-urban difference in female breast cancer diagnosis in Missouri. Rural Remote Health. 2015 Jul-Sep; 15(3):3063.

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