**[Suggested Comment Letter: Please Place on Your Practice's
Letterhead]{.underline}**

August 14, 2008

Kerry Weems, Acting Administrator

Centers for Medicare and Medicaid Services

Department of Health and Human Services

Room 445-G

Hubert H. Humphrey Building

200 Independence Avenue, S.W.

Washington, D.C. 20201

**Re: Medicare Program; Revisions to Payment Policies Under the
Physician Fee Schedule and Other Revisions to Part B for CY 2009;
\[CMS-1403-P\]**

Dear Acting Administrator Weems,

I am writing as a practicing breast surgeon at University of
Massachusetts in Worcester, to comment on CMS' proposed rule for
physician payment for 2009. I am a part of a University based
Comprehensive Breast Center and run a robust office based ultrasound
facility for our patients. We work in close collaboration with our
radiologists to provide the most efficient care to our patients while
focusing on minimizing patient inconvenience and anxiety. **Most
importantly, surgeons have used ultrasounds to enhance the outcomes of
surgical procedures in the operating rooms and I have reported these
data during past few years. The role of surgical office based breast
ultrasound is clearly pivotal in quality care for our patients. I
believe very strongly that any step that compromises this approach would
be a detriment to quality patient care.**

On average, I see approximately 300 Medicare beneficiaries a month to
diagnose or manage their breast disease. I am concerned about the
proposal to require physicians to enroll as IDTFs in order to provide
diagnostic testing services. This would require me to enroll as an IDTF
in order to continue to diagnose and manage my patients using
ultrasound.

In my breast surgical practice, ultrasound is deeply integrated into the
care that I provide my patients. I operate the equipment myself to make
immediate patient management decisions and to guide minimally invasive
diagnostic and therapeutic procedures.

IDTF regulations require the presence of a "supervising physician" and
it is my understanding that, under local carriers policies, I may not
qualify as a "supervising physician". This would mean that I would have
to hire a radiologist to supervise my use of breast ultrasound in my own
office. It is extremely unlikely that I would even be able to find a
radiologist willing to assume such a position. This requirement is
unnecessary. I have the training and expertise needed to supervise these
studies by virtue of subspecialty fellowship training with specific
focus on image guidance, several CME courses and certification through
the American Society of Breast Surgeons. I am also on National
Ultrasound faculty for training other physicians in the skill. I perform
approx. 800 breast ultrasounds (including diagnostic and
interventional).

Our institute is already facing great difficulty to have adequate
radiology support in breast imaging within the department of radiology;
it would impossible for them to supervise the surgical facility.

My primary concern is that the expense and administrative burden of
hiring another "supervising physician," as well as the additional
unwarranted burdens imposed under the IDTF regulations, may force me to
forego performing ultrasound in my practice. This would deny my patients
the full benefits of a technology that not only decreases the costs of
caring for women with suspected breast pathology but results in fewer
invasive procedures. There is a significant difference between
performing a real-time ultrasound evaluation in conjunction with my
physical examination of the patient and sending the patient out for an
ultrasound examination by others. In many cases in which I have
identified an area of concern in my patient, I would be reluctant to
rely on a report and static images from an outside imaging facility to
rule out the need for a surgical biopsy. I am concerned that my
inability to perform ultrasound evaluations in real time will result in
my performing more open surgical biopsies.

Imposing IDTF requirements on my practice will not improve the quality
of healthcare or decrease costs, and it will be detrimental to my
patients. I urge CMS to withdraw the proposal and to refrain from any
proposal that would subject breast surgeons to IDTF regulations in order
to diagnose and manage their patients using ultrasound.

I greatly appreciate the opportunity to submit these comments. Please do
not hesitate to contact me at 508-334-5086 with questions or if I can
provide you with additional information.

Sincerely,

Rakhshanda Layeequr Rahman, MD

Div. Surgical Oncology

UMass Memorial Health Care