The breast imaging center. Successful management in today's environment.

Radiologists who specialize in breast cancer detection have been buffeted by the many changes that are taking place in the medical field. Twenty-five years ago, the radiologist's sole contribution to the diagnosis of breast cancer consisted of interpreting mammograms. Since that time, however, increasing numbers of radiologists have developed expertise in the clinical evaluation of patients with breast problems and have used ancillary imaging and diagnostic tests, most notably ductography, ultrasonography, fine-needle aspiration cytology (FNAC), and large-core needle biopsies (NB). Radiologists using these procedures are more efficient than surgeons in establishing the diagnosis of breast carcinoma. Expert use of these ancillary procedures results in a more cost-effective diagnosis of breast carcinoma without delay in diagnosis, 1,3,4,5,6,9 but several problems have emerged as this metamorphosis has taken place. First, radiologists now evaluating patients who have aberrations on screening mammograms and patients with clinical breast problems are devoting a significant amount of additional time with patients, beyond the time used for the ancillary diagnostic procedures. This additional time is necessary, not only to obtain a pertinent breast history and perform a clinical examination on the patient, but also to counsel the patient after a diagnosis has been rendered following FNAC and NB. At the same time, reimbursements for screening mammograms and ancillary diagnostic procedures have considerably decreased. For example, Medicare reimbursement for a screening mammogram decreased from $79.08 in 1990 to $66.22 in 1999, and the reimbursement for breast ultrasound decreased from $94.55 in 1990 to $65.07 in 1999. Furthermore, health maintenance organization (HMO) and fee-for-service reimbursements have also decreased because their reimbursements tend to vary in tandem with those of Medicare. Although the radiologic diagnosis of breast carcinoma is resulting in fewer unnecessary open-surgical biopsies (OSBs) for women, many radiology departments are discovering that the financial reimbursements for the procedures are insufficient to support the radiologists in their expanded diagnostic and consultant role. Breast diagnostic clinics must operate as efficiently as possible to minimize the overhead costs. In addition, radiologists must convince health carriers that increased reimbursement is necessary to support the increased radiologists' endeavors. Second, there has been a decrease in the number of fellowships in mammography training throughout the country, primarily because most mammography centers cannot afford to subsidize these fellowships because of the progressively decreasing Medicare and HMO reimbursements and because there is no federal support for these fellowships. Nationally, mammography fellowships have decreased from 76 in 1994 to 57 in 1999 (Barbara Monsees, MD, personal communication, August 1999). At the same time, HMOs are rewarding primary care physicians for encouraging patient compliance for mammography. As a result, mammographers are seeing increasing numbers of patients, but are finding themselves in competition with other institutions in recruiting the few radiologists who have had mammography fellowship training. This article describes the operation and procedures performed by a large breast clinic in upstate New York, The Elizabeth Wende Breast Clinic (EWBC), which has been continually modified to adapt to the radiologist's expanding role in breast cancer diagnosis. Because the radiologists' salaries are greater than those of the remaining employees, all of the physicians' duties have been carefully scrutinized. Those activities that do not need to be performed by physicians have been delegated to assistants who are not physicians. This allows the radiologists to evaluate more patients. Since the inception of this clinic in 1976, all screening and diagnostic patients have been evaluated on-line and all results have been given to the patients on the day of their visit, or within 24 hours (NB results). The patients greatly appreciate receiving the results as soon as possible. Furthermore, this method is much more efficient and less expensive than recalling patients to return for additional procedures after an initial mammogram. The radiologists expend the same amount of energy, whether they interpret the mammograms on-line or batch interpret them at another time. EWBC evaluated 60,417 patients in 1998, an average of 240 patients per day. A schematic diagram of the 25,000 square foot clinic is shown in Figure 1. In 1998, there were 45,927 screening mammograms, 7308 (16%) of which were converted to diagnostic screening mammograms because of additional mammographic views. Of these 7308 women, 5380 were considered to be normal after these additional views and were told to return in 1 year for a routine mammogram. A total of 1840 ultrasound procedures, 252 cyst aspirations, 290 FNACs, and 693 NBs were performed on the remaining 1928 (4% of all screening patients) of these 7308 women, resulting in a diagnosis of 582 benign conditions (528 NBs only, 22 OSBs only, 32 NBs and OSBs) and 342 cancers. There were 13,003 patients seen for clinical abnormalities and 1487 patients seen for second opinion. The radiologists performed a total of 11,479 ultrasound procedures, 1323 cyst aspirations, 2218 FNACs, and 857 NBs on these patients. There were 471 benign lesions (361 NBs only, 98 OSBs only, 12 NBs and OSBs) and 208 cancers diagnosed in these women. These ancillary procedures were cost-effective, because in 1995 our clinic recommended only 1.5 OSBs for each diagnosed breast cancer, whereas the remainder of the city of Rochester performed four OSBs for each diagnosed breast cancer. The clinic's cancelled OSBs resulted in a $1,200,000 reduction in medical costs for the health care system. 6 Five full-time radiologists and 70 full-time employees are employed by the clinic (Table 1). Most of the office workers are cross-trained in several additional areas of expertise so they can temporarily replace those who are vacationing or who are ill. Cross-training also prevents employees from burnout from performing the same tasks every day. Many efforts have been expended to maintain high employee morale, such as flexible working hours and a retirement plan. Employees are encouraged to make recommendations for office improvements. Morale is also enhanced by the excellent relationship between the radiologist, the radiology technologists, 2 and other office employees. Eight screening patients and two patients with problems are scheduled every 15 minutes from 7:30 am to 2:30 pm. From 2:30 pm to 4:00 pm, eight screening patients are scheduled every 15 minutes. Only rarely are patients with problems seen after 2:30 pm because it sometimes takes as many as 2 to 3 hours to schedule and perform procedures on patients who have clinical problems or who are being seen for second opinions. Because patients and their referring physicians greatly appreciate timely service, 10 emergency slots are available each day for patients who wish to be seen immediately for a new clinical problem or a second opinion. Each patient (except for a patient whose appointment is made at the last moment) is mailed the following information: a map showing the clinic's location, billing information forms to be filled out in advance, and a 20-page information booklet 7 that explains breast self-examination and answers many questions about the office procedures. This reduces the number of questions that the patients ask at the time of the office visit. When screening appointments are made, every effort is made to determine whether the patient has a clinical problem. The patient is also asked if she has a clinical problem when she enters the office, when she is escorted by a receptionist to the changing area, by the technologist who performs her mammogram, and by the secretary who gives her the results. One of the major problems in operating a clinic of this size occurs when a patient who has had a screening mammogram admits that she has a palpable mass when her results are given to her. This disrupts the schedule, because she then becomes an additional patient who needs to be seen by the radiologist. Patients are escorted from the main waiting room to changing areas—one for screening patients and one for patients with clinical problems. They then change into warm, long sleeved, cloth dressing robes. The office waiting rooms and x-ray rooms are decorated with comfortable home-like furnishings (Fig. 2). Large selections of up-to-date magazines and many cookbooks are available for the patients to browse through while waiting for the results of the mammogram. Decaffeinated coffee and tea are available in the waiting rooms. A movie on breast self-examination is available in each waiting room for those patients who are interested in learning this procedure. When the technologists perform screening or diagnostic mammograms, they compare those films with the patients' prior studies and then submit all films to screening assistants or medical assistants, who then place the films on alternators for the radiologists to interpret. Each mammogram is independently interpreted by two radiologists. Additional mammographic views are obtained if either of these physicians is concerned. If both radiologists decide the mammogram is normal after these films have been interpreted, the assistants remove the films and place them back in the folders.