The Battle Over the Breast

With the early work of Parker et al (1) and others,(2) percutaneous biopsy of the breast became recognized as a viable substitute for most open surgical biopsy, and the so-called turf battle between radiology and surgery for control of biopsy was joined. Radiologists asserted that core needle biopsy (CNB), under either stereotactic or ultrasound guidance, was clearly an imaging procedure, while surgeons argued that biopsy was and should remain a surgical procedure, because of the surgeon’s training and experience in managing patient care.

The turf war might well have resolved itself had it not been superimposed on the radical upheavals in the traditional doctor-patient relationship and the reimbursement system that managed care was driving during the 1990s. Suddenly both specialties began to experience steady erosion in fee income, reduction in the ability to exercise medical judgement, and limitation of access to large groups of patients. The concept that dominated the decade is change and, while change may be perceived by some as creating opportunity, the prevalent response is one of distrust, apprehension, and fear.

There is already clear evidence that this turf skirmish has helped to delay the application and availability of minimally invasive biopsy across the nation. A perfect case in point is the state of California, where organized radiology was able to persuade the regulatory authorities that being a radiologist should be one of the credentialing requirements for performing stereotactic biopsy. While surgeons have, in some instances, referred breast patients to radiologists for biopsy, in the majority of cases they continue to use the more invasive, and expensive, needle-localized open surgical biopsy procedure. The failure to consider CNB diagnosis as part of a continuum of care requiring interdisciplinary cooperation inevitably leads to many unnecessary surgical biopsies.

DYNAMICS OF DISCORD

In pre-managed care days, patients with breast lumps were referred to surgeons. As mammography developed, the same pattern prevailed for patients with screen-detected lesions. Mammography was simply a service, and a mammogram was like a chest radiograph, one more piece of information that the surgeon would utilize in making a diagnostic decision.

Over time, particularly as screening mammography began to be recognized as a valuable method of finding lesions that were not clinically discoverable, radiologists began to develop other imaging studies — diagnostic mammography, ultrasound, ductography — that were valuable in arriving at a biopsy decision. A subset of radiologists realized that they could become highly effective in prebiopsy diagnosis, and began to be dissatisfied with a system that allowed them to perform only studies that were ordered by other physicians. Why not, they reasoned, do a full imaging examination of patients that would result in a benign finding, a recommendation for short-interval follow-up, or a recommendation for a biopsy?

At about this time (late 1980s, early 1990s), managed care began to control rapidly increasing numbers of patient-lives. No longer could physicians freely refer to the specialist of their choice; rather they had to refer to members of physician panels. Reimbursement for individual procedures also began to be ratcheted down, and physicians often were required to get permission from payors to do specific procedures. These changes went to the core of the health care delivery system, and altered every physician’s perception of medical practice.

It was in this volatile and confusing environment that radiologists suddenly received a pair of new tools that enabled them to complete the histologic diagnosis of a patient: the automated large-core biopsy needle and the stereotactic biopsy table. General surgeons, coming under increasing pressure from payors and gatekeepers, and having witnessed the erosion of their own specialty as it became more and more subspecialized, reacted predictably. They manned the barricades and began to fight for what they believed, or at least would have had others believe, was sacred ground for surgeons.

The turf war has taken two forms, defensive and offensive. On the defensive side are the surgeons who believe that the way to combat radiology and its newly found competency is by strengthening their primary care practitioner referral base and continue to perform needle-localized biopsies. In this effort they are often assisted by radiologists who also choose not to utilize CNB, and who are quite content limiting their services to localization of biopsy sites for surgeons. On the offensive side are the surgeons who recognize the potential of CNB, but who believe that it is properly a surgical technique.

The development of vacuum-assisted biopsy (VAB) and its demonstrated improvement over CNB (3-6) have served only to exacerbate the already contentious environment. VAB is becoming recognized as providing significant clinical benefits in the biopsy of suspicious microcalcifications. VAB also has demonstrated improved characterization of atypical ductal hyperplasia (ADH) and ductal carcinoma in situ (DCIS) lesions, reducing the need for subsequent biopsy. It has, however, tended to bring more surgeons from the defensive to the offensive side of the argument, as VAB points the way toward eventual percutaneous breast therapies.

THE MEDICAL LOGIC

The Radiology Perspective. Nonpalpable lesions are, by definition, not discoverable by clinical evaluation of the patient, but only through sophisticated imaging. Radiologists are trained and experienced imagers, and have ready access to the technologies of imaging. They also are trained and experienced in performing invasive, image-guided procedures in other organs in the body. These other invasive procedures have been performed since the 1970s with little complaint from surgeons. Therefore, radiologists conclude they should perform all image-guided biopsies, rather than surgeons who are not primarily trained in imaging. Surgeons, radiologists contend, are too quick to biopsy, and too often take the attitude: “she is going to want that out anyway.” Last, but not least, the radiologist believes that he or she can provide the patient with the benefit of a rapid diagnosis, or one-stop shopping. All of the procedures necessary to diagnose a breast cancer can be done in one patient visit, while if the patient goes instead to a surgeon there often will be long scheduling delays that will increase the patient’s anxiety.

The Surgical Perspective. Nonpalpable breast cancers are small breast cancers that can be imaged before they are large enough to be discovered through a clinical examination. Patients with breast lesions, whether palpable or nonpalpable, need the benefit of a surgeon whose training and everyday experience includes managing patient care. Radiologists, by contrast, may do specific procedures, but are not trained to manage the patient’s care or to perform ongoing, nonimaging follow-up. For example, what is the radiologist going to do with a benign condition — just tell the patient to live with it? Also, all too often there is not continuity of care even within the radiologist’s office. One radiologist may read the mammogram and another do the biopsy, and neither correlates the pathology with the mammogram.

The radiology and surgery positions are both powerful. The reality is that everything in the two previous paragraphs is true in many practice environments. There is, however, a minority of practices in which the breast radiologist has become subspecialized and has developed an interest and expertise in managing patient care, or the surgeon is a breast surgeon who has developed his or her breast imaging skills beyond those of the average radiologist. In these instances there often is no turf battle, as the patient benefits of subspecialization attain recognition by the entire medical community. This paper, however, addresses itself to the all too common situation in which the turf issues remain unresolved. As will be seen in the discussion that follows, the reconciliation of these issues is an essential part of ending the turf war on a local basis.

FINANCIAL ASPECTS

No examination of the turf battle would be complete without a close inspection of the financial effect that it has on the participants. Tables 1-5 explore a few of the financial relationships that are important, in several different scenarios.

Scenario 1: The Ambulatory Surgery Setting.Figure 1 compares reimbursement rates for both physicians and facilities for the various biopsy procedures, when those procedures are performed in an ambulatory facility that is licensed by Medicare. In these instances, there is some reduction in the professional surgical fee (CPT 19101, 19120, and 19125 codes), but the facility is allowed to collect both the technical component (TC) of all radiology fees and a Medicare Ambulatory Surgical Code fee for the procedure, or the rate in effect for the commercial payor. The break-even point for such a facility-based stereotactic table is approximately three cases per week, based on a table cost of $250,000 ($50,000 residual value), 5-year life, 9% annual maintenance cost, and annual salary costs for a dedicated technologist of $45,000.

Note, in Figure 1, that there is very little difference in professional reimbursement between the various procedures paid pursuant to Medicare, or according to the commercial plan. In fact, the professional difference by plan is $47 to $41 (16% to 8%) for Medicare and the commercial payor, respectively. From the institution or facility side, the financial return from the minimally invasive procedures is much more attractive than the traditional open procedures (44% – 29%). When considering the additional savings in time available with minimally invasive procedures, they are even more financially advantageous. It is evident that the payment dynamic is not material to the choice of procedure for those procedures performed in an ambulatory facility.

Access is the basic issue in utilization of minimally invasive breast biopsy procedures. Who is allowed to utilize the stereotactic table has, in many institutions, become an ongoing struggle, with the patient as unintended victim. Radiologists may insist that hospital-based stereotactic equipment is exclusively the province of radiology, but surgeons hold the trump card-the ability to do open surgical breast biopsies. The surgeon’s imperative likely influences the fact that an estimated 78% of the breast biopsies in this nation are still performed utilizing traditional procedures.(7)

Scenario 2: The Physician Office Setting.Figure 2 illustrates reimbursement rates for stereotactic biopsies performed in an office setting. The office reimbursement figures shown in Figure 2 reflect the technical portion of fees for the biopsy and related procedures. (Fees for procedures performed in office settings are billed on a global basis, reflecting both technical and professional components in one charge.) Except for a minimal allowance for a surgery tray (which is in the process of being phased out), no separate reimbursement is available from Medicare. However, many practices have been able to negotiate a facility reimbursement from certain commercial payors for office-based stereotactic procedures. For the purpose of Figure 2, however, it will be assumed that there is no separate facility reimbursement, but that commercial payors will reimburse for the cost of tissue acquisition disposable supplies.

It is important to note that the cost of the tissue acquisition disposables ($45, core biopsy; $300, vacuum-assisted biopsy ) has not been included in any of the tables. Medicare does not currently reimburse for the cost of disposables utilized in the biopsy procedure, and the only allowance made is the professional fee differential paid to the physician for CPT-4 code 19101 between procedures performed in an approved ambulatory surgical center ($212) and those performed in an office setting ($253). This failure to provide reimbursement for actual costs incurred by the physician or office results in a net reduction of $45 to $300 in net revenue from Medicare cases performed in the office setting.

Many commercial payors, on the other hand, will reimburse for the cost of biopsy disposables, especially after receiving concise, evidence-based explanation of the benefits of minimally invasive biopsy. There are several studies that address the cost-effectiveness of CNB and VAB; however, individual programs are encouraged to develop their own outcomes data to support effective utilization of the procedures.(8, 9) Assuming a 30% Medicare biopsy volume and that VAB is used exclusively with stereotactic guidance, the break-even point for the office-based table is approximately seven stereotactic cases per week.

Both the use of freestanding ambulatory facilities and the purchase of dedicated stereotactic equipment will achieve access for surgeons, but these are individual, not system, solutions. The system challenge in breast cancer diagnosis is not merely to change the biopsy paradigm for individual physicians, it is to discover more early-stage cancers. These cancers are predominately mammographically detected, with an increasing number of DCIS cases included in the mix. All of these cases are ideal subjects for diagnosis using minimally invasive techniques. The fact is that these tiny cancers are detected by breast radiologists using advanced imaging techniques. Mammographically detected cancers are not, by definition, discovered by surgeons. It is, therefore, only through encouraging collaboration between radiologists and surgeons that the goal of discovering more early-cancers can be realized. How can this be accomplished given the reality of the turf war?

A COLLABORATIVE APPROACH

The reimbursement picture for stereotactic breast biopsy is usually one-sided: either the case is done by the radiologist or it is done in its entirety by the surgeon. The hospital, unfortunately, is often caught in the middle, and it may, in fact, be suffering the effect of too many needle-localized biopsies, or the off-loading of underreimbursed cases. In any event, the all-or-nothing approach is often at the heart of the turf war.

Scenario 3: The Surgeon-Radiologist Clinical Collaboration. In Figure 3 the information in Figure 1 has been recategorized to reflect collaboration between the radiologist and surgeon. Essentially the surgeon performs the procedure and manages the patient, while the radiologist is responsible for stereotactic targeting decisions. In this setting, there would be a $40+ financial incentive for the surgeon to perform an open procedure unless time is considered. A good breast physician, assisted by a good stereotactic technologist, can perform a biopsy in 10 to 15 minutes, far less than the time required even for an uncomplicated open surgical biopsy. With the caveat that an excellent technologist is required, the stereotactic procedure can and should be far more time-effective for the active surgeon.

Time is a critical element for the radiologist as well. Allowing radiologists to perform the targeting may satisfy their concern for the importance of imaging to the success of the procedure, but it really is relatively easy to complete the biopsy once the targeting has been accomplished. There may be some reluctance to have the surgeon take over the routine part of the procedure, and the larger share of reimbursement. Once again, a review of the time is important. A good stereotactic technologist will completely set up the case, leaving the decision to proceed or to adjust the final coordinates up to the physician. This requires very little physician time, particularly when compared to the time required for pre- and post-procedure counseling of the patient, and continuing patient management responsibilities.

The process can be made very convenient as well for the radiologist. Technology from at least one manufacturer now allows the supervising radiologist to remotely view the prefire and other targeting information, and to actually control targeting coordinates from a remote location, enabling the stereotactic equipment to be located remotely from the radiology department (eg, in an on- or off-site ambulatory surgery facility), which is more convenient for surgeons.

There is another very important non-financial consideration in involving the radiologist in the stereotactic biopsy process: Quality. Stereotactic biopsy is an imaging modality. To be effective, the physician must be certain that the lesion being targeted is, in fact, the lesion that was found to be suspicious on the diagnostic mammogram. Good technologists are very important in the process of targeting, but the decision to acquire tissue is solely that of the attending physician. The majority of surgeons who perform breast biopsies are not subspecialized in breast and are not expert imagers. With delayed diagnosis of breast cancer reported as the number one source of medical malpractice claims and payments, general surgeons need both the assistance and the malpractice protection of an expert breast radiologist’s opinion on targeting.(10)

The professional fee for needle localization is slightly higher than for stereotactic targeting ($90 to $100). Some radiologists have suggested that if surgeons are going to perform biopsies, radiologists are actually better off by doing the prebiopsy needle localization of the suspect lesion than they would be by targeting the lesion stereotactically. Disregarding the obvious patient care benefits of minimally invasive breast biopsy, this proposition should be analyzed in the context of time. Needle localizations are complicated, requiring pre- and post-localization mammographic views, and the insertion of a locating wire into the suspect lesion. This is hands-on physician time. By contrast, verification of targeting for stereotactic biopsy involves the review of a digital image and possibly a mouse click or two to alter targeting coordinates. Especially with the remote workstation, the time required for the stereotactic targeting is far less than the average needle localization procedure. Even when the stereotactic unit is utilized for the needle localization procedure, the time involved is not justified by the reimbursement received.

Scenario 4: The Surgeon-Radiologist Technical Collaboration.Figure 4 illustrates yet another possibility. This table contains essentially the same information as in Figure 2, with physician reimbursement itemized between the surgeon and radiologist, as in Figure 3. Figure 4 begins to infer an intriguing possibility for breast centers. Unlike physician fees, technical revenue can be shared between investors in a program or entity. A complete discussion of the regulations governing this kind of medical endeavor is beyond the scope of this paper, but the model of hospital/physician joint ventures may be reviewed for direction. Essentially the technical delivery system is separated financially from the professional. Professional fees are paid to the radiologists and surgeons, and the technical fees are, after deduction of expenses, distributed in a ratio equal to the capital invested in the venture by the joint venture partners.

There are potential regulatory issues for physician investment in a diagnostic breast center, but there are far fewer issues for a joint venture between radiologists and a health care organization, than between a health care organization and surgeons. The importance of this venture possibility facilitates the following scenario:

Scenario 5: The Radiologist-Health Care Organization Collaboration. If it is assumed that the total capital attributed to each partner is equal, Figure 5 illustrates the recast distribution of reimbursement revenue described in Figure 4. If the same assumptions are followed as used in conjunction with Figure 2, this system will break even at seven cases per week. Radiologists, as entrepreneurs, will find it in their best interest to encourage, rather than to block, utilization by surgeons.

The only downside from the standpoint of the radiologist is the reduced reimbursement for Medicare vacuum-assisted biopsies (the cost of the probe will have to be absorbed). Even in this case, however, the technical revenue is sufficient to cover most of the costs involved. The only situation in which this would not work financially for the radiologists is in a practice that has low patient volume and a very high percentage of Medicare or Medicaid patients. Such instances are rare in this country. It should also be considered that increased adoption of VAB will eventually result in a revision of the coding structure to provide for payment of the cost of VAB disposables.

Note that as this article is going to press there is a strong rumor that an announcement of a new or amended reimbursement code for VAB is imminent. The exact nature of this change is still unclear; however, it is being designed to recognize the cost of the biopsy disposables.

The most significant potential gain from a collaborative system, particularly the joint-venture breast center approach, is for patients. Physicians are working together, rather than as unwilling partners in a patient’s care. Diagnosis becomes a well-orchestrated continuum, and service quality improves along with clinical quality. Importantly, the community gains the perception that there is a breast program, rather than just random physicians who performed breast procedures. This new perception, over time, can be expected to increase both the number of women being regularly screened (and thereby the number and percentage of mammographically discovered, early-stage cancers), and the referrals of patients from beyond what otherwise might be considered the service area for the institution.

Gerald R. Kolb, JD, is CEO of Breast Health Management Inc, Bend, Ore, and Susan Granucci, CCS-P, is a coding and reimbursement consultant specializing in oncology, based in Albuquerque, NM.