Low Payment Rate Influences Use of Core-Needle Breast Biopsy Procedure

How doctors are paid sometimes "encourages the use of older, more expensive and sometimes riskier medical procedures when better options exist," a discrepancy highlighted by the different payment rates for breast biopsy procedures. The Wall Street Journal reports that the core-needle biopsy procedure, which is performed with a needle under local anesthesia and has been available for about 10 years, is "cheaper [and] less traumatic" than the traditional surgical biopsy, which is done with a scalpel under general anesthesia. However, many doctors still advise women to have surgical biopsies, partly because physicians get paid more to do surgical rather than nonsurgical procedures, according to the Journal. For instance, Medicare pays physicians about $400 for surgical biopsies performed in hospitals and $128 for core-needle biopsies. Many private insurers follow Medicare rates; both Aetna Inc. and Cigna Corp. pay more for surgical biopsies than core-needle ones. Surgical biopsies cost more -- up to $3,000 -- than core-needle biopsies because they require general anesthesia, an operating room and a nurse-monitored, post-surgery recovery area. Core-needle biopsies can be performed within about 15 minutes in an outpatient setting.

Rate Changes
In January, HCFA adopted new payment scales for core-needle biopsies after a panel of physicians conducted a survey of other doctors to determine the amount of time and resources required for the nonsurgical procedure. As a result, Medicare now pays doctors $128 for core-needle biopsies, down from $228 in previous years. Many doctors who participated in the survey said they were "shocked" by the new rate and are petitioning the panel for a new survey. Some lawmakers are also pushing HCFA to reconsider the rate change. In a July letter to the agency, Rep. Bob Barr (R-Ga.) said that fully implementing core-needle biopsies would save the health care system $2 billion per year and HCFA $750 million. In addition, Sen. Arlen Specter (R-Pa.) sent the agency a letter in August, saying that "reimbursement policy in this area should not provide a financial incentive to continue to perform open surgical biopsy to the detriment of new technology." However, Mark Miller, deputy director of HCFA's Center for Health Plans and Providers, the group that oversees Medicare, said that the agency would have to be "very careful about not choosing to accept" the doctor panel's recommendation for the rate change. He added that HCFA's goal is to have "payment rates that don't favor one procedure over another," stating that he believes the payment rates for breast biopsies uphold that philosophy. Despite opposition to the new rate, it will stand for this year (Martinez, Wall Street Journal, 3/28).