Currently medical studies have identified Magnetic Resonance Imaging as a
better test than mammograms for the detection of breast cancer. Under new
guidelines, women at higher risk for breast cancer should obtain an MRI. Of
course the nation is hardly ready for this good news.

The price tag for this will not be small. About 1.5 million women are
impacted. If the test becomes more common, you can bet that there will be
additional women who will manage to gain the extra security of an MRI
rather than a mammogram. The guidelines for MRI include two close relatives
with breast cancer. This will be a difficult concept. With even 1 close
relative, women will be demanding MRIs. This will mean a much larger group
than just 1.5 million. Then there will be the liability pressures…  Who
will want to take the chance that some lawyer will not find a second family
member years later or other reasons why the test should have been done.

Now the bar has been set even higher. Any woman with breast cancer will
expect total diagnosis and early treatment and cure.

For practical purposes in estimating the costs we will stay with the
original 1.5 million scans a year costing $2,000 each. The hope is that
40,000 lives will be saved, although as with most such estimates, this is
difficult to determine. This is 3 billion dollars a year in new and
unanticipated health expenditures. All that prevents this is insurance
changes almost certain to be enacted, given the strong lobby for women’s
health fueled by our national intentions to attempt to live forever and
most damaging our children and their children who may not have much of a
chance in this scenario.

The winners and losers

The possible 40,000 women saved and their families are the possible
winners. Of course those who are in certain states, lower income groups,
and middle income groups will not have the same health care coverage and
the same access, they will pay more out of pocket that they do not have, as
with all of their health care in the nation. You can bet that the 10,000
from the top quartile will be saved, but variable success will involve the
30,000 from the middle and lower income quartiles. This does not prevent
the use of the entire 40,000 in the deliberations at hand however.

How many would have actually been saved will never be known as we rarely do
large scale studies with implementation. We move right from the smallest
scale to the largest in such matters.

The MRI companies will be the big winners as well as the corporations who
market and sell such equipment and that promote their use.

Initially radiologists will benefit, but I have some fears about their
discipline. This may be the straw that breaks the camel’s back. Much of
radiology has become automated and digitized. It is entirely possible that
MRI reads will become very competitive. Radiologists anywhere in the world
can read them. Medical students are very aware of the vulnerable nature of
radiology, and already move to interventional radiology, a portion of the
discipline less amenable to global competition.

Much of the cost of the MRI is the physician cost of reading, and the
appropriate support and technology could reduce this to a few hundred
dollars. The pressures to reduce these new costs will be enormous. Then
there is the liability increase for all in the entire pathway involving
breast cancer screening and evaluation and failure to diagnose, the most
common cause of liability suits.

This will also potentially highlight a number of massive increases in
medical costs where technology has technically reduced the actual costs and
increased productivity, but each year the patient pays even more.

This may also be a dramatic illustration of how much specialists make as
compared to the physicians that actually work with their patients directly.
Reforms in this area are long overdue and the nation has basically
compromised all primary care in this delay. This is a minority probability
however.

Each year for decades more and more funding has been shifted to procedures,
technology, major medical centers, and specialists. The basic forms of
primary care are being compromised. The debates over Gardasil immunizations
also highlight the problem. While some are hung up over a forced
immunization or sexuality issues, a major issue not fully discussed is
adding new and major health care costs to the nation.

Few comprehend the steady, subtle changes in the landscape of our nation.
Increased health care costs already dominate state budgets, business
profitability, and even the jobs of teachers. Schools and education lose
two ways. State budgets continue to include more for health and education
and other areas face more difficulties. Also school district budget
officers are forced to make major cuts to provide health care coverage. The
major item cut is school teachers, a major part of the budget and the most
important part. The nation can ill afford to cut teaching and disable
business, especially the heart of the American economy, small business.

Robert C. Bowman, M.D.
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