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For PPOs - Strategies to Promote Evidence Based MIBB
PPO executives have an interest in encouraging the appropriate use of minimally invasive breast biopsy. These reasons are both for quality of care for patients, and efficiency of services for payers. For patients, use of a less invasive procedure such as core needle or vacuum assisted biopsy for diagnosis is effective and is the standard of care for diagnosis. For those with no cancer, a minimally invasive biopsy eliminates the need for surgery. This avoids the pain, scarring and lost time of surgery. There are cost implications too: for payers, minimally invasive biopsy can be carried out more cost effectively than surgery, and can prevent the need for surgery. A State of The Art Consensus conference reports that reducing the rate of open biopsies to 10% instead of the current 35-40% could save $1.1 billion, based on current Medicare rates.
The Message for PPOs
PPOs should know that there is a large opportunity for improvement in the area of breast biopsy. PPOs can use this website to identify guidelines, resources and ideas for strategies to align practice on breast biopsies with standards of care and recommendations. The key takeaway points are:
For patients: Patients should know that expert physicians agree that the preferred method for conducting a biopsy of a breast abnormality is a core needle biopsy. Physician practice guidelines and statements of physician specialty societies agree [hyperlink to references page] that research shows core needle biopsy should be chosen for diagnosis, rather than excisional biopsy, the vast majority of the time. Many surgeries will be avoided if the abnormality is benign. Patients should research the biopsy options that are available, discuss them with their physician, and consider seeking care in a facility specializing in state of the art breast care.
For physicians and hospitals: Physicians treating or referring women with breast abnormalities for biopsy should be aware of the standards of care for breast biopsy. A biopsy can be done by a surgeon or radiologist or both, but a multidisciplinary team experienced in breast care is the preferred approach. Training and certification is available to physicians that will enable them to develop expertise in core needle biopsies – the minimally invasive approach, and specialized breast centers offer needle biopsy as the diagnostic method of choice. Specialized facilities also have access to pathologists experienced in breast disease. Breast centers of excellence should be the preferred choice for patients and should be preferred in PPO contracting strategies.
For PPOs: PPOs have a role in guiding patients and physicians towards physician-recommended best practices e.g. evidence based care outlined in professional clinical practice guidelines. To make this possible, PPOs need to identify quality providers for the PPO network, contract with certified breast care providers and facilities and adopt quality metrics for biopsy and pathology services. PPOs can also work with payers/employers to implement incentive programs or precertification to encourage minimally invasive biopsy instead of surgical biopsy. To truly drive practice improvements, PPO medical policy, which is permissive of minimally invasive procedures, would need to become more directive that MIBB is preferred over surgical biopsy except where medically necessary.
Network Quality Strategies for PPOs
PPOs have an important role in assuring that women cared for by network providers receive the highest quality diagnostic services to reduce the risk of false positive or false negative findings. Several strategies can be adopted to promote evidence based care:
1) Ensure that Providers Measure Breast Care Quality
PPOs have the opportunity to seek out certified breast centers and encourage contracted centers and facilities, certified or not, to report breast care quality data. The National Consortium of Breast Centers has developed a certification program for breast centers and requires centers to report quality metrics on breast cancer screening, diagnostic, and treatment activities. PPOs also have a role in assuring the quality of tissue specimens and may have a role in promoting pathology quality metrics related to breast biopsy.
The most direct approach a PPO can take to identify high quality biopsy and pathology providers is to contract with Breast Centers of Excellence. The National Quality Measures for Breast Centers (NQMBC) initiative offers performance-based designations of “Quality Breast Center,” and “Quality Breast Center of Excellence.”
2) Contract with Qualified Providers
PPOs also have opportunities to seek out qualified practitioners for network participation and to develop communications modalities to help patients easily identify qualified providers for breast cancer screening and diagnosis. Some independent indicators of physician quality that can be used for contracting and for receiving “preferred status” in the network include:
Individual Physician Certifications:
Facility Accreditation / Certification for Breast Care
3) Medical Policy
To drive more rapid improvements in meeting the standard of care for breast biopsy, PPOs could use medical policy and reimbursement incentives to encourage providers to increase use of minimally invasive biopsy before surgical biopsy.
PPO medical policy on breast biopsies specifies which procedures are covered. Current PPO medical policies identified on public websites describe the types of biopsies available to women, but are neutral in recommending minimally invasive approaches over surgical biopsies. PPOs have the opportunity to be more proactive in promoting MIBB for breast abnormalities. This would be consistent with evidence-based guidelines, better for patients, and more cost effective. Practitioners could be rewarded for consistently completing a minimally invasive diagnostic procedure prior to surgical intervention or documenting the rationale for open excision when required.
Most PPOs will provide benefit coverage of any type of biopsy, including minimally invasive approaches, when medically necessary. For example, see the publicly available Aetna Medical Policy and CIGNA Medical Policy. Surprisingly, many plans appeared to have no policy at all about breast biopsy, suggesting that PPOs may need to review additional evidence in order to guide providers and members to evidence-based care.
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