Mammogram madness......

The U.S. Preventive Services' new guidelines on routine mammograms have cause quite the firestorm. When I first read them, my first action was to call my local hospital and gather some list prices on the services in question. A routine mammogram costs $475; a routine ultrasound costs $750 and an uncomplicated breast biopsy costs a staggering $6750. Of course, most insurance companies pay a discount on these prices. Still, these are pretty steep prices.

In a typical case, a woman will get a screening mammogram. If a suspicious lesion is seen, an ultrsaound is ordered which will determine if the lesion is cystic (fluid filled) or solid. A solid lesion usually indicates the need for a biopsy to prove or disprove Cancer. To perform a biopsy, a radiologist inserts a needle through the skin to the lesion and takes a specimen called a core biopsy and sends it to Pathology. The needle is guided to the lesion by imaging and is done under local anesthesia; it takes about fifteen minutes.

While I was obtaining these quotes from the hospital, I inquired what a breast augmentation would cost. Breast augmentation requires about 90 minutes of Operating Room time with an anesthesiologist giving general anesthesia, with a plastic surgeon performing the surgery; it requires the purchase of the implants (which are not cheap) as well as some time in the recovery room. The total estimate was $5000.

A friend of mine was visiting from Mars and inquired why our system was subsidizing Breast Augmentation by padding (excuse the pun) the Cancer Screening procedures. He reasoned that the Augmentation was a much more complicated and resource-intensive procedure than the biopsy but cost about 25% less. Since he was from Mars, I did not want to delve into the black-hole of discussing the human obsession with the breast; so, I thought that I would be clever and explain it in rational, deliberate terms: I would turn to Economics.

The demand for a breast biopsy is a classic example of an inelastic demand. An inelastic demand is a demand curve which is relatively price insensitive. A woman facing the possibility of Breast Cancer would pay virtually any price to find the answer. She would not shop around for a better deal; she would not put off doing it because of the price. On the other hand, an augmentation is a classic example of an elastic demand. An elastic demand is a demand curve which is highly price sensitive. A woman shopping for an augmentation would explore her options as if she were buying a luxury item. She is in no hurry. She might buy it as a present to herself for a birthday or for Christmas. She probably will compare prices and "shop around". There is no hurry. This type of demand is price sensitive. The hospital sets the price high for the needle biopsy to maximize its revenue; it sets the price relatively low for the augmentation because the "shopper" is not captured by the situation and may go elsewhere depending on price.

I thought that my friend from Mars would find this to be a pretty reasonable explanation. I was slightly disconcerted when he asked: "Isn' t this kicking them while they are down?" All of a sudden, my clever rational explanation looked cynical and immoral.

Without being sidetracked by emotional sidebars, we need to realistically look at the pricing, the true costs and the utility of the medical procedures which we are advocating as good health care. In its present form, it looks stupid, disingenuous and socially harmful. You do not have to be from Mars to see this. Screening for Breast Cancer is important; let's get it right and spend our resources wisely.