Rate of Timely Follow-up on Abnormal Screening Mammograms for Breast Cancer Detection

BCBSA supports this measure.

We recommend credit for documented outreach and navigation efforts and alignment with payer prior authorization timelines to avoid penalizing providers for delays outside their control. 

MUC2025-042: Rate of Timely Follow-up on Abnormal Screening Mammograms for Breast Cancer Detection (MIPS)

Merck supports the proposed “Timely Follow-up on Abnormal Screening Mammograms for Breast Cancer Detection” measure (MUC2025-042), recognizing its potential to enhance the quality of care in breast cancer. Breast cancer was the second most common cause of cancer deaths among women in the U.S. in 2023.^[1] Research has highlighted the importance of timely follow-up care for breast cancer after receiving abnormal screening mammograms, as delays can lead to further progression of the disease and worsening outcomes.^[2] Five-year survival for breast cancer is about 99.6% when diagnosed at a localized stage but drops to roughly 32.9% for metastatic disease.^[3]

The measure specifications align with clinical practice guidelines, which emphasize the importance of timely follow-up care and appropriate diagnostics that can lead to earlier, treatment opportunities.^[4] However, gaps in timely follow-up on abnormal screening mammograms are significant; one systematic review found 7.2%-33% did not have any follow-up within 3 months and 27.3%-71.6% within 6 months.^[5] The wide variability in the lack of follow-up post-abnormal screening may indicate barriers limiting mammography facilities from carrying out complete diagnostic resolution within a timely manner for all patients. This quality measure can be used to address quality gaps by monitoring timeliness and completeness of care to improve breast cancer screening and diagnostic processes.

Overall, Merck encourages CMS to implement the “Timely Follow-up on Abnormal Screening Mammograms for Breast Cancer Detection” measure in the MIPS program. We are encouraged that CMS is continuing to prioritize care improvements for patients at risk of, or living with, cancer.

References
 

[1] U.S. Cancer Statistics Working Group. United States Cancer Cases and Death Statistics At a Glance. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention and National Cancer Institute. Published June 2025. Accessed December 16, 2025. https://gis.cdc.gov/Cancer/USCS/.

[2] Reece JC, Neal EF, Nguyen P, et al. Delayed or failure to follow-up abnormal breast cancer screening mammograms in primary care: a systematic review. BMC Cancer. 2021 Apr 7;21(1):373.

[3] Centers for Disease Control and Prevention. U.S. Cancer Statistics Female Breast Cancer Stat Bite. U.S. Department of Health and Human Services. Published June 2, 2025. Accessed December 18, 2025. https://www.cdc.gov/united-states-cancer-statistics/publications/breast….

[4] Monticciolo DL, Malak SF, Friedewald SM, et al. Breast cancer screening recommendations inclusive of all women at average risk: update from the ACR and Society of Breast Imaging. J Am Coll Radiol. 2021 Sep 1;18(9):1280-8.

[5] Reece JC, Neal EF, Nguyen P, et al. Delayed or failure to follow-up abnormal breast cancer screening mammograms in primary care: a systematic review. BMC Cancer. 2021 Apr 7;21(1):373.

The American College of Radiology (ACR)—a professional association representing more than 40,000 physicians practicing diagnostic radiology, interventional radiology, radiation oncology, and nuclear medicine, as well as medical physicists— appreciates the opportunity to comment on the Centers for Medicare & Medicaid Services (CMS) 2025 Measures Under Consideration (MUC) List. Of the 24 measures included, only one pertains to radiology, MUC2025-042: Rate of Timely Follow-up on Abnormal Screening Mammograms for Breast Cancer Detection.

This electronic clinical quality measure (eCQM) was designed and tested for facility-level implementation, and it was endorsed by the Partnership for Quality Measurement (PQM) for use in programs such as CMS’s Hospital Outpatient Quality Reporting Program. However, in the MUC List, it is being considered for inclusion in the Merit-based Incentive Payment System (MIPS), which is a clinician-level program—a significant shift from its original intended use. (Partnership for Quality Measurement, 2024)

During the PQM endorsement process, ACR supported implementation at the facility level based on testing that demonstrated scientific acceptability for that setting. At the time, the measure had not been tested for clinician or group-level reporting. 

While we appreciate CMS’s efforts to improve timely follow-up care, we have significant concerns about applying this measure at the clinician level. Our main concerns include:

• High Stakes for Radiologists: If finalized, this would be the only breast imaging measure in MIPS, making accuracy and feasibility critical. Any errors in data capture or reporting could disproportionately affect radiologists’ MIPS scores, payment adjustments, and public reporting.
• Technical Feasibility: Imaging reports (including BI-RADS results) are often stored in unstructured electronic health record (EHR) fields, requiring complex extraction methods like string searches or custom interfaces. Limited interoperability between imaging and EHR systems, vendor variability, and the need for custom IT solutions increase workload and risk of inaccurate reporting. These challenges may result in negative scoring and discourage participation.
• Accountability for System-Level Factors: Radiologists may be penalized for delays outside their control, such as scheduling bottlenecks, patient navigation issues, and patient-driven delays. (Neiman Health Policy Institute, 2023; RSNA, 2023) These issues are compounded by workforce shortages and rising imaging volumes. While most facilities meet the 60-day benchmark for follow-up, some do not, and there is significant variability across facilities and patient subgroups. (Oluyemi et al., 2023) These findings show that systemic factors—unrelated to individual radiologist performance—can affect timely follow-up.
• Resource Burden: Practices, especially small or rural ones, will need dedicated IT resources to extract BI-RADS data and maintain reporting systems. This will increase the cost and complexity of providing breast imaging services, putting smaller and rural practices at a significant disadvantage compared to large health systems.  Additionally, the measure is currently specified in Fast Healthcare Interoperability Resources (FHIR), which may result in implementation barriers within MIPS if program updates are delayed.

ACR appreciates that the developer has since retested the measure. The group- and clinician-level testing demonstrates reliability, validity, and technical feasibility at both levels. However, clinician-level test results were derived from a single facility/group TIN, and group-level results were from only six groups within a single hospital system. Because clinician-level testing included only NPIs under a single TIN and lacked detail on the practice’s characteristics, we are hesitant to assume the reliability results will be generalized. This limited sample may reflect uniform workflows and IT infrastructure, rather than robustness and reproducibility across diverse practices. Additional multi-TIN testing is needed to confirm reliability for MIPS adoption. Further, feasibility testing was conducted in controlled environments with developer-provided tools (such as the BI-RADS string search algorithm), and the report does not confirm universal access to these tools or vendor integration. Real-world implementation could therefore vary substantially. As a result, practices without robust IT resources, especially small or rural practices, may face significant burdens, leading to imbalances in reporting and scoring. The testing also did not address delays outside clinicians’ control, and using the same target population for both facility and clinician testing raises concerns about the measure’s suitability. We are therefore very concerned that the current evidence does not support including this measure in MIPS.

Given these considerations, ACR strongly urges CMS to delay introducing this measure for clinician-level reporting in MIPS until the challenges described above are addressed. While testing confirms scientific acceptability, unresolved issues—such as access to extraction tools, interoperability limitations, and systemic delays—pose risks to fairness and accuracy. The ACR greatly appreciates this opportunity to provide this feedback to ensure the successful implementation of this measure. To avoid unintended consequences, we recommend that CMS either limit initial implementation to facility-level reporting or ensure robust resources, guidance, and safeguards are in place before considering clinician-level adoption. 

References

1. Oluyemi, E. T., Grimm, L. J., Goldman, L., Burleson, J., Simanowith, M., Yao, K., & Rosenberg, R. D. (2023). Rate and timeliness of diagnostic evaluation and biopsy after recall from screening mammography in the National Mammography Database. Journal of the American College of Radiology, 20(5), 555–564. https://doi.org/10.1016/j.jacr.2023.01.012
2. Partnership for Quality Measurement. (2024). Measure endorsement summary: Rate of timely follow-up on abnormal screening mammograms for breast cancer detection. Retrieved from https://p4qm.org/measures
3. Neiman Health Policy Institute. (2023). Radiologist workforce projections and imaging demand. Retrieved from https://www.neimanhpi.org
4. Radiological Society of North America (RSNA). (2023). Technologist shortage and its impact on imaging services. Retrieved from https://www.rsna.org

The American Medical Association (AMA) supports the intent of this measure; however, we have many concerns with considering this measure for inclusion in the Merit-based Incentive Payment System (MIPS). The preliminary assessment bases its evaluation on the measure’s endorsement; however, it was endorsed at the facility and integrated delivery system level using hospital outpatient and integrated delivery system data. On review of the additional testing provided at the individual clinician and group level, we do not believe that this measure should be considered appropriate for inclusion in MIPS for the following reasons:

• The performance scores provided across the three health systems and at all levels (clinician, group, and health system) are generally above 90% across several years. The current MIPS benchmarking approach will not allow this high rate of performance to be spread across the 10 deciles, and we believe that this measure could quickly become topped out. While no information was provided on the characteristics of the health systems (e.g., state or region, rural vs. urban, academic medical center vs. community hospital), we are also concerned that any scores that are below 90% may reflect staffing challenges or decreased access to imaging facilities in a region rather than true performance. Additional investigation into why performance that was generally high even during the COVID-19 public health emergency decreased in a subsequent year would be beneficial to understand if there are other factors outside of the control of the clinician, group and/or health system.
• The electronic clinical quality measure (eCQM) specification requires integration of the Breast Imaging – Reporting and Data System (BI-RADS) into the electronic health record system (EHRs); however, the feasibility assessment and data element testing demonstrated that the BI-RADS data are not consistent captured in discrete fields. In fact, one of the testing sites used a simple string search to capture the unstructured data, which is inconsistent with current MIPS requirements that there be end-to-end reporting from EHRs without manual manipulation. Additional testing must be completed to demonstrate the agreement rates for each data element in a manner that is consistent with the current eCQM requirements (i.e., not include data from the string search unless it is integrated into discrete fields).
• The reliability results were acceptable at the health system and facility group levels and while the median signal-to-noise ratio (SNR) at the individual clinician level was over 0.9, the minimum SNR was 0.142. All results were based on a minimum sample size of 40 patients; however, MIPS benchmarks are determined based on minimum sample sizes of 20 patients. We are extremely concerned that the reliability scores will be significantly lower when the 20-patient minimum is applied.  

Given these concerns, the AMA does not support inclusion of this measure in MIPS. 

Please see attachment.  Thank you for the opportunity to submit a comment.

Advocate Health appreciates the opportunity to provide feedback on MUC 2025-042, Rate of Timely Follow Up of Abnormal Mammogram Screening measure. We ask for clarification that the measure is only focused on the first abnormal screening, and not any subsequent abnormal screenings to account for those who are receiving 6 month follow-ups for continued screening, as an example. 

ECRI, a global nonprofit advancing evidence-based healthcare, has submitted the attached comments on the MUC with an emphasis on measures most relevant to patient safety and diagnostic excellence. 

ECRI supports the CMS Measures Under Consideration (MUC) List and its role in advancing meaningful, high-value measurement. Of particular significance are the measures focused on chronic disease management and diagnostic safety. Strengthening measurements in these domains supports more efficient, timely, and coordinated care across the healthcare system to better serve patients. 

The attached comments from ECRI include recommendations on the importance of patient-reported outcomes, minimizing unnecessary reporting burdens, and feedback in support of the following measures: 

• Timely Follow-up on Abnormal Screening Mammograms for Breast Cancer Detection (MUC2025-042)
• Timely Follow-up on Positive Stool-based Tests for Colorectal Cancer Detection (MUC2025-043)
• Adult Community-Onset (CO) Sepsis Standardized Mortality Ratio (MUC2025-045)
• Hospital Sepsis Program Core Elements Score (MUC2025-047)
• Hospital 30-Day, All-Cause, Risk-Standardized Readmission Rate Following Sepsis Hospitalization (MUC2025-055)
• Hospital Harm - Postoperative Venous Thromboembolism (MUC2025-067)

The AAFP supports the goal of improving timely follow-up after abnormal screening mammograms, recognizing its importance for patient outcomes and breast cancer detection. However, the implementation of this measure in Medicare payment programs, especially MIPS, raises significant concerns regarding feasibility, accountability, equity, and unintended consequences. We strongly encourage CMS to consider the challenges outlined below and work to resolve these issues.

1. Meaningfulness

• Intent and Patient Benefit: The measure is meaningful in its aim to ensure patients receive timely follow-up imaging or biopsy after abnormal screening mammograms, which can improve patient care, outcomes, and reduce mortality. 

2. Appropriateness of Scale

• Timeline: Having a 60-day completion period for follow-up is appropriate and can help limit harm by providing definitive results sooner.
• Attribution and Accountability: There are unresolved questions about attribution—whether responsibility lies with radiologists, primary care physicians, or others. The measure risks being applied at the wrong accountability level, penalizing individual practices for system-level issues such as scheduling, network access, and payer authorization.
  • For example, there are many places a patient can walk-in and get a mammogram without an order. We support this to increase access to important, life-saving screenings. However, the results in these walk-in situations are not always communicated to the patient’s PCP (if they have one).
• Equity Considerations: Access to higher-level imaging and diagnostic procedures may be limited in rural and low-income populations, impacting timely follow-up. Social risk and access factors must be considered so practices are not penalized for delays outside their control. 

3. Feasibility and Implementation

• Data Extraction Challenges: Mammogram results may not be readily extractable as structured data in EMRs, making implementation and tracking difficult. Reports often appear as images rather than data, complicating documentation and workflow.
• Documentation Burden: The measure risks duplicative effort and workflow disruption for practices, especially when external imaging reports must be obtained and documented.

4. Time to Value Realization

• Positive Impacts: The measure has potential for near- and long-term positive impacts on patient outcomes, but further discussion is needed on how benefits and harms may change over time as the measure matures. 

5. Recommendations for CMS

• Clarify Attribution: We encourage CMS to provide clear guidance on attribution for follow-up responsibility.
• Reduce Burden: Efforts should be made to minimize documentation and workflow burden, including improving EHR data extraction capabilities.
• Improve Access: We encourage CMS to consider social risk and access factors and provide support for practices serving underserved populations.
• Consider Modifications: The measure should grant “credit” to clinicians for documented outreach and navigation efforts and it should align with payer prior authorization timelines to avoid penalizing physicians for delays outside their control.
• Monitor and Update: Ongoing assessment of the measure’s impact and feasibility is needed, with updates as necessary to maintain clinical relevance and fairness.

Conclusion

We appreciate the opportunity to provide the important family physician perspective on this and other measures under consideration. The AAFP supports the concept of timely follow-up on abnormal screening mammograms but recommends against implementing the current measure in MIPS until concerns about feasibility, accountability, equity, and documentation burden are adequately addressed. We encourage CMS to carefully consider our insight and suggestions outlined above.

Rationale: This measure reports the percentage of female patients aged 40 to 75 years with at least one abnormal screening mammogram who received timely diagnostic resolution within 60 days after their abnormal screening mammogram. Breast cancer is the second most common cause of cancer deaths among women in the United States. In 2025, around 42,170 women will die from breast cancer, and an estimated 316,950 new cases of invasive breast cancer will be diagnosed.  Breast cancer survival is dependent upon cancer stage at diagnosis. Approximately 99% of women diagnosed with early-stage breast cancer live for 5 years or more. However, survival is only about 32% for those diagnosed at the most advanced stage.  CMS is considering adding this measure as a new measure to the clinician payment program for future performance years. Currently, it does not have any related measures that examine timely follow-up for abnormal screening mammograms. This measure fills an important gap.

Timely follow-up after an abnormal screening mammogram is critical for early breast cancer detection, and it is especially important in minority populations because delays worsen outcomes and widen existing health disparities. An abnormal mammogram does not mean cancer, but it requires prompt diagnostic follow-up (additional imaging or biopsy). When breast cancer is found early, it is:
More treatable, Less likely to have spread, Associated with much higher survival rates. Research consistently shows that racial and ethnic minority women—including Black, Hispanic/Latina, Native American, and some Asian populations—are less likely to receive timely follow-up after abnormal mammograms. Contributing factors include: Limited access to specialty care. Lack of insurance or underinsurance, Transportation difficulties, Language barriers etc.