Times are tough. The Great Recession isn't over, at least not in mammography. We are just now fully experiencing the aftershock effect of high unemployment rates and collective belt-tightening across the nation.

I've spoken with enough breast center managers, both in Illinois, where I live, and around the country, to know that volumes are down. Significantly. I've also noticed that call volumes have increased, regarding costs of breast imaging. I've always gotten the occasional concern about mis-coding or errors in charging. But never have I experienced the kind of calls I'm getting now. They seem to boil down to the following frequently asked questions:

• I have no insurance. What does a mammogram cost?

• Is there a discount for self-pay?

• I have insurance, but my deductible is very high. What can I do?

• My insurance will pay for a screening mammogram, but not for a diagnostic one. Can you write that I don't have any symptoms (even though I do)?

Since our hospital system does our billing, in the past I have very rarely needed to be involved. But lately I've noticed my participation becoming much greater, sometimes in an effort to ensure that a patient gets her essential testing done.

We are fortunate in our area to have a state program that funds mammography for women over 40 who have no insurance. Still, it's not enough. For one thing, there is not enough funding in that program to help everyone in a timely manner. Additionally, it's only for women with no insurance at all. Those with insurance but a high deductible have no recourse but to self-pay or skip the service. As a result, many women elect to skip. We do have a self-pay discount at our center, but again, only for women with no insurance.

Also, there seems to be a loophole in coverage that affects many women. That is the so-called "wellness benefit," where a screening mammogram is covered by insurance. But if the patient has symptoms or gets called back for an imaging abnormality, those diagnostic studies go toward the deductible and the patient pays the bill. The result is that patients want us to code every exam as a screening exam, even when it's not. Of course we can't do that--it would be insurance fraud. But the results: frustration, complaints-and skipping the exam.

Do you see a pattern here? I do. Patients start to believe they might be safe to wait a year, or even two, for their screening mammograms. Combine that with changing recommendations regarding the need for screening mammography (start at age 50, every two years, per those of a U.S. government task force), and a much smaller screening population is now coming through our doors.

But cheer up. We'll probably have more advanced breast cancer patients to take care of. Because we all know what happens when women skip their screenings.