Peter R. Eby, MD, FACR, FSBI

Under a new Washington State law that took effect on Jan. 1, 2024, patients who need medically necessary breast imaging no longer have to pay out of pocket, eliminating cost-sharing requirements that often caused people to skip the exams. The ACR Bulletin recently sat down with Peter R. Eby, MD, FACR, FSBI, section head of breast imaging for the Virginia Mason Medical Center Department of Radiology in Seattle and chair of the ACR Breast Screening and Emerging Technology Committee, to discuss his personal experience as a physician advocate who participated in getting the legislation passed.  

Can you share your motivation behind advocating for this legislation, and what specific challenges did you encounter during the process?

The motivation was rooted in helping women access care when they need it. We as physicians recognize that some individuals are underinsured or face high deductibles, forcing them to make tough choices between spending on necessities like food, rent, utilities and getting follow-up care after screening mammograms. 

We also understand that delays in cancer diagnosis can result in increased expenses or poorer outcomes. For example, discovering a lump in the shower shouldn't force individuals to choose between a clinical diagnosis and putting food on the table. Our aim is to eliminate out-of-pocket costs for diagnostic breast imaging, ensuring patients receive evaluations as soon as possible. The fear of out-of-pocket costs should not deter anyone from seeking timely diagnostic care, especially when it comes to potential breast health issues. 

The legislative effort for diagnostic imaging unfolded in a single year, focusing on copay. While supplemental screening bills had been introduced in prior years, it did not gain universal backing as the diagnostic parity bill and lack of universal support, in turn, made it difficult to garner buy-in from legislators across all districts. The key difference was that the diagnostic screening bill garnered more support from legislators, as it could benefit anyone, regardless of their risk level, in all districts.

The fear of out-of-pocket costs should not deter anyone from seeking timely diagnostic care, especially when it comes to potential breast health issues.

An important lesson we learned from observing this bill written, advocated for and passed suggested to us that we have the option and power to introduce something. The diagnostic imaging bill was introduced by Komen and we joined that effort. When legislators reached out to us in prior sessions, we provided education and offered suggestions for correcting high-risk language or describing the patient population. However, those earlier bills didn't gain traction to get out of committee. 

Another notable difference in this last session was the full support from the medical community, along with support from other medical societies such as the Washington State Medical Association and the Komen organization. The sponsors were bipartisan, with clear bipartisan support evident from early testimonies. The primary resistance came from insurance companies, prompting discussions with fiscally conservative representatives about the anticipated costs. The Office of the Insurance Commissioner was also involved, stating that the fiscal impact would be borne by insurance companies and not the state budget, making it considerably easier to pass.

Did you encounter any unexpected developments in navigating the legislative landscape?

The process went fairly smoothly. Some legislators wanted to make tweaks, but we weighed in consistently to ensure clinical accuracy.

What strategies or alliances did you find most effective in building support for the legislation, both within the medical community and among policymakers?

The Washington State Radiological Society (WSRS) conducts an annual visit to Olympia, Washington. We try to bring WSRS members from as many districts as possible to meet face-to-face with senators and representatives. This particular bill was one of three measures that we identified as key pieces of interest, and during these visits, we aimed to connect with legislators to build support, answer questions and address concerns.

Were there any lessons learned during your advocacy efforts that could be valuable to others looking to pursue similar legislation?

Having prior examples of language that's been vetted and refined in other states was incredibly helpful. It's important to get the bill drafted well in advance. In Washington, our legislative sessions are either short or long, starting in December and extending to February or March. Showing up with a draft bill in December for the first time is not a viable approach. Our lobbyist always encourages us to check in with legislators during the summer to build and maintain relationships with our legislators during less busy times of the year. This proactive engagement keeps the legislation on their radar and allows for any necessary adjustments or refinements. 

Leading with how the legislation benefits the patient and staying focused on that message is crucial during these meetings. Share scenarios and patient stories to emphasize the real-world impact and necessity of the bill. A key factor that significantly influenced the success of our legislation was the support of the committee chair. Having the committee chair's backing held considerable sway and played a pivotal role in advancing the bill.

When providing testimony to committees, be aware of the required format and logistics, ensure that you have a clear understanding of the proceedings. Once you have your turn to speak, be efficient with your time, as you typically have only a brief window to convey your message. In your testimony, make sure to clearly state who you are, who you represent and your district. A little practice can go a long way, and it's important to get these details right to avoid wasting your precious seconds. 

Remember that making your points concisely and in the right order is essential. Learn from each experience and refine your approach for subsequent rounds of advocacy. Collaboration with experts and stakeholders can also enhance the effectiveness of your advocacy efforts because it allows you to enhance your messaging or to re-state important points.

The first time I was providing testimony to the committee, our lobbyist scheduled me for expert testimony and I was given a two-minute window. Virtual testimony turned out to be an efficient process, but I must add that two minutes go by quickly. Just to introduce yourself and your affiliation eats up 15 seconds, so you have to get to the point right away. For the second round of hearings, I was more efficient in preparing my notes and conveying my points. There are always opportunities to submit written testimony as well if you need to elaborate or give detailed explanations. 

What advice would you give to other colleagues who are passionate about advocating for legislative change?

Two things about legislative involvement stood out to me personally. First, it absolutely can be done. This process showed us that we can get involved and help make it happen, impacting people’s lives on a daily basis. Once you see it happen, there's more excitement about what we may achieve as WSRS. Second, I've published and spent energy on papers, I’ve worked closely with incredible radiologists, and I am proud of my achievements. However, this bill will likely have a more significant impact on patients’ lives than any paper I’ve ever published. 

I keep thinking about that impact and contribution to the women of Washington and their families. The bill was passed and took effect 90 days after it was signed. What's interesting is that it is not widely known. 

Raising awareness is crucial, and we're working on that aspect now. We're partnering with breast cancer events and institutions, conducting Grand Rounds and presentations, and speaking to primary care doctors to spread the word. The post-legislative work, often overlooked, is essential in ensuring the legislation's real impact on those it was designed to help. 

The entire legislative experience this year was a powerful reminder of the importance of our advocacy efforts in improving healthcare access.