Making the Business Case for Cardiac CT (Even in a Recession)
Screenshot images (from left): 71-year-old male with atypical chest pain imaged, in diastasis, to rule out coronary artery disease (CAD); shows mixed plaque in right coronary artery (RCA) & left anterior descending (LAD). Visualization enhanced via Magic Glass. Image courtesy of Philips Healthcare. Scan generated using 1.8 mSv at 100Kvp, 350 mA on a LightSpeed VCT using SnapShot Pulse. Image courtesy of GE Healthcare. 70-year-old male with chest pain, indeterminate stress test, imaged to rule out CAD. Small, non-stenotic calcified plaques found in proximal LAD and in mid and distal RCA. Images courtesy of Jeffrey Dardinger, MD, St. Luke Hospital, using Toshiba’s 320-slice CT.
Clinical studies are demonstrating the utility of cardiac CT as an essential imaging modality—with studies showing the non-invasive study yields results comparable to invasive coronary angiograms. Other supporting data are beginning to emerge, too, hinting that cardiac CT saves time and money throughout the health system. On the downside, reimbursement remains a local decision, and in most places, current rates don’t leave much room for profit.

This month, we’re exploring the business case for cardiac CT, listing and evaluating the variables that factor into the decision-making process. “It’s a complicated equation,” warns John Lesser, MD, co-director for cardiac CT at Minneapolis Heart Institute in Minnesota. Developing a fiscally sensible cardiac CT program hinges on multiple variables including: volume, procedure mix, staffing, local reimbursement and workflow.

Variable No. 1: Referrals

One of the first factors to consider in the cardiac CT decision-making process is the local patient population. Are there enough cardiologists referring cases to generate a volume of studies to support the breakeven point? “Practices require a base mass of cardiologists to make cardiac CT cost-effective,” says Vance Chunn, CEO of Cardiology Associates in Mobile, Ala. Although exact numbers vary, Chunn estimates that practices of 10 or more physicians can sustain the investment. Groups of five or six, on the other hand, may struggle to make ends meet, particularly if one or more physicians is not committed to cardiac CT. Estimates of the minimum daily volume vary from four to eight scans.

For some sites operating a cardiac CT program using a 64-slice system, the break-even point is a minimum of four CT angiograms a day, says Matthew Budoff, MD, director of cardiac CT at UCLA Harborview Medical Center in Los Angeles. Practices need to factor in staff and rent costs, which could raise minimum volume to six or eight studies. Financing is another challenge. “In the current [U.S. economic] climate, practices need to understand what financing companies require,” cautions Tony DeFrance, MD, medical director of CVCTA Education Center in San Francisco. Vendors may require both corporate and personal guarantees when financing a new system.

Auxiliary exams provide critical breathing room. In fact, most practices employ a three-legged business model that includes CT angiography, peripheral vascular studies and calcium scoring. Peripheral vascular studies represent a critical supplement and may be reimbursed at a higher rate than cardiac CT exams, depending on the location. At Cardiology Associates, peripheral vascular volume accounts for nearly half of its CT volume. Cardiology Associates also uses calcium scoring to boost revenue derived from its GE Healthcare LightSpeed VCT 64-slice scanner with patients paying $125 for the unreimbursed procedure. (In some parts of the country, private payors and Medicare cover calcium scoring.) Local primary-care physicians embrace the study because it helps them determine how aggressively to treat patients. Calcium scoring requires seconds of scan time, and does not require administration of beta blockers or contrast. Scores are computed automatically at the workstation, and cardiologists typically spend five to 10 minutes meeting with patients after the study.

Other supplementary options include non-cardiac studies including chest CT exams or head and neck CT studies. DeFrance, for example, partners with a radiologist and uses Toshiba America Medical Systems Aquilion 64 and Aquilion One scanners for general body CT exams in addition to cardiac studies.

Secondary costs

A state-of-the-art cardiac CT scanner is a seven-figure investment, but imaging technology isn’t the only cost variable to enter into the equation. “People tend to under-appreciate the IT investment associated with cardiac CT,” says De France. A cardiac CT program requires at least two dedicated workstations and software. Sites should budget $100,000 or more for each workstation, says Lesser, whose 45-cardiologist group employs Siemens Healthcare’s Somatom Definition Dual-Source CT scanner and Vital Images Vitrea workstation as part of its comprehensive patient services.

Other essentials include DICOM storage. Cardiology groups that haven’t yet invested in PACS may be at a disadvantage compared to their radiology peers because most radiology practices can scale PACS to include cardiac CT studies. Some groups do manage without PACS. Cardiology Associates, for example, has stored cardiac CT studies on optical disk since 2005. But that is far from the norm.

A final cost is staff. “Staffing is critically important and very expensive,” shares Chunn. A cardiac CT program typically requires one or two technologists, a scheduler and a nurse. Cardiac CT warrants an investment in dedicated technologists because scans differ from conventional CT imaging; techs must be well-versed in cardiac protocols including contrast timing and gating. The commitment to dedicated cardiac CT techs ultimately benefits the practice because they understand how to acquire scans with superior image quality, says Chunn.

Small or new cardiac CT practices may bypass a dedicated nurse. If daily CT volume hovers around three studies, the physician can administer beta blockers; however, as volume increases the back and forth becomes a productivity issue, says DeFrance, who recommends hiring a dedicated nurse when daily volume exceeds six to eight cardiac scans.

Michael Ridner, MD, director of cardiac CT for The Heart Center, a full-service cardiac imaging practice in Huntsville, Ala., puts the cardiac CT staffing equation in perspective. The Heart Center completes 25 to 30 cardiac CT weekly on its Siemens Somatom Sensation Cardiac 64 with a staff of three: one tech and two nurses. In contrast, the nuclear department relies on a staff of 15 to complete 35 to 40 nuclear studies daily. “CT doesn’t require a large staff. On the other hand, nuclear studies are very labor intensive for staff and time-consuming for the patient,” sums Ridner. The average nuclear study is a three-to four-hour patient visit. In contrast, cardiac CT patients may be in and out of the office in less than an hour. 

Reimbursement, marketing and more

Cardiac CT reimbursement remains a work in progress. The Centers for Medicare & Medicaid Services (CMS) has not yet issued a national coverage determination, so reimbursement is decided at the local level. Third-party payments also vary across the county. Consequently, education of local payors becomes part of the program. Cardiology Associates, for example, initiated an aggressive educational campaign focused on the medical advantages and cost-savings associated with cardiac CT when it deployed its scanner in April 2005.

The arguments are compelling; the negative predictive value of cardiac CT is 99 percent, which translates into fewer negative invasive catheterizations. The price tag of a conventional invasive cath study with hospital stay comes in the $4,000 to $5,000 range, so replacing unnecessary caths with a cardiac CT study makes sense, says Chunn.

Experienced centers do see cardiac CT evolve into a substitute for other imaging modalities, which could help convince reluctant payors. Take for example The Heart Center. The 30-cardiologist practice initiated its cardiac CT program in 2005 and has seen significant changes in other imaging procedures. “Nuclear stress perfusion volume has dropped by 10 percent,” shares Ridner, “which is appropriate because it isn’t an ideal test for detecting coronary artery disease.” In fact, data show that nearly 50 percent of patients with coronary disease documented by cardiac CT produce normal perfusion results. Invasive catheterization volume also increased. The Heart Center realized a 10 percent increase in total invasive cath volume with a 25 percent decrease in normal studies. That’s because fewer patients with equivocal stress perfusion results are referred for diagnostic cath studies. In many cases, the cardiologist orders a cardiac CT prior to other diagnostic imaging tests, which eliminates diagnostic cath studies for patients with negative results. 

In addition to educating local payors, a practice needs to develop a plan to educate local physicians. The physician champion is essential, says DeFrance. One physician needs to commit to educational talks that encourage physicians to reconsider referral patterns. Smart practices hold educational seminars once weekly for several months as the cardiac CT program ramps up.

Optimizing workflow

South Florida Medical Imaging Cardiovascular Institute in Boca Raton, Fla., is one of the nation’s premiere outpatient imaging centers. The state-of-the-art facility features a Society for Cardiac Computed Tomography-accredited teaching center. Cardiac CT solutions include Philips Healthcare Brilliance 64-slice scanner, Philips Brilliance workstation and 4.0 software and Philips Brilliance Everywhere thin-client portal.

The institute, which averages seven to 12 cardiac CT scans daily, has mastered the nuances of cardiac CT workflow. The goal for cardiac CT is to have the patient in and out of the room in 15 minutes, says Claudio Smuclovisky, MD, director. South Florida Medical Imaging, the model of hyper-efficiency, regularly achieves patient turn-around time of 10 minutes or less, including administration of intravenous beta blockers.

One critical ingredient in the recipe for optimum workflow is the holding area. Patients may require additional beta blockers or post-scan monitoring. Using external holding areas minimizes the time on the table and frees the scanner for additional patients.

In addition to focusing on optimal use of its scanner, South Florida Medical Imaging also hones in on optimal use of staff. “We developed cardiac CT workflow from scratch and stick to a very precise protocol for technologists,” explains Smuclovisky. Unlike many other cardiac CT sites, the institute does not use a nurse or physician assistant in the cardiac CT suite. Instead, the physician injects beta blockers. “This protocol eliminates wasted time. The tech does not need to call the physician if there are questions because we are in the room with the patient. The physician can quickly evaluate what the patient needs,” states Smuclovisky. The hands-on approach also produces high-quality images because the physician helps the tech modify techniques, achieve proper field of view and manage heart rate changes.

South Florida Medical Imaging weds its hands-on clinical model with high-tech. Cardiac CT requires a minimum 1 gigabyte network for rapid data flow, says Smuclovisky. In addition, Philips Brilliance workstations are equipped with 16 gigabytes of RAM to facilitate loading and manipulating 4,000-slice studies. The workstation also incorporates concurrent analysis and review screens to minimize time-consuming, back and forth toggling between screens.

On the reporting side, Smuclovisky and colleagues use a robust voice recognition system with templates to produce comprehensive, multi-page reports outlining the extent of coronary disease, cardiac function and more. After a radiologist and cardiologist review the study, it’s signed electronically and faxed to the referring physician, usually within hours of the study. The ability to provide high-quality service and a comprehensive report is the cornerstone of the center’s marketing plan. “We’re a boutique practice. Our goal is to be the best, which means providing a precise report that answers the cardiologist’s clinical questions.”

Smart business

Cardiac CT continues to gain momentum, and the swell will continue as reimbursement improves and clinical data accumulates. Entering the market is a major business decision. Sound plans are comprehensive and take into account a variety of factors: physician and payor education, imaging and IT investments, staffing patterns and supplemental studies. The right mix will produce positive outcomes including more comprehensive patient service and a more solid, diverse bottom line.

Answering the Radiation Dose Challenge
Radiation dose remains a challenge for cardiac CT providers.  A recent study published in the Journal of the American Medical Association equated the radiation dose of a single cardiac CT scan with 600 chest x-rays, and the American Heart Association is calling for more careful selection of diagnostic cardiac CT patients.

Fairfax Radiological Consultants in Fairfax, Va., an early adopter of GE Healthcare LightSpeed VCT for cardiac imaging, sounded the dose alert several years ago. James Earls, MD, medical director, recalls, “The system employed retrospective gating, a low-pitch technique that requires multiple overlapping scans of the heart several times. The result is a high cumulative radiation dose.” At the time, the average radiation dose for a cardiac scan amounted to 15 to 18 mSv.

In 2008, Earls deployed GE SnapShot Pulse dose reduction technology, which promised to reduce dose by 80 percent. SnapShot uses prospective imaging, which requires a single exposure for each area of the heart instead of overlapping images. “We were dubious about image quality and patient criteria for the technique, but concerns about radiation were high among radiologists and patients,” says Earls. Early results using a prototype achieved an 83 percent dose reduction, with the average dose plummeting to 3.1 mSv. Equally important, Earls and his colleagues completed a critical analysis of 2,000 prospective scans and concluded SnapShot image quality is equal to or better than retrospective studies.

Candidates for prospective gating are limited to patients who maintain a steady heart rate in the 65 to 70 beat per minute range. Fairfax Radiological Consultants uses beta blockers to achieve the target heart rate in most patients. About 10 percent of cardiac CT patients are imaged using the conventional retrospective protocol because they don’t tolerate beta blockers or cannot achieve the target heart rate.

Similarly, cardiac CT scans at South Florida Medical Imaging Cardiovascular Institute in Boca Raton, Fla., average 1 to 3 mSv—an 80 to 90 percent reduction over conventional cardiac CT scans. Claudio Smuclovisky, MD, director, credits prospective gated axial imaging or Philips Healthcare Step & Shoot technology with the impressive reduction. The institute employs strict criteria for the step-and-shoot protocol. The technique is limited to patients under age 65 with no previous cardiac surgeries or interventions. The institute achieves minimal dose for all patients by adjusting dose to the patient’s body size and restricting the field of view to the heart.

One factor practices need to consider as they embrace prospective gating is reduced reimbursement. Currently, CT angiography reimbursement is split between one component for the evaluation of coronary arteries and structure and a second for evaluation of cardiac function. Prospective gating techniques apply to the structural data only. “The billing implication is that physicians will lose about 40 percent of reimbursement,” shares Michael Ridner, director of cardiac CT at The Heart Center in Mobile, Ala. When necessary, functional information can be obtained through echocardiography.

Although an early commitment to dose reduction has paid off, it is possible to achieve further incremental reductions. Fairfax Radiological Consultants recently deployed the GE Healthcare HD 750. Earls predicts that average dose could drop to 2 mSv because the new system enables reconstruction techniques that further lower dose.