Making the Business Case for Cardiac CT (Even in a Recession)

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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