Cardiac CT: A Sound Business Investment?

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 This triple rule out cardiac image was captured on the Somatom Definition Dual Source CT without the use of beta blockers at a heart rate of 90bpm. The image was processed on the Siemens syngo MultiModality Workplace. Image courtesy of Siemens Medical Solutions and Nagoya City University Hospital, Nagoya, Japan.

Insurers and the government may not be on board, but the medical community sure is: when it comes to improving patient care, cardiac CT is a must-have technology. But depending on the size and scope of your practice, department or hospital, the business case is a little less clear. Clouding the picture are uneven reimbursement rates across the country, the steep learning curve toward reading proficiency and the expense of the equipment and third-party advanced visualization software.

Armed with an understanding of the barriers to entry as well as the potential clinical applications and cross-practice uses, hospitals, physician groups and imaging centers are either actively investing or seriously considering investing in 64-slice cardiac CT technology. Whether a particular facility can sustain a consistent enough patient flow so that the technology pays off depends on a number of factors, including the number of physicians practicing there, the expertise of the technological and IT staff and the variety of procedures performed. And the state of reimbursement in the area weighs in heavily, too.

With cardiac CT enthroned as a state-of-the-art technology and with the current 64-slice and dual source systems representing a substantial improvement from the previous 16- and 32-slice scanners, the question is really not if, but when, you’re going to adopt the technology. If you wait too long, your competitors may be so far ahead of the curve that you’re left in the dust as your referral base becomes more aware of the technological capabilities and demands it for their cardiac patients.

Not only are the diagnostic gains huge when compared with other technologies, but a facility with a well-thought out plan, a sufficient number of physicians and a steady flow of patients can make the return on investment pay off in a year. “Some groups don’t make money in the first year, but there are plenty that do,” says Tony DeFrance, MD, an interventional cardiologist and medical director of CVCTA Education, an independent cardiac imaging company.

For James Min, MD, assistant professor, Division of Cardiology and Radiology at Weill Cornell Medical College, who practices at New York Presbyterian Hospital in New York, N.Y., the potential preventative power of cardiac CT demands widespread acceptance by providers and payors. “This tool is the most significant advance in cardiac imaging in the last 20 years and has incredible potential to prevent sudden cardiac death in patients who previously wouldn’t have been picked up,” he says. “Think of how much death and disease we can prevent if we put our resources towards tools like this that are aimed at prevention.”


From payor to payor and region to region, reimbursement practices may either spur you on to add cardiac CT services—or not. The good news is that the Centers for Medicare and Medicaid Services (CMS) is expected to deliver a decision memo on Dec. 13; that memo will be based on feedback given during a 30-day comment period that ended July 13. Following the decision memo, CMS is scheduled to complete a national coverage analysis by March 12, 2008.

The bad news is that local reimbursement varies depending on the individual guidelines issued by the local Medicare carriers (LCM) in each state. Private payors are divided on the reimbursement issue—some are covering selected types of procedures, while others aren’t covering much at all or are still studying the issue.

The result is a potentially nasty headache for physicians looking to invest in the technology because local differences in reimbursement can make or break you in your bid to at least break even on the investment. “In Alabama, Blue Cross/Blue Shield is reimbursing for CTA and since they cover a high percentage of the population there, it’s a good environment there as is Minnesota, Arkansas and New York,” says Michael Zucker, FACHE, president of Partners Imaging, a joint venture cardiac CT company in Dallas, Texas. “But if you’re in Arizona or California, some major payors aren’t reimbursing, so it can be tough.”

Costs of Adoption

Depending on the vendor and whether you purchase third-party software and workstations, cost for the equipment will run from $1 million to $2 million.

Original equipment manufacturers include:

  • Toshiba America Medical Systems: The Aquilion 64
  • Siemens Medical Solutions: The Somatom Sensation 64 and the Somatom Definition
  • Philips Medical Systems: The Brilliance 64
  • GE Healthcare: GE LightSpeed VCT and the GE LightSpeed VCT XT
  • Third-party workstations and software is available from:
  • TeraRecon: Aquarius Workstation
  • Vital Images: Vitrea 2 Software
  • Emageon: HeartSuite

While the hardware is necessary, you might be able to save some up-front cash by using the hardware vendor’s workstations and software versus third-party workstations and software. There are pros and cons to both approaches. Rob Schwartz, MD, FAAC, FAHA, a cardiologist with the Minneapolis Heart Institute, believes the investment in third-party workstations and software is well worth the out-of-pocket costs. “The companies building hardware tend to try to be all things to all people, and the software side is so complex that those companies focused on the software have gained an advantage because they are more nimble.

“The state-of-the-art [advanced visualization software] vendors make it much easier to navigate around a particular case so that you can interpret the study more quickly and more easily.” Schwarz uses a Siemens Somatom 64-slice CT scanner with Vital Images Vitrea 2 software. The Minneapolis Heart Institute is affiliated with the 128-bed Heart Hospital at Abbott Northwestern Hospital in Minneapolis. The Institute has 52 cardiologists.

Many facilities will need to add on room to their existing building to house the new equipment, adding construction costs and lengthening out the time frame for when the technology actually comes on line. You’ll need to hire a technologist in a market that is fiercely competitive due to a shortage of trained cardiac CT technologists or train your own in house.

Technology Applications

The potential uses of the technology are running way ahead of current reimbursement levels, but provide a view of how the technology is revolutionizing cardiology, raising the number of applications that physicians may eventually receive reimbursement for.

Experienced cardiologists and radiologists as well as recent studies are finding a number of applications for the technology, including:

  • Screening low and medium Framingham risk patients for coronary artery disease
  • Peripheral vascular disease assessment
  • Calcium scoring
  • Emergency department triage for patients with undifferentiated chest pain
  • Monitoring coronary artery disease progress over time
  • Pre-operative planning for repeat bypass and stent patients
  • Guidance of placement for biventricular pacemakers

While more data are needed to provide evidence that all of these applications are appropriate, preliminary data are convincing. At the Cleveland Clinic, Scott Flamm, MD, FACR, a radiologist who is the head of the Department of Cardiovascular Imaging, reports that patients undergoing repeat coronary bypass for the second, third, fourth or even fifth time are experiencing dramatically lower complication rates when surgeons use cardiac CT to visualize previous bypass graphs prior to the surgery.

“We are seeing complication rates from redos of bypass surgery approach the national rate for first-time bypass surgeries, which is just amazing,” he says. Flamm uses a Philips Brilliance 64-slice CT scanner. The Clinic’s Heart and Vascular Institute’s section of Clinical Cardiology has 24 cardiologists; the Clinic overall has 1,008 beds and completes 7,000 CT scans a year.

Schwartz is running a study in the emergency department about the use of cardiac CT on patients with undifferentiated chest pain. Under the study protocols, half the patients are sent for cardiac CT and half are observed in the hospital for 36 to 48 hours and given EKGs; depending on the results, they are either sent for a cardiac catherization or sent home. “Our ER docs are seeing better results when the patients are sent right in for a cardiac CT and that it’s cheaper and faster,” he says. “They’d like to send all the patients for a cardiac CT, but we have to finish the study and prove with evidence-based medicine that this really works.”

Ideal Facility Size

There’s disagreement about the size of a group practice or hospital needed to sustain enough work so that cardiac CT pays off. It also depends on the specialties in a group of cardiologists, the types of procedures and local reimbursement patterns. “If you’ve got a group that focuses mainly on cardiac care, I’d say you need at least 10 cardiologists to make it work,” says DeFrance, who also is a board member of SCCT and a board certified interventional cardiologist. “But if you’ve got some peripheral vascular specialists, you could have fewer physicians. There’s a group in Houston with six physicians who are doing well with their scanner—they do a ton of peripheral vascular [cases].” DeFrance is in solo practice but partners with a group of 14 cardiologists and one radiologist; together they do approximately 3,500 scans a year.

Min, agrees, saying “Hospitals and large groups can make it work, especially if they look outside the box for as many potential uses as possible, such as peripheral vascular. But currently, the environment is difficult—either the payors are going to have to pay more or the vendors are going to have to charge less because economically it isn’t sustainable. Right now, I don’t think small and medium sized groups can make it work financially.” Min’s department conducts between 1,000 and 2,000 scans per year; he uses a GE LightSpeed VCT with SnapShot Pulse and a GE Advantage Workstation. The New York Presbyterian Health System has 2,335 beds and 174 cardiologists.

In states such as Arizona where the reimbursement environment is difficult, measurement of calcium scores for intermediate risk patients is one way a group or hospital can make the technology pay, says Zucker. Joint ventures between groups of cardiologists and other specialists, such as urologists, oncologists, neurologists and orthopedists also can make the technology affordable. Companies such as Partners Imaging will work with practices and set up joint ventures, providing assistance with financing, construction, installation, staffing and reimbursement if a particular practice and market looks promising enough.

Educating primary-care physicians as to the benefits of the technology is absolutely critical to success, says James Adams, MD, FACC, a cardiologist at Cardiovascular Associates of Marin and San Francisco in Larkspur, Calif., and a principal in Civic Associates, a CT training firm. “You have to educate local primary-care doctors about the technology because they are your referral network,” he says. “It’s all about being a good consultant and helping your customer take better care of his or her customer. This is the responsible way to run a practice rather than the groups that are just out for volume.”

Cardiovascular Associates has 12 cardiologists and three surgeons in the practice and uses the TeraRecon Aquarius workstation. In a year’s time, the practice performs approximately 1,200 calcium scans, 500 cardiac angiograms and 300 peripheral vascular CT scans. The practice is affiliated with the Marin Heart Institute.

Work Flow

With trained staff, most facilities can handle four or five patients an hour; six patients an hour is possible, but stretching the capabilities of the staff and the technology, says Flamm. From the patient’s point of view, the test takes about an hour and is much less invasive and time-consuming than a trip to the cardiac cath lab, just as it is less time consuming for the physician.

Keeping the scanner and the related staff busy is the key, says Adams, as is avoiding turf wars with other specialties. For Schwarz, the threshold for justifying installing the equipment is 10 cases a day, even at the currently low levels of reimbursement. Not only is trained staff key, but the cardiologists and radiologists also must make the investment so that they can read and interpret the scans without getting backed up. “You need at least one partner trained in cardiac CT to make it work and for that person to get really up to speed they need to have read 500 cases, but you can definitely interpret cases at the end of a training course,” says Schwarz.

Despite the barriers to entry, cardiac CT has incredible promise, some of which is already being realized. “I’m very bullish about the technology,” says Zucker. “The patients can get in and out quickly, there is no doubt that it improves patient care and the efficiencies will save money for payors. It is a genuinely revolutionary technology.”


Cardiac CT Training: Acquiring the Skills
To get the most bang for your technology investment buck, you’ve got to invest in acquiring the needed skills to make the most of that technology. With cardiac CT, achieving certification and becoming proficient are two different things.

“It’s a pretty steep learning curve,” says Tony DeFrance, MD, an interventional cardiologist and medical director of CVCTA Education, an independent cardiac imaging company. “It’s something a physician has to focus on. It is a different technology than cardiologists are used to in terms of the 3D workstation.”

In terms of the acquisition of skills, many cardiologists and radiologists opt for training courses to become Level 2 certified, required by most insurers for reimbursement. The table below provides information about the number of cases required and deadlines for the three levels of training currently available.

While the certification guidelines note the number of cases that have to be live for levels 2 and 3, there isn’t currently any clarity about whether those cases actually have to be done in person or whether they can be done through a live feed. The Society of Cardiovascular Computed Tomography (SCCT) is now certifying training centers; courses certified by the SCCT are considered high quality.

Gaining proficiency in reading and interpreting cases takes months of practice, says Scott Flamm, MD, FACR, a radiologist who is the head of the Department of Cardiovascular Imaging at Cleveland Clinic. “You can’t become competent in a weekend-long course,” he says. “It is ridiculous and insulting to patients to think that you could. You have to put in the time to gain an in-depth understanding so that you can interpret studies correctly.”

Confidence is an important factor in becoming competent in the practice of conducting and analyzing cardiac CT scans for James Adams, MD, FACC, a cardiologist at Cardiovascular Associates of Marin and San Francisco in Larkspur, Calif., and a principal in Civic Associates, a CT training firm. “To have confidence in your ability is to interpret a study and decide whether to cath or not to cath based on the results and knowing that you are doing the right thing,” he says.

When deciding to make the investment to become certified and competent in cardiac CT, consider both the investment of training dollars—which typically cost from $1,800 for a two-day course to $7,000 to $10,000 for a three-to-five day course—but also the revenue you’ll lose by being away from your practice. Better to make that investment now rather than later; if you wait until after July 1, 2010, you’ll have to give up two months of your time to receive fellowship training for Level 2 certification.

Business Model: Setting Up a CT Angiography Service Line

Like an increasing number of cardiology groups across the country, Cardiac Study Center in Tacoma, Wash., determined 64-slice CT was a must-have and started down the purchase path. That was in October 2004. Some 18 months and many, many decisions later, the group’s new service line was up and rolling with its Siemens Medical Solution Somatom Sensation 64-slice CT scanner.

Education was the first step to initiating the program, with the group reviewing cardiac CT systems on the market and literature, and clinical indications and limitations, says Vinay Malhotra, MD, FACC, a partner with the group. The team developed a business model and proforma analysis, met with CT business experts, initiated relationships with referring physicians and radiologists for over-reads. Visits to a variety of vendor sites and discussions with end-users proved useful in system selection, as well as looking at local vendor relationships and reviewing service records. The center determined they’d need to fortify to absorb the first year revenue.

Once a system was chosen, price was negotiated based on workstations, PACS, service agreements and thin-client environments. Time also was spent identifying and training leaders, recruiting and training their team, developing protocols and questionnaires for technologists, nurses and scheduling clerks, creating AV teaching tools to educate referring physicians and developing a peripheral vascular program.

The Cardiac Study Center’s business model estimated the CT scanner optimally would run 10 hours a day, five days a week. Five diagnostic CTAs and six calcium scoring exams would be completed each hour; four CTs would be interpreted. The payor mix in Washington is 50-50 Medicare/non-Medicare. No revenue was included from urology exams, virtual colonoscopy, lung screening and full-body scans.

Malhotra says a cardiology group can expect $1 million to $2 million in revenue from one CT unit, assuming $1 million in annual fixed costs and $25 per diagnostic scan in direct costs—supplies, film, storage and billing. Reimbursement for contrast media and beta blockers offsets expenses, while calcium scoring revenue ($199 per exam) pays for the marketing budget and radiologist over-reads.

Marketing has been a key to success, namely via visits to referring physician offices with appropriate and current information on exams specific to the patient mix of the practice and leaving behind referral pads and educational material. The group ran newspaper ads for six months, too, and created a detailed website and CME conferences. An open house and attending health fairs also were part of the plan.

In the first 12-months of operation, the Cardiac Study Group has completed 1,388 procedures, including 708 coronary CTAs, 350 peripheral CTAs, 200 calcium scoring exams, 100 chest CTs and 30 electrophysiology mapping exams.