The Back Page: Despite Higher Up-Front Cost, Cardiac PET Has Its Place

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Mr. Cockrell is administrator of CVA in Birmingham, Ala.

Given the current SPECT isotope shortage, what role does PET play in cardiology from a business and clinical standpoint? Compared with SPECT imaging, PET is a relatively expensive technology. Therefore, could an investment in PET be the right choice for some?

CardioVascular Associates (CVA) in Birmingham, Ala., consists of 32 physicians working out of three main offices and numerous outreach locations. CVA has utilized PET for more than five years, performing more than 14,000 studies in that time. We receive reimbursement from Medicare, BlueCross BlueShield of Alabama and most other third parties.

We have a streamlined system that allows us to perform 18 studies in a nine-hour period starting at 7 a.m. on a 16-slice PET/CT unit (GE Healthcare). The CT is used to speed the processing and not for other purposes. We utilize three prep rooms, two nurses and two nuclear techs and receive a rubidium generator (Bracco) approximately every three weeks.

Patient response to PET studies, from a time and convenience standpoint, has been overwhelmingly positive. A PET study takes about 90 minutes compared with up to four hours for SPECT. PET studies also have reduced radiation doses and a shorter period of radiation retention.

Under the current clinical guidelines, using PET with Medicare patients works well, but there are challenges with other payors, including the requirement of an equivocal SPECT study or body mass index limits before a PET scan can be performed. We have about a 50 percent Medicare patient mix. Our default in most cases is PET over SPECT unless there is an insurance or medical contraindication.

As a result, we have dropped from five SPECT cameras (two single- and three dual-head) to two dual-head cameras and the PET unit. While we have seen a reduction in volume due to more mobile services providing imaging in primary care offices, internally, we now have a 55/45 percent split on PET/SPECT studies.

Financially, Medicare PET reimbursement exceeds SPECT reimbursement. Third-party payors essentially reimburse PET and SPECT at the same rate. However, depending on volume, the incremental cost of PET steadily decreases as a fixed rate is paid for the generator, the equipment is amortized and staffing is consistent. For that reason, PET has a positive financial impact, that is, once you overcome the significant up-front expense associated with the equipment. A PET/CT system ranges from $500,000 (used) to more than $2 million (new). 

The diagnostic quality of PET images is superior to technetium-99m (Tc-99m) SPECT, resulting in a higher accuracy for PET, particularly on larger patients. The move to more SPECT thallium studies, however, as a result of the Tc-99m shortage, often results in tests that are even more inferior or equivocal, requiring either an additional PET study or catheter angiography, adding cost and risk. More accurate readings, such as those from PET, can lead to a lower frequency of additional tests and fewer invasive procedures, resulting in lower overall costs to the healthcare system. 

We can clearly demonstrate the accuracy of PET in terms of fewer false positives, which lead to a reduction in caths. Of course, this impacts groups with an outpatient cath lab (OPCL), which we’ve had for 14 years, and impacts hospital cath labs as well. A reduction in downstream procedures and revenues, however, has prepared us to work with payors and employers on carve-out models based on quality and efficiency.

We have been aggressively utilizing our data from PET, SPECT and our OPCL to show third-party payors the advantages of PET. It should be hard to argue with a modality that significantly reduces downstream costs and risks through reduced invasive procedures. 

Our plan is to continue taking our results to existing payors, large employers and any other exchange, co-op or other payment network so we can show why CVA should be an integral part of any payment model.

Mr. Cockrell is administrator of CVA in Birmingham, Ala.