SPECT/CT for Cardiac Disease Detection: An Economic Conundrum

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 Daniel Berman, MD, director of cardiovascular imaging at Cedars-Sinai Medical Center in Los Angeles
 Kim Allan Williams, MD, director of nuclear cardiology at the University of Chicago

Since its emergence within molecular imaging, SPECT/CT has steadily gained momentum. Early, as well as late adopters now look to the dual modality to create new opportunities for revenue expansion and methods of improving patient care. Still, it can be a hard sell to a group practice or department to purchase a hybrid system because the economic justification for it within nuclear cardiology remains unclear.

The marriage of SPECT, which provides functional information, with CT, which provides anatomic data and attenuation correction, is ideal. The hybrid combination helps clarify results, increases diagnostic confidence, and reduces patient callbacks. With better images, the expectation is to cut down on repeated imaging, a source of concern for many payors as well as providers.

With the Deficit Reduction Act of 2005, the nuclear medicine market saw a significant drop in 2006 procedure volume as well as sales of SPECT dedicated-cardiac cameras. The North American nuclear medicine market, a once stagnant market, has since started to see growth again and analysts attribute the movement to increased adoption of SPECT/CT. An analysis from Frost & Sullivan shows that the nuclear medicine market earned revenues in 2007 of $298.4 million. The firm estimates that growth will continue to climb, reaching $325.3 million in 2014.

Despite the anticipated growth, SPECT/CT could experience slow clinical adoption due to reimbursement reductions, tight end-user budgets, narrow physician referral bases and low levels of physician education, says Travis Chong, a research analyst at Frost & Sullivan.

Know the economic climate

As with any major purchase, it’s prudent to conduct due diligence, and in the case of cardiac SPECT/CT, it’s important to research the economic climate. “If four out of five insurers are not going to pay for a SPECT/CT study, then it does not make sense to buy the machine, even if it is good for my patients,” says Stephen Weiss, MD, who operates West Side Cardiology, a private practice in New York, N.Y.

Logistically, it probably makes sense to buy a machine that does both SPECT and CT, Weiss says. He has been performing in-house SPECT studies for about nine years, using an upright system from Digirad. “Purchasing a SPECT/CT is not economically viable for me based on my personal economic climate,” he says. “If I had a practice in which there were no reimbursement restrictions, then it would make absolute economic and clinical sense for me to look to SPECT/CT.”

At the heart of the issue are the reimbursement and third-party payor policies and the concern over repeated imaging with CT, specifically with layered testing, and, in the process, perhaps under-reimbursing CT. “If we ignore reimbursement and insurance coverage issues, then from a purely medical perspective, it makes perfect sense to purchase and use SPECT/CT. The problem is that you have these other issues that make a reasonable and valid medical decision a potential economic problem for the private practitioner,” Weiss says.

For example, some academic centers or teaching hospitals can use the hybrid imaging technology and not be concerned with reimbursement since they have other resources available—grant money or research funds—to offset losses. “But if you are in private practice, the unfortunate reality is that you have to focus on doing what your market will reimburse you for,” Weiss says.

Cost-effectiveness vs. cost and reimbursement

“Cost-effectiveness is an artificial construct,” according to Kim Allan Williams, MD, director of nuclear cardiology at the University of Chicago. Trying to determine the economic benefits to SPECT/CT for cardiac disease detection is difficult, since the cost to do the two tests are different than the charges, and the charges are different than the reimbursements. “To speak of SPECT/CT cost-effectiveness assumes you know some of these variables, which we really do not since the data are lacking,” Williams adds.

Figuring out the cost-effectiveness of SPECT/CT for cardiac disease detection will happen once there is significant appropriateness data available on which patients will benefit from it. “Once you have that, you have to then have prospective studies to look at outcomes and make sure the outcomes with SPECT/CT are better than with CT or SPECT alone,” Williams says. “Then you can find out the select population that is benefiting from the combination—whether or not it is changing patient management.”

The actual cost of the equipment must be examined when trying to look at whether the modality is cost-effective. The hybrid imaging modalities typically cost between $1.5 million and $2 million dollars, depending on particular siting needs. That is anywhere from four to seven times more than a single camera model.

“Because of room renovation, equipment cost, and additional training, SPECT/CT does not always translate into financial benefits,” Chong says. The information provided with these tests for patient management, however, more often than not outweighs these costs, he adds.

Additional economic justifications—or lack thereof—fall under the realm of reimbursement. Currently, the Centers for Medicare & Medicaid Services (CMS) has no reimbursement policy regarding hardware or software fusion of SPECT/CT data for anatomic localization and the hybrid modality has no CPT codes for billing. According to the American College of Radiology, it is appropriate to report separate codes for SPECT, CT and fusion localization only if each procedure is a complete study, medically necessary and interpreted separately.

“The two types of information are incremental additives to each other in terms of predicting risk,” says Daniel Berman, MD, director of cardiovascular imaging at Cedars-Sinai Medical Center in Los Angeles. “The problem with the attenuation correction is there is no added reimbursement for it. There is added value, but no added economic benefit.”

There is some burgeoning cost-effectiveness data for CT with a caveat. “Chest pain centers in the ER are evaluating people with acute chest pain with CT or nuclear stress tests, and claim it is very clear that CT is more cost-effective than nuclear—but they are basing that on the reimbursement and the charges, which, again, are artificial,” William says.

Clinical study results presented at the 2008 American College of Cardiology conference by James K. Min, MD, a cardiologist from New York Presbyterian/Weill Cornell in New York City, suggests that coronary CTA may be used as a cost-efficient alternative to nuclear stress testing to evaluate low- to intermediate-risk patients with suspected coronary artery disease.

“Of course it is less costly, if you undervalue the procedure,” Williams says. In the case of Min’s study, simply saying that CTA is less costly over SPECT for CAD does not mean that it is truly cost-effective from a business standpoint. For example, in comparing two similar merchandise items, if one item is not selling as well as another, a common practice is to slash the price of one to drive sales or usage. This does not signify that one is more “cost-effective” than the other, but that one merely costs less.

Figuring out the cost-effectiveness of SPECT/CT for cardiac disease detection will happen once there is significant appropriateness data available on patient benefit. “Then you need to have prospective studies to look at outcomes, which should be better than with CT or SPECT alone,” Williams says. “Then you can find out the select population that is benefiting from the combination and whether or not it is changing patient management.”

Berman says that SPECT is still a very powerful modality and it is good without the added value of CT and is more promising for its whole-body scanning within the other disciplines of nuclear medicine than for cardiac disease detection. SPECT/CT does enable more accurate attenuation correction scanning in the heart. “It is as good as what we do with PET scanning and in that sense, we get around the problems of non-uniform soft-tissue attenuation that occurs in patients,” Berman adds. For example, a woman with large breasts might have a false-positive SPECT scan that corrects itself on SPECT/CT via attenuation correction. “However, we can get almost the same information with standard SPECT by imaging patients in the prone and supine position,” Berman says.

Since is not clear to what degree that attenuation correction is truly more beneficial than standard SPECT and since there is no extra reimbursement for using attenuation correction, it cannot be said with certainty that adding SPECT/CT to a business’s portfolio would make the case for better economic sense. For Berman, if you want the best in cardiac imaging, facilities should look to PET/CT for cardiac disease detection over SPECT/CT.

Despite the low cost of SPECT/CT compared to PET/CT, the latter has a better ability to measure absolute myocardial blood flow at rest and stress and to image left ventricular function at peak of a pharmacological stress, rather than after.

“If you give a patient adenosine with PET, you can actually image the patient during the stress test unlike the SPECT/CT, where you image after the stress test.” Perhaps the most important advantage is that PET has demonstrated very high resolution compared to SPECT—the higher resolution is more likely to lead to more accurate diagnoses potentially with better identification of patients with multi-vessel coronary artery disease, Berman notes.

“If SPECT were to achieve its ultimate potential in resolution and if new SPECT tracers image focused targets like thrombus in the left atrial appendage or help determine if plaque is stable or unstable, then the possibility of having a SPECT/CT scanner might become important for cardiac disease detection,” Berman concludes.

According to Williams, the economic justification for SPECT/CT is really a “catch 22.” “No one will adopt widely until there is hard proof and without wide adoption, proof will be tough to obtain,” he says. “Business answers depend on cost, location, usage and reimbursement, and none of these are settled issues at this time.”

While the medical or clinical value of SPECT/CT, with its attenuation correction and image acquisition tools, have been proven and have enhanced the hybrid imaging modality’s diagnostic and prognostic capabilities within molecular imaging, the question as to whether the dual modality has true economic advantages in the narrow market of cardiac disease detection remains unanswered for many, due to current economic climates and reimbursement issues.


Slice and Price Plateau of SPECT/CT Could Drive Sales and Utilization
Manufacturers continue to offer higher-end SPECT/CT cameras with advanced CT technology that offer a higher number of slices. Accordingly, the average unit price for SPECT/CT has increased from $599,000 in 2004 to $636,000 in 2008, according to Travis Chong, an analyst with Frost & Sullivan.*

However, people have increasingly asked the following questions:
  • What is the optimal number of slices needed for SPECT/CT?
  • What will be reimbursed?
  • What benefits do more slices present?
Several studies have begun to address this issue and an optimal number of slices is expected to emerge within six years, Chong says.

As this specific number gains clinical acceptance, the CT within SPECT/CT will assumably be capped. This cap, along with price erosion of CT technology, will cause the average unit price for SPECT/CT units to plateau at $650,000 in 2011 and maybe even experience some price erosion, falling to $641,000 by 2014.

The lower average unit price could drive SPECT/CT sales growth and, thus, clinical utilization, Chong concludes.

*The average unit price reflects the price for the equipment only and not any renovation and/or additional costs associated with SPECT/CT installation. It also reflects all SPECT/CT cameras from single- to 16-slice, but does not reflect any specific brand.