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