Increasing overhead, decreasing reimbursement, fierce competition and practice buy-outs...all are conspiring against the nuclear cardiologist.
Office-based cardiology practices offering nuclear imaging services are dealing with bundled CPT codes, tightened budgets and more restrictive reimbursement. The cost of running at peak operating efficiency is high due to office space expenses, equipment needs, staff and licensure, as well as accreditation fees.
Until recently, the technical revenue from office-based imaging provided “a small, but important, portion of overall revenue for cardiology practices,” according to Dennis Calnon, MD, director of nuclear imaging at MidOhio Cardiology and Vascular Consultants in Columbus. He attributes the decline as a result of the “perfect storm” that includes reductions in relative value units (RVUs) because of a five-year review by the RVU Update Committee (RUC); practice expense methodology changes; the Deficit Reduction Act; and plans for bundling radiopharmaceutical tracer, wall motion and ejection fraction “add on” codes (78478 and 78480) for gated SPECT.
The economic pressures of increasing costs in the setting of decreasing reimbursement were the motivations to sell the 16-member MidOhio practice to OhioHealth hospital system, something that Calnon, one of five imaging specialists in the practice, says would have been unthinkable five years ago. “We just came to the conclusion that the private practice of cardiology was no longer a viable option in today’s healthcare environment.”
But it’s not impossible to be a profitable practice offering nuclear cardiology services, says Howard Lewin, MD, medical director of Cardiac Imaging Associates in Los Angeles. “It depends largely on referral patterns, but if a group would bring in-house the 20 patients it is referring per week for perfusion imaging to a radiology group or a hospital, the group would be a profit center from day one,” Lewin says.
The use of radiology benefit managers (RBMs) to cut imaging costs has enjoyed renewed attention, especially since President Barack Obama outlined a plan to require diagnostic imaging pre-authorization for Medicare beneficiaries from RBMs, suggesting that such a measure would save $260 million over a decade.
The Government Accountability Office (GAO) last year suggested that the Centers for Medicare & Medicaid Services (CMS) use RBMs to cut imaging costs. The Department of Health and Human Services (HHS), however, commented that the GAO did not conduct “any independent review of the methodology or data used by plans to determine that the use of RBMs was successful or of the manner in which RBMs make their prior authorization determinations.”
David Wolinsky, MD, of Albany Associates in Cardiology in Albany, N.Y., expresses similar sentiments as HHS. Problems occur, Wolinsky says, when RBMs don’t base their algorithms on established guidelines or misinterpret the guidelines by not calculating patients’ Framingham risk appropriately and therefore do not approve clinically indicated tests. In addition, “appropriateness guidelines are being established for each imaging modality. There may be competing techniques not all of which are subject to the same scrutiny,” he says.
Dealing with RBMs is time-consuming and may not be cost-effective for smaller practices. In addition, RBMs do not promote transparency on their decision-making, says Robert C. Hendel, MD, clinical cardiologist at Midwest Heart Specialists in Winfield, Ill. “The money paid to RBMs does not improve quality of care. Rather, it takes money away from healthcare and gives it to a business. A more targeted approach toward imaging should be undertaken, with an attempt to reduce inappropriate testing, not restrict tests,” says Hendel, who presented such an alternative at the 2009 American College of Cardiology meeting (see sidebar).
Regardless of the challenges of nuclear imaging, there are strategies that office-based practices can employ to help streamline workflow and maintain a sustainable revenue stream. Shorter image acquisition and processing times could help alleviate technologists’ time and increase patient throughput. Newer cameras allow acquisition times of less than five minutes, using less amounts of radiopharmaceutical as well. A practice would have to weigh