Quantification and analyzation software can help increase patient throughput. Source: Cedars-Sinai Medical Center

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.

Prior-authorization

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).

Effective strategies

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 the cost of a new camera with the benefit it would bring it. One caveat to consider, however, is that some new software for imaging and processing is pending ICANL (Intersocietal Commission for the Accreditation of Nuclear Medicine Laboratories) approval, suggesting that if similar software isn’t certified, “users could end up with non-ICANL certified protocols and payors could decide not to pay for them,” says Calnon.

Practices also could employ a strategy of using stress-only imaging for low-risk patients. A problem with that approach, however, is that patients might need to come back for follow-up rest images, creating potential scheduling complexity. Other strategies include auditing billing and coding to ensure the practice is being paid appropriately, and using generic stress imaging agents, which are now on the market. Some practices also have begun looking for alternatives to the industry’s reliance on RBMs for prior-authorization or pre-certification.   

There is no one path to follow or one best strategy to employ to optimize revenues within a nuclear cardiology practice during this slow economic drag. Practices of all sizes and volumes are being forced to make difficult decisions regarding equipment and supply purchases, imaging protocol utilization and practice management, in terms of remaining independent or be absorbed by a hospital system. The bottom line is, the cost of providing nuclear imaging services within an office-based cardiology practice has gone up and practices are doing more with less, while striving to maintain high-quality patient services.

Software Program Vies to Replace RBMs

Researchers downloaded the appropriateness criteria for SPECT MPI into a program that sorted through a database of more than 6,000 patients referred to six community practices. They reported the study at the 2009 American College of Cardiology meeting in March. The software, essentially intended to replace radiology business managers (RBMs) as gatekeepers for appropriate imaging, determined that two-thirds of the SPECT studies were appropriate, 13 percent inappropriate, and the rest either uncertain or undetermined. The most common instance of inappropriate testing (44 percent) was in asymptomatic, low-risk patients. Lead investigator Robert C. Hendel, MD, from Midwest Heart Specialists in Winfield, Ill., concluded that “self-referral is not the key issue,” as the study “demonstrated that physicians outside cardiologists’ offices more often prescribe inappropriate testing.” Researchers also concluded that with such a program as they used in the study, cardiologists can be the gatekeepers to ensure “the right test is ordered for the right person,” eliminating the need for RBMs.