Repair, Replace or Refer?

Cardiac imaging equipment doesn’t always pay for itself anymore. What should providers do about that aging suite?

Economic uncertainty continues to rattle U.S. healthcare, but the spring of 2013 will find at least one cardiology administrator upbeat about the years ahead. Rosemary Owen, manager of cardiovascular labs at the 523-bed, seven-cath lab Providence St. Vincent Medical Center in Portland, Ore., expects business to pick up—or at least hold steady—largely on the strength of a key investment: a $2 million-plus biplane mixed cardiovascular x-ray system that will be used to treat patients with cardiovascular diseases. Planning started last summer with a target completion date of this spring.

“It’s a big opportunity because it will lead to greater satisfaction among the physicians,” explains Owen, adding that the redesigned and re-equipped room was, until now, her oldest. “[Physicians are] going to bring in business, because they can work on complex cases that this room wouldn’t support before. Now that we’ve got the imaging to show very small vessels sharp and clear, nonsurgical interventions are a stronger option.”

Owen’s experience may be instructive for heart and vascular departments and practices hanging on to old imaging equipment while waiting, possibly in vain, for healthcare economics to stabilize if not improve.

Cold-facts case

Owen first had an inkling the outdated equipment’s time had come when repair technicians, who were engaged by a long-term service contract, started having difficulties locating replacement parts. She had them pull up detailed service data. The records showed that problems, issues and downtime had increased markedly and predictably according to age and utilization. Documentation in hand, Owen pulled together stakeholders, wrote a business plan and presented a requisition to hospital leadership. She also had to get a green light from Oregon’s health policy office.

Improvements to care quality are a given with the changes, says Owen. For instance, the replacement is expected to minimize radiation dose to patients and staff. She allows that the financial return on investment is harder to predict, but “we wouldn’t have gone forward with this if we thought our numbers were going to go down. Right now, we have the business to fill all seven rooms, and we certainly feel we can maintain, at least, and go from there.”

She also points out that, although the institution is not affiliated with a medical school, research and teaching are in its mission. “We can accommodate clinical trials; we have the right equipment to support it.” That can make for a persuasive point in a competitive grant proposal. 

Asked to name challenges she anticipates as the room goes from newly live to fully implemented, Owen points to three she knows from past experience: working out bugs that the manufacturer has never seen before (a previous project was plagued for weeks), comprehensively training technologists even on rarely used functions and, most vexing of all, avoiding buyer’s remorse over pricey software add-ons. “You always have physicians who hear the sales pitch from the vendor and insist they have to have just about everything,” says Owen. “Then you get it and they don’t use it.”

Private or bust

If unnecessary outlays are frustrating for hospital departments, they can be crushing to private cardiology practices. Joel Sauer, MBA, vice president of consulting for MedAxiom, a cardiology consultancy firm in Neptune Beach, Fla., notes that, eight years ago, not one of its members was employed by hospitals. In 2012, the count topped 60 percent and, Sauer says, it’s on its way to 80 percent if it isn’t there already. Imaging costs are just one of many pressures causing private practices to yield to acquisition offers from hospitals, but their sheer size suggests they may represent low-hanging fruit for the pruning. Does it ever make sense for a group to neither repair nor replace but, instead, sell off the big-ticket equipment and refer imaging procedures outside?

“Ever is a long time,” replies Sauer, “but when you’re hanging on to your private status by your fingernails, every dollar you can keep is good because it allows you to stay private.”

Sauer points to recent market studies showing that reimbursement’s movement from volume-based to value-based is causing cardiac CT and MR suites to morph from profit centers to cost centers—a factor that is forcing many private groups to “go over to the hospital side.” He adds that nuclear studies and echocardiography have remained profitable, citing a recent MedAxiom survey. The discrepancy is “probably partly due to lobbying,” says Sauer. “You could also argue that tests that were over-reimbursed historically have now gotten to a more appropriate level.”

As for advising private practices on when to make a big imaging buy, Sauer says there’s no formula to follow—“but if your maintenance costs are running one-third of the replacement cost, you have to scratch your head and wonder if you’re making a good business decision by not replacing. And when your service costs hit half the replacement cost, you should have a really hard time writing that check” to prolong the life of equipment that’s not getting any younger.

At that point, quality of care comes into question, too. “It’s nearly medical malpractice to run patients through equipment that is four generations behind on the technology,” says Sauer. “And you have to make darn sure that any new patient-care equipment will talk to your EMR.”

This, of course, may go without saying. “We don’t hear as much about equipment as we used to,” says Sauer, “and that’s partly because people are so focused on IT.”

Innovative drivers

Hearing less is not hearing nothing, and many people are still talking plenty about cardiac imaging equipment. Julianna M. Czum, MD, director of cardiothoracic imaging at Dartmouth-Hitchcock Medical Center in Lebanon, N.H., says it’s impossible to predict how the mix of test orders will change over the next few years—but, if the past is prologue, expect surprises.

Czum describes emerging techniques in coronary CT angiography (CCTA) that have been facilitated, in part, by recent years’ dramatic reductions in radiation doses. Patients slated to receive transcatheter aortic valve replacements, for example, undergo combinations of cardiac CT and abdominal-pelvic arterial CT. This allows for the creation of detailed pre-procedural planning models.

“Lo and behold, some really breakthrough procedure comes along,” she says. “People who never could get the surgery before now can get this alternate procedure and, boom, we’re doing cardiac CTs left and right for them. So something like this can be even more disruptive than the original introduction of coronary CTA.”

Of course, Dartmouth-Hitchcock is a major academic medical center. Most hospitals and private cardiology practices lack the resources to so aggressively explore technology’s bleeding edge. Then again, if it improves care and reduces costs, today’s bleeding edge may become tomorrow’s routine protocol.

Owen offers two quick tips for cardiology administrators hoping for a green light to acquire new imaging equipment. One, get the support of an influential physician who wants the change and can convincingly present the clinical perspective on both expectations and limitations. And two, engage numerous high-level stakeholders—directors or managers of finance, construction, equipment service, health and safety—and involve them often.

“We always start those conversations well ahead of the game so that, when we go out and bid, we know who is responsible for what,” Owen says.  

If all goes as planned, years will pass before it’s time to repeat the process for any one piece of imaging equipment.