This policy brief originally appeared in the American Journal of Roentgenology, written by Dr. David Dowe, a radiologist with Atlantic Medical Imaging in Galloway, NJ. The opinions expressed in this policy brief are those of Dr. Dowe; they do not necessarily reflect the viewpoint or position of the editors, reviewers, or publisher of the American Journal of Roentgenology or AuntMinnie.com.
Although conventional cardiac imaging by echocardiography, SPECT stress tests, and catheter angiography has its roots in radiology, these procedures have almost universally slipped away to cardiologists. In some cases, as with SPECT stress examinations, this is because radiologists cannot perform this examination without the participation of cardiologists who perform the stress portion of the examination. Coronary CT angiography (CCTA) is changing this dynamic.
Radiologists are the experts in CT and CTA, which include all aspects of CCTA, and are very capable of performing CCTA independently. The resulting breakup of what for decades has been a monopoly on cardiac imaging by cardiologists has resulted in an aggressive response by cardiologists. Radiologists, in turn, have recognized the tremendous opportunity this is to regain turf in cardiac imaging. This policy brief deals with the three critical elements of how to win this turf back -- that is, imaging quality, service, and marketing -- and addresses strategies for both hospital and private office-based radiologists, and touches on the interaction with managed care companies.
The battle for patients
There has been a lot of heated discussion about which specialist is most qualified to do CCTA. The American Heart Association (AHA) recently published (Circulation, April 4, 2006, Vol. 113:13, pp. 1715-1716) principles in the use of existing and emerging cardiac imaging techniques that stated that imaging studies should be performed by physicians who "meet published standards of training and experience from medical societies accredited by the Accreditation Council for Graduate Medical Education. These procedures should be performed in high-quality laboratories with appropriate facilities and technical personnel who are adequately trained in imaging procedures and related safety standards."
The American College of Radiology (ACR) states as part of its practice guidelines that the physician should have prior qualifications in general and/or thoracic CT interpretation and training in cardiac CT from an approved training program that includes "education in cardiac anatomy, physiology, pathology, and cardiac CT for a time equivalent to at least 30 hours of CME and the interpretation, reporting and/or supervised review of at least 75 cardiac CT examinations in the last 36 months" or "the completion of at least 30 hours of category 1 CME in cardiac imaging ... and the interpretation, reporting and/or supervised review of at least 50 cardiac CT examinations in the last 36 months."
Radiologists can certainly meet these criteria, but training won't be enough. Image quality, service, and marketing also will play a major role in who wins this turf battle.
Image quality translates into diagnostic accuracy. Nobody is going to win the turf war if performing a CCTA results in a patient still getting stress tests and cardiac catheterizations while their competitors are able to more accurately assess a patient for coronary artery disease with one simpler, cheaper test.
Referring primary care providers and medical and surgical specialists are quick to praise CCTA because it prevents a longer and more invasive workup. To create reconstructed coronary artery images of excellent quality, one has to be able to produce axial source images of even greater quality. This requires a careful, thorough approach at the CT scanner by the technologist as well as the radiologist.
Every coronary CTA is tailor-made for each patient at that moment in his or her life. We customize heart rate management -- that is, beta-blocker preparation. We select the proper pitch, milliamperage (mA), and contrast injection rate, and calculate the circulation time for each patient. By doing these things, we maximize image quality, which results in an exponential improvement in the quality of our coronary artery reconstructions. This improves diagnostic accuracy.
By investing 10 minutes and going to the CT scanner to assist the technologist in selecting the critical variables, we save up to 30 minutes at the workstation. This is sometimes difficult for radiologists to accept but it is very much true. By rapidly reconstructing images, we can improve the second critical aspect of winning the turf war: service.
Patients and referring providers dislike the current workup of coronary artery disease because it frequently results in more testing, which may be invasive and take days if not weeks to unfold. Patients and referring providers want an examination that is accurate, noninvasive, and can be rapidly produced and reported.
This begins by prepping the patient with beta-blockers in advance. We provide the beta-blocker before the date of the examination. Patients take the oral beta-blocker at home, then drive themselves to our facility. This markedly diminishes the time the patient spends with us.
More important, by optimizing image quality by being very particular about technique, we are able to process our coronary artery reconstructions rapidly, and show the images and discuss future care with patients before they leave the office. This easily obtainable level of service is so uncommon in medicine that patients are surprised by it. Without provocation, they compare and contrast this with prior workups they have experienced, many for coronary artery disease. Of greater importance, they get to see their images, which when abnormal greatly motivates them to make the changes necessary to improve their health.
"CCTA saves lives every single day and changes lives every single hour" is our motto. One would think that referring providers would balk at us discussing the results with a patient because that is what they do. Contrarily, they have embraced our policy because it results in a much more motivated patient returning to them. We report the examination the same day and call in wet readings of significant positive findings immediately.
What is usually unstated but shouldn't be lost is that these providers greatly prefer sending these patients to radiologists rather than cardiologists because they recognize our expertise in imaging, including CTA everywhere else in the body, and there is no danger of radiologists "stealing the patient" from them. Furthermore, radiologists cannot self-refer. Patients and providers recognize this for different reasons because it has a common ground with them. Patients who get CCTA at our facility get one very accurate examination with immediate results and have to spend less than 30 minutes in our office. This is unheard of in medicine and word quickly spreads.
Radiologists will never gain a shred of market share in cardiac imaging unless they alter their current practice patterns. It is mission critical to go to the scanner and optimize image quality. You should meet with patients and show them their images immediately, or at the very least bring the patient back later in the day. This is the best piece of marketing advice I can give you, but other aspects of marketing also are important. Early on it is advisable that you share your images with everyone. Give patients and referrers alike a CD of the study. Include only images that they will understand and that tell the story that is your report. Coronary CTA images are breathtaking and they sell themselves.
It is important for you to educate your community. Host free public forums to discuss CCTA with patients. Speak before civic and patient groups. Have dinner lectures with those who will likely refer to you, preferably with CME credit offerings. Educate these referrers at a time of day that meets their needs, such as over lunch in their office. Bring a Microsoft PowerPoint presentation, literature, and lunch, and teach them how CCTA will benefit their patients. This need not be a high-tech presentation and it should not be longer than 30 minutes. Patient wellness and executive screening programs have vanished because no one is looking for more opportunities to spend on healthcare.
We frequently use advertising to promote our CCTA practice. We prefer print media but also have used radio and television. This can be expensive, and nothing is more effective anyway than your face-to-face meeting with patients and physicians, and your images.
The battle for payment
In addition to the turf battle, another war wages around CCTA -- the battle for payment. There is growing concern about the potential contribution of cardiac imaging cost to overall healthcare costs. The Medicare Payment Advisory Committee's report to Congress in March 2005 noted recent increases in the use of imaging services within the Medicare program, and Congress also recently has focused its eye on the cost of imaging. It is in this context that reimbursement for CCTA is and will be considered.
It is unlikely that the current T codes used by Medicare will be converted to CPT codes sooner than 2009. Decision to reimburse these T codes is made by your local Medicare carrier. In New Jersey, there is reimbursement for the CCTA code 0146T at a rate similar to that of 71275, CTA of the chest. Private insurers may reimburse for CCTA, but this is more dependent on whether the patient has a PPO plan versus a tightly managed HMO plan. There doesn't seem to be any medical rationale to their decisions.
At our facility, if insurance will not reimburse for CCTA, patients will be asked to pay cash if they qualify for the examination. Patients qualify for the examination if they have a risk factor or are symptomatic. If they do not have cash, we make the examination available based on our needs-assessment policy. Our chief financial officer will assess their income and number of dependents, then determine if they qualify for a free or a reduced-fee examination.
Everything outlined above is achievable whether you work in an office or a hospital. What changes in a hospital is the amount of clout cardiologists carry with hospital administration. It is common for cardiologists to extract CCTA image interpretation privileges despite their often complete lack of CT experience. It is critical that this be limited to their patients and not all CCTA patients.
Radiologists put themselves at risk of extinction if they allow cardiologists and other specialists to divide their professional component income by 50% through split interpretation fees. This fee splitting has come under close scrutiny and in fact is considered illegal by some.
The ACR states "[r]egarding the propriety of split interpretations, the ACR has taken the position that a single qualified physician should be responsible for the supervision and interpretation of cardiac CT and coronary CTA examinations." The ACR encourages radiologists to consult with their corporate attorneys, malpractice carriers, and billing services before participating in these types of relationships because they may violate antikickback laws and increase exposure to medical liability.
Radiologists who are in this type of situation should, at the very least, make certain that their hospital and medical malpractice insurance carrier indemnify them for any errors made by cardiologists interpreting a portion of the examination. We have never entered into these arrangements in either our hospital or offices, and we never will. Eventually hospitals will have to choose whether they want to have a radiology department or not, and accept the legal responsibility of images being interpreted by physicians not qualified to interpret the entire imaging examination.
Insurance carriers are quick to point out that CCTA is a new examination and requires more medical evidence of its effectiveness in diagnosing coronary artery disease. Studies are under way. The ACR practice guidelines list some indications for contrast-enhanced cardiac CT and, the American College of Cardiology has released its appropriateness criteria for the use of CCTA.
Carriers are well aware that CCTA is reimbursed less than SPECT stress tests and cardiac catheterizations. They are also well aware of their financial history with the workup and treatment of coronary artery disease -- these are one of the highest sources of medical loss for insurance carriers. Many carriers suspect that CCTA will not replace other diagnostic examinations and in fact will be complementary, thus increasing the cost of workup even more. They know that CCTA will definitely result in more patients being placed on statin therapy and may result in even more cardiac interventions, therefore, the carriers' decision to reimburse for CCTA is a financial one, and one that they are not ready to make.
CCTA will soon replace stress tests as the first-line test in evaluating patients suspected of having coronary artery disease. It no doubt will replace the elective diagnostic catheterizations whether they are preceded by a stress test or CCTA. Based on the prevalence of coronary artery disease in our population, this represents an avalanche of CT soon to hit the medical community.
Radiologists can only stand to win because none of these patients are in the system now, they have noncardiac CT referrals necessary to make their 64-MDCT scanners profitable, they are well recognized by noncardiologist referrers as the experts in CTA imaging everywhere else in the body, and they are not in a position to "steal the patient." None of this will happen if radiologists do not put the extra effort into maximizing image quality; creating unique, outstanding service models; and marketing themselves to the sources from which they are most likely to receive referrals.
By Dr. David Dowe
AuntMinnie.com contributing writer
October 9, 2006
This article originally appeared in the American Journal of Roentgenology (October 2006, Vol. 187:4, pp.849-852). Reprinted by permission of the ARRS.
Copyright © 2006 American Roentgen Ray Society