A certificate-of-need ruling in Missouri has initiated a temporary cease-fire in the medical arms race in St. Louis.
The state's CON committee on Dec. 15 told two hospital operators it would permit them to build only one gamma knife, an expensive radiological device, for both to share.
It's a precedent-setting arrangement in St. Louis, where BJC Health System and St. Louis University Hospital had both proposed building gamma knives, at about $4 million each, at the city's two competing academic medical centers.
The gamma knife uses 201 beams of cobalt in a fixed array that can target radiation on a cancerous tumor or blood vessel malformation. There's no cutting, no blood, no lengthy recovery time. The gamma knife was developed in Sweden in the early 1970s and is marketed by Elekta Instruments in Atlanta. There are 35 of them in the U.S.
State and local business interests pointed out that a patient base of about 7.5 million is needed to support just one of these high-tech installations and pressed the two institutions to find a compromise. The hectic negotiations lasted until the day before the CON committee hearing.
The gamma knife will be installed at BJC's 1,221-bed Barnes-Jewish Hospital in St. Louis, the teaching hospital for Washington University School of Medicine. The machine costs $3 million, and construction of a special bunker costs $700,000.
BJC was the first applicant, in a 50-50 joint venture with HealthSouth Corp. The second application was from 303-bed SLU Hospital and American Shared Hospital Services, based in San Francisco. American Shared owns and operates three gamma knives and has several more in development.
That proposal had been scheduled to be heard by the CON committee Feb. 2. Under Missouri's CON rules, the applicant who files first gets precedence and any subsequent applicant must prove the additional capacity is warranted. Given that the CON staff review found that need wasn't documented for even one gamma knife, the committee would have been unlikely to grant approval for the second one.
The St. Louis Business Health Coalition thought only one gamma knife could be justified, and it asked the players to work out a cooperative arrangement.
In the final compromise, BJC will establish a medical advisory board, which will have equal representation from BJC, SLU and the medical community, said G. Joseph McCarthy, vice president for planning at SLU. That board will set policy for scheduling patients, to ensure equal access for all groups. The device will be located at Barnes-Jewish, but BJC will extend hospital privileges to all admitting physicians who qualify to use it. Ralph Dacey, M.D., neurosurgeon in chief at Barnes-Jewish, was named medical director of the gamma knife.
"It is good news for everybody," McCarthy said. "BJC and Washington University School of Medicine recognized that this is a new technology, and the community needed it. (BJC was) willing to work with SLU physicians."
BJC and SLU have been involved in some joint ventures for ambulance and air ambulance services, but this is the first time they've cooperated on a new piece of medical technology, McCarthy said.
Kristi Short, planning director for BJC, said construction will begin shortly and procedures should start next April or May. She said charges for procedures would be about $2,000 higher than those for a modified linear accelerator, which runs about $18,000 for a course of treatment.
"We believe they'll get more effective treatment because of the precision of the gamma knife, and the fact that it can treat really small lesions without any additional cost," she said.
Missouri already has one gamma knife, at 479-bed Research Medical Center in Kansas City. Its 1993 CON application said its catchment area would include Arkansas, Iowa, Kansas, Missouri, Nebraska and Oklahoma.
Its gamma knife was approved against the CON staff's recommendation and over the objections of two physicians at another hospital.
Arthur Elman, M.D., a radiation oncologist at 508-bed Saint Luke's Hospital in Kansas City, and a neurosurgeon colleague told the 1993 CON hearing that a linear accelerator, modified with updated software, can do the same thing as a gamma knife at a fraction of the cost.
"The dedicated gamma knife, which cannot do anything but treat a head, was not a good selection," Elman said. "We were overruled."
At Saint Luke's, "we just spent about a half a million to upgrade our software and hardware" for a linear accelerator, Elman said. "We feel we have a more versatile system in 1997 than people who use a gamma knife. We're not saying we have superior results; we're saying it is a more cost-effective way of treating patients."
St. Louis already has two linear accelerators, one at Barnes-Jewish and one at 495-bed St. Luke's Hospital in suburban Chesterfield. There is a third at the University of Missouri hospital in Columbia, halfway between St. Louis and Kansas City.
Doctors partial to the gamma knife regard linear accelerators as not quite up to snuff. They think they're yesterday's technology -- inaccurate and slow.
"We haven't been as successful at marketing the linear accelerator," Elman said. "We've never come up with a name that captures the public's attention. The patients are all on the Internet now and they know the term gamma knife."