Haunted by a family history of heart disease and uneasily facing his 50th birthday, Alan Muney couldn't resist the offer to undergo a cardiac computed tomography test that his employer, Oxford Health Plans, in most cases won't pay for.
Muney, executive vice president and chief medical officer of the insurer, never experienced any symptoms of heart disease, but his father suffered a massive heart attack when he was 45 years old and died at 49. Both his grandfathers also died of heart disease. Muney has been under a cardiologist's care and was considering another stress test, which he had passed with flying colors in the past, but a radiologist colleague suggested a CT angiography instead. Though not well accepted by cardiologists yet, "the radiology community believes it is going to be the up-and-coming thing, so I volunteered," Muney says.
Some cardiologists may view this new technology as a Trojan horse, commandeered by radiologists prepared to steal away their business--if they don't steal it from the radiologists first. CT is growing increasingly adept at quickly capturing three-dimensional X-ray images, and there is little doubt that it will eventually become a key diagnostic tool in detecting life-threatening plaque buildup in the coronary arteries. The only question is when. Certainly it is not expected until public programs and private payers uniformly reimburse for it.
"I don't think it's quite ready for prime time," says Barry Katzen, an interventional radiologist who is founder and medical director of the Miami (Fla.) Cardiac and Vascular Institute at 551-bed Baptist Hospital of Miami. "We're very excited about it. It is definitely going to change the paradigm of how the coronary arteries are looked at."
A new tool or just a new cost?
When it does become a standard, it is still uncertain whether CT angiography as a screening tool will become yet another cost layer or a substitution for existing technologies. Some such as Muney predict it will replace, upstream, the standard stress test, a nuclear-based physiological test that is ubiquitous in cardiologists' offices but tends to produce a lot of false-positive results. Others such as Katzen say they believe that, downstream, it will eventually offer a patient-friendly substitution for diagnostic cardiac catheterization, also known as coronary angiography, a lucrative invasive procedure for peeking into coronary arteries that helps fortify the bottom line of hospitals that offer it. (Magnetic resonance imaging also is quickly becoming a standard for noninvasive imaging of the peripheral areas of the cardiovascular system, but cardiologists are less likely to co-opt it because of the technology's sophistication and cost.)
Discarding diagnostic catheterization in favor of CT angiography could be an economic boon for hospitals as long as they are prepared to mediate the inevitable battles between cardiologists and radiologists. The noninvasive, diagnostic alternative to cardiac catheterization can screen patients in a fraction of the time and could free staff-intensive catheterization laboratory space. In the process, it promises to dramatically boost volumes for more profitable therapeutic procedures employing cardiac catheterization, such as coronary angioplasty and stenting, the standard of care for clearing and then propping open narrowed coronary arteries.
What's more worrisome for hospital executives is deciding which specialty will own CT technology in the hospital's cardiovascular suite.
"Most cardiologists have agreements with their hospital that they will do all the (cardiology) interpretation. On the other hand, hospitals also have agreements with radiology groups that they will do all the study interpretations for MRI and CT. That's where the war begins," says Brett Hickman, national director of the healthcare consulting practice for PricewaterhouseCoopers. "They both say they own it, and the only person that ends up in the middle is the hospital."
It's a significant issue that could make or break a hospital's competitive edge. Cardiovascular services can represent 60% of a hospital's net revenue and 150% of their bottom-line profits, subsidizing unprofitable operations, Hickman says. "Most hospitals, if they lose their cardiac-service line, are in deep trouble," he says.
Rumors of war
Although no one who has survived the reportedly bruising disagreements is eager to talk about it, stories about turf wars between radiologists and cardiologists have been legion. Indeed, radiologists were once the proprietors of stress testing and cardiac catheterization until cardiologists co-opted those modalities, says Stephen Koch, medical director of Imaging Heart, a New York-based company that offers cardiac CT, relying heavily on referrals from cardiology groups. Cardiologists can easily justify the need to oversee a stress test in case something goes awry for the patient, and it's a relatively inexpensive technology to install in a private practice. For many of the same reasons, radiologists would want a cardiologist on hand when performing a cardiac catheterization, Koch says.
But CT is different.
"There are going to be huge turf wars," Koch says. "What's different now is that CT imaging is the bread and butter of radiology groups."
Cardiologists first put nuclear stress testing in their offices--for as much as $600,000--when hospitals barred them from reading the nuclear portions of the exams, says Karen Hartman, vice president of Corazon Consulting, a firm specializing in cardiovascular programs. She estimates that as many as 80% of all cardiology offices have purchased the technology. Some cardiologists likewise will move to bring CT into their practices, but the winners in the end will be the hospitals that successfully bring the two specialties together, she says. Hospitals that allow the animosity to fester could face the same situation as a community hospital she left unnamed. A key radiology group left the facility after cardiologists exclusively were given peripheral vascular services, Hartman says.
There is not much time to deal with the issues: In the next few months the 32-slice CT will be introduced, offering more detectors for even better resolution and speed, she notes.
Rapidly advancing multislice CT technology has paved the way for its inroads into the cardiovascular suite, especially the introduction of the 16-slice machine in 2002, says Bernd Ohnesorge, vice president of the CT division of Siemens Medical Solutions. The 16-slice CT, priced at approximately $1.2 million, offered image resolution and speed that made it conducive to capturing the small anatomy of a beating heart, from the arteries carrying life-giving blood to small lesions that could impede that flow.
Philips Medical Systems introduced its 16-slice version in late June. Its freeze-frame imaging has the capability to capture an image of most hearts at less than 120 beats per minute, and it requires patients to hold their breath for only 15 seconds compared with the 55 seconds that older technology required, says Phillip Prather, Philips' market director of cardiology products.
Ohnesorge estimates that among the four major vendors--GE Medical Systems, Philips, Siemens and Toshiba America Medical Systems--some 2,500 16-slice scanners have been sold worldwide with more than 600 used exclusively for cardiac imaging.
Making a case
The business case for cardiac CT is building, even if reimbursement is spotty at best. Image to image, CT has many advantages over diagnostic cardiac catheterization in patient turnaround. One CT machine can easily push through one patient every 15 minutes, Prather says. Meanwhile, catheterization labs at best can turn around about one patient per hour, he says.
However, if the coronary angiogram uncovers a problem requiring an intervention in the same setting--and as many as 70% of them do--"your schedule is blown for the day," Hickman says. "An interventional procedure can absorb 30% to 50% of the capacity of your cath lab," costing the hospital much-needed revenue if the catheterization laboratory's fixed resources aren't managed properly, he says.
Ultimately, taking the diagnostic procedures out of the catheterization lab to make more time for therapeutic procedures will bring in more revenue for the hospital, says DeAnn Haas, global marketing manager of cardiac CT for GE Medical Systems. Haas says most of GE's customers are radiologists purchasing cardiac applications for their multislice scanners. She estimates that 75% of the multislice scanners that are sold are leaving GE with cardiac applications built into them.
Still, the two-dimensional images provided by a diagnostic cardiac catheterization remain the gold standard, especially since CT could not replace subsequent interventional procedures, such as stenting, that might be needed as a result of the exam, Ohnesorge says. But in the next three to five years, he predicts technologies will merge so that CT imaging also will become a part of interventional procedures. But currently CT can "be an alternative in a select group of patients for ruling out the presence of disease," he says.
Hickman says CT angiography would open the market to "a whole new population"--between ages 35 and 45 with no symptoms but a family history of heart disease--who wouldn't consider undergoing a diagnostic catheterization, knowing the high odds of a problem being found.
The potential new market raises questions regarding the new technology's cost, especially in light of a study released last month that found that the more a technology is available, the more it gets used, fueling greater healthcare spending (Nov. 10, p. 9). Of four areas examined in the study--cancer, cardiac and newborn care and diagnostic imaging--the researchers found free-standing diagnostic imaging had the strongest link between higher availability and higher spending.
"There's always a potential that with new things like (CT angiography) the technology will get added on," says Laurence Baker, the lead author of the study, which was released by the journal Health Affairs and bankrolled by the Blue Cross and Blue Shield Association. "Giving everyone a CT instead of a catheterization would look like a cost savings, but there is a dynamic aspect." The new market of patients Hickman describes could generate a lot of additional procedures, Baker notes. Then again, if those additional procedures save lives "it all comes down to cost benefit," Baker says.
Studying the costs
A study examining the clinical and economic efficacy of screening cardiac patients with CT and other imaging modalities is under way at 905-bed Mount Sinai Medical Center in New York. Patients with no symptoms but a 20% or greater risk of suffering a heart attack in the next 10 years are undergoing four different exams, including CT angiography and MRI. Valentin Fuster, director of Mount Sinai's cardiovascular institute, says as much as 10% of the population over the age of 30 is in this risk group. The study is funded by the National Institutes of Health and a consortium that includes imaging vendors.
Fuster says he is certain the technology will prove less expensive. CT angiography costs about $600 per procedure and about the same for MRI images, but costs can run to as much as $3,000 for a diagnostic catheterization, he says. "We cannot go into 10% of the population who don't have symptoms at all and do catheterization," Fuster says. "These noninvasive technologies are going to be incredibly important in the future."
Although trained as a cardiologist, Fuster brought MRI as a cardiac diagnostic technique to Mount Sinai, putting it in the radiology department because "radiologists have better infrastructure technologies," he says. But it's a technology "that needs to be shared" by both specialties, he says.
Mount Sinai never became the victim of turf battles because "we both realized that was a losing strategy," says Burton Drayer, Mount Sinai's chairman, professor of radiology and executive vice president of hospital and clinical affairs. "When you think in terms of turf, you think in terms of failure. No one wins a turf battle. ... The winning strategy is for everybody to collaborate."
Heart patients are referred to radiology at Mount Sinai through the cardiologists, but the technical expertise for accomplishing CT angiography and cardiac MRI is supplied by the radiologists, Drayer says. Although noninvasive tests such as CT angiography might seem to take some business away from the catheterization lab, Drayer insists that everyone will win because of the much higher volume of patients who will be screened earlier for heart disease.
As to whether earlier detection represents a win for the healthcare system as a whole, "that will be argued over the next 100 years," Drayer says. "I think society is requesting of us that we are able to look at them in a noninvasive manner and tell them whether anything is wrong, so I only see the numbers increasing as they become more health-conscious."
It's a double-edged sword, he adds, because with more patients being screened, more patients are found to have something wrong, "and then you are forced to move on to the next step. ... When you have almost miraculous techniques, you begin to see almost too much." Drayer says he "would hope" that by 2010, the typical cardiac catheterization will be therapeutic rather than diagnostic.
Katzen of the Miami Cardiac and Vascular Institute already is thinking about the day when CT technology fully arrives in cardiovascular suites, and when that happens, there will be "a tremendous impact," he says. For one, patients won't need cardiologists any longer for referrals; primary-care physicians and internists will be able to order the procedure. That scenario would seem to alienate cardiologists, but from the day the institute was opened in 1987, "we tried to build an infrastructure dedicated to the delivery of integrated cardiology care," he says. "The idea was to bring all the disciplines of care together--cardiologists, vascular surgeons, neurologists, nephrologists--all of whom participate. ... We wanted to treat the cardiovascular system as a single system."
The cardiac institute--which includes about 100 cardiologists, 15 interventional cardiologists, eight interventional radiologists, three fellows and four radiologists dedicated to noninvasive cardiovascular imaging--has dealt with turf issues before, such as when pacemaker technology arrived, setting up a potential battle between surgeons and cardiologists, Katzen says. "Philosophically we view a wholesale shift of work from one discipline to another as not a particularly healthy thing politically. So we take steps to achieve balance," he says.
Based on past experience with vascular imaging in noncoronary areas, Katzen says they know that less-invasive techniques such as CT angiography can replace about 70% of corresponding invasive procedures such as coronary angiography. "What we're looking at in terms of the future is to create teams of physicians that would involve cardiology and radiology," he says. Right now cardiologists are reading coronary angiograms, but "if images are acquired in another modality, my feeling is those people would be involved along with radiology in the interpretation. The question is going to be how to partner and I think here's where having a multidisciplinary environment helps," Katzen says.
Currently, the Miami institute performs as many as four CT angiographies a month at the request of physicians or patients, he says.
When the technology does fully arrive, Katzen, like Drayer, says CT angiography will eventually substitute for coronary angiography, boosting the volume of invasive therapeutic procedures as the number of diagnostic catheterizations decline.
It's the referrals, stupid
One place where CT angiography has fully arrived is at Imaging Heart in New York. The company is a sister to Imaging for Life, a retail imaging center that opened in late 2001 targeting worried baby boomers and offering self-pay tests such as virtual colonoscopy and full-body scans, which similarly rely on CT technology. Many of these entrepreneurial screening centers that briefly flourished around the country have closed this year, says Monali Patel, industry manager of medical imaging at Frost & Sullivan, a consulting and research firm. The retail centers failed because other than radiologists, physicians never bought into the concept, refusing to generate the much-needed referrals.
But Imaging Heart is thriving--and getting reimbursed for it, says Koch, its medical director.
"It's a billable event," Koch says. "We wanted to separate (Imaging Heart) from the self-pay endeavor. It's a completely different animal."
In October, the center used CT to scan 200 hearts, with at least 80% of those patients referred by cardiologists, he says. The center also is talking with two hospitals he declined to name about bringing the program to their radiology department and there are also discussions with several multispecialty groups, he adds.
Koch says the company is working with the largest interventional cardiology groups in the New York area, screening patients "with atypical chest pains," a big gray area of patients who often receive inconclusive results from other tests.
Koch declines to explain how he is able to bill Medicare and other payers for the procedure for fear of cluing in the competition. But "cardiologists love me because I'm including them. I work with them," he says.
Radiologists should guard their territory, he says. Cardiologists gained control of stress testing, he says, because they "influenced billing codes to keep it in their domain. The only way radiologists are going to keep CT angiography in their domain is by controlling the billing codes."
Prather of Philips says that as a vendor he has seen all the scenarios: working alliances between radiology and cardiology groups and also some animosity.
"One thing to realize is that patient access is one thing that gives radiologists trouble each time," Prather says. "They don't have their own patients and they need referrals. If there is going to be a change with radiology taking more ownership of cardiac CT, they will need to take more responsibility of the patient or the referral pattern needs to change."
Muney of Oxford says the images produced by his CT angiography "were unbelievable in terms of quality." The results gave him a clean bill of health and peace of mind. Still, he says he believes it should remain an elective procedure for the time being until guidelines are established to ensure that the technology does not become overused in the same way nuclear cardiology arguably has become now that most cardiologists have the wherewithal to provide it in their offices. When they have it, they use it more, Muney says, echoing the findings of Baker's study.
"It's a good example of how medicine continually pushes the envelope," Muney says.