Cardiovascular Business - March/April 2008 - (Page 26) CORONARy INTERVENTION: FINANCIAL FACTORS FACING CATH LABS Reasons for Decline in PCI Normalized to 100 ESC 110 105 100 95 90 85 80 75 Sep Oct Nov Dec Jan Feb Mar Apr May Jun FDC Panel COURAGE PCI ~10% decline 86% Jul Aug 89% Sep 2006 2007 studies and issued guidelines and their media coverage drove a 10 percent decline in coronary interventional procedures. These drivers include the European society of Cardiology’s release of the first European Guidelines on Percutaneous Coronary interventions (PCi); the FdA’s drug-eluting stents advisory panel recommending that the agency change the labels of the two approved coronary devices to warn that off-label use may increase the risk of thrombosis, myocardial infarction, and death; and results of the COUrAGE trial. (source: Boston scientific) ter handle on their patient population rather than referring them and their business on to larger facilities, says U. Joseph Schoepf, MD, an associate professor of radiology and director of CT research and development at the Medical University of South Carolina in Charleston. Maloney agrees with Schoepf. He points out that before MDCT, younger patients would have been referred to the cath lab for angina. Now, CT, as a triage tool for low- to intermediate-risk patients can keep them out of the cath lab when tests are negative. “Multislice CT is definitely going to take off,” he says, which will help balance the field between smaller facilities and larger, academic medical centers that have invested in state-of-the-art cath labs. Another financial aspect of MDCT is its ability to prevent rather than cure, says Furqan H. Tejani, MD, director of advanced cardiovascular imaging at Long Island College Hospital in Brooklyn, N.Y. “If you can prevent a sentinel event, even one, the cost containment is large enough that one MI prevented is enough to pay for 10 patients’ CT angiography.” That’s crucial right now as the Centers for Medicare & Medicaid Services continues to scrutinize the evidence supporting CT angiography. While CMS at this point has chosen to allow local Medicare carriers to pay for CT angiography, it can still decide in the future to restrict payment. If the agency restricts reimbursement for CT angiography, the technique could go the way of MR, says Tejani. CMS has taken a very long time to adequately reimburse for cardiac MR. “When you take the financial incentive out of certain technologies, adoption becomes very slow.” Physicians are seeing more gatekeeping from insurance companies, says North Shore University’s Green. Insurers are refusing nuclear stress tests on patients who would have been routinely triaged to that test two years ago. Mild symptoms or no symptoms means all testing stops and this patient population doesn’t make it to the cath lab for intervention. About $300 billion of annual healthcare expenditures in the United States pays for the assessment and care of ischemic heart disease. Medicare and other payers are increasing their scrutiny of these expenditures, which makes MDCT ideal for the cardiac community, says Schoepf. “A CT scanner is an ideal tool to keep growth in healthcare spending in check. It allows you to end up with the same diagnostic information from diagnostic catheterization at a fraction of the cost.” There is some debate as to what is the best gatekeeper test for cardiac patients: stress test, CT angiography or cardiac catheterization. The initial thought was that CT angiography would decrease stress testing but Tejani says the opposite is happening. “We see plaques or lesions and want to assess whether they are hemodynamically significant.” Patients with a moderate risk of coronary artery disease, moderate stenosis and positive stress test results end up in the cath lab. “CT angiography has taken away some of the negative caths but it hasn’t actually reduced the number of caths being done.” The majority of coronary caths—60 percent—are for diagnostic purposes and unconnected to any type of intervention. Typically, reimbursement for diagnostic cath without therapy is a wash, says Schoepf. “By utilizing CT to rule out significant stenosis and, therefore, eliminating an unnecessary cath procedure and intervention, cath labs can make better use of cath suite time, which typically results in a better reimbursement scheme.” Tejani says that a real-world registry would help the medical community get enough information to accurately establish a gatekeeper test. A central repository would help determine whether the current clinical hypothesis requires little or substantial change. “If sensitivity and specificity precipitately drop, then CT angiography is not a good test for the emergency department, where the majority of cardiac admissions originate.” The only way to determine exactly where this test fits in is by doing extensive registry of these patients, he says. Meanwhile, physicians are performing the study on a few patients and trying to come up with their own consensus statement, but, “clinical anecdotes have no value in clinical medicine,” Tejani says. It may be inevitable that CT becomes a part of the evolving role of interventional cardiologists: to what degree, remains to be seen. In the short-term, it’s clear that leaders in cardiology departments are responding to the changing healthcare market by initiating several steps: opening up cath labs to other specialists; incorporating multi-imaging modalities into their labs; and reaching out to physicians and consumers alike to educate and inform them about the new possibilities in interventional cardiology. 26 Cardiovascular Business March/April 2008
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