Cardiac CT wins one battle, but struggle has just begun

Medicare's decision against a national coverage determination for coronary CT angiography is not the end of conflict for the modality. It is just the beginning. The next battle involves fulfilling the promises the multisociety alliance made to assure the Centers for Medicare and Medicaid Services that its acceptance of coronary CT will not turn into a multibillion-dollar debacle.

Here's the background: In mid-December, CMS proposed a national coverage determination that would have set aside local policies that authorize payment for coronary CT angiography in all 50 states. Instead, CMS would have limited reimbursement for coronary CTA to symptomatic patients with chronic angina at intermediate risk of coronary artery disease and symptomatic patients with unstable angina at low short-term risk of death or intermediate risk of CAD.

To qualify for payment, patients would have had to undergo the procedure at facilities participating in CMS-approved clinical trials. At the same time, Medicare payment would have been denied until the end of the trials to most of the estimated 2000 U.S. facilities equipped with multislice scanners capable of performing coronary CTA.

The reaction from both the radiology and cardiology communities was swift and overwhelmingly negative; there was an underlying concern that CMS had ignored relevant data pointing to the value of coronary CTA as a triage tool and was driven mainly by concern about the cost this new and highly effective technology would add to chest pain workups. Critics of the procedure argued that it might be "layered on" to a long series of other procedures-including perfusion SPECT scans and traditional angiography-and boost costs without improving outcomes.

CMS had good reason to fear the financial ramifications of this technology. Through self-referral practices exempted from federal law, cardiologists have fueled much of the utilization increase that made medical imaging the biggest contributor to the growth of Medicare-covered physician services.

Research by Dr. Vijay Rao, radiology chair at Thomas Jefferson University Hospital in Philadelphia, found that cardiologists experienced a 65% increase in Medicare imaging utilization, from 400 scans per 1000 Medicare beneficiaries in 2000 to nearly 700 scans per 1000 in 2005. The rapid proliferation of cardiac CT-capable scanners in the field and the record-breaking acceptance of coronary CT by local Medicare carriers in 50 states must have raised red flags at Medicare.

In the end, CMS set aside its objections because of compelling research data and assurances from a coalition of imaging societies that a tsunami of coronary CT utilization would not follow. In combination, the societies possess the administrative mechanisms to hold back such a wave:

• Multimodality appropriateness criteria, based on recent clinical trials, could employ decision-tree analysis to define roles for each imaging modality and electrophysiological test that influences diagnosis and treatment planning for coronary artery disease.
• Physician credentialing criteria, already in place for cardiologists and radiologists, could be linked to public and private payment policy.
• Facility accreditation could become another mandatory requirement for payment.

• Preauthorization or integration of appropriateness criteria into physician order entry systems could be considered.

These are potentially harsh measures. The unscrupulous elements within medical imaging that hope to exploit coronary CT are sure to complain. But these steps are necessary to assure that coronary CT is properly applied and that payers remain receptive to the introduction of future imaging technologies.

What are your thoughts on this topic? Please e-mail me at james.brice@cmpmedica.com.