CINDY SANDERS

Echo, SPECT, PET, MRI, CTA, EKG, Ultrasound –– So many options … so few insurance dollars.

Over the past several decades, technology has increased to a point where cardiac care providers truly have a proliferation of diagnostic and screening tools available to them. However, creating universally accepted guidelines to determine which tests are most appropriate for any given patient haven’t been easy to come by.

The motivation behind ordering a battery of tests varies. Everything from a desire to provide the most technologically advanced care to practicing defensive medicine can factor into a physician’s order for multiple imaging studies. However, the “more is more” mentality is beginning to come into question.

Mounting concerns over the sustainability of Medicare and Medicaid coupled with private sector worries about the continued viability of individual carriers have led a number of groups and organizations to delve into the concept of access vs. excess.

It seems politics isn’t the only market sector to create strange bedfellows. Late last fall, the American College of Cardiology (ACC) launched a pilot program with UnitedHealthcare to assist physicians in adhering to ACC-established guidelines regarding the appropriateness of using Single-Photon Emission Computed Tomography Myocardial Perfusion Imaging (SPECT MPI).

Dr. Robert C. Hendel, who chairs the Appropriateness Criteria Evaluation pilot project for the ACC, said the organization’s leadership recognizes imaging utilization concerns exist and has been looking at the issue for the past several years. He added the ACC readily acknowledges the rate of growth in medical imaging has far exceeded that of other procedures.

In a 2005 statement to subcommittee members of the U.S. House of Representatives, Mark Miller, PhD, executive director of the Medicare Payment Advisory Commission, noted: “Diagnostic imaging services paid under Medicare’s physician fee schedule grew more rapidly than any other type of physician service between 1999 and 2003. While the sum of all physician services grew 22 percent in those years, imaging services grew twice as fast, by 45 percent.”

However, Miller also underscored the benefits of imaging technology and the promise newer measures hold for improved diagnosis, treatment and outcomes.

“It’s not a question of whether or not it provides good information, both diagnostic and risk stratification,” Hendel said of imaging technology, “but is it the right test for the right patient at the right time done in the right way?”

To that end, Hendel, who is also a member of the ACC’s overarching Appropriateness Criteria Working Group and past president of the American Society of Nuclear Cardiology, said the ACC published utilization criteria for SPECT MPI in October 2005. The group looked at 52 indications and decided whether or not the imaging test was appropriate for each based on current evidence and consensus. Of the group, a dozen indications were deemed improper.

“So really,” he said, “the dawn of appropriateness of testing happened then.”

Hendel added that since 2005, the ACC has been going through other imaging modalities and evaluating indications for use. He also noted this isn’t a static process and that the workgroup would revisit criteria as new data and studies become available.

According to the ACC, the pilot project, which was launched at 10 sites across the country, is designed to help physicians evaluate their performance by providing feedback about their use of SPECT MPI based upon empirical appropriateness criteria set forth by the ACC and ASNC.

Hendel said no one expects a participating site to hit the 100 percent “appropriateness” mark because there will always be exceptions to the set criteria. However, he continued, the feedback ought to help providers see patterns of inappropriate use.

“This has created quite a lot of excitement, as well as concern,” Hendel said of the ACC’s recent push. “We’re hearing from insurance plans and Capitol Hill that they’re pleased the American College of Cardiology is willing to re-look at criteria.

“We believe this is the right approach,” he added of those concerned that testing might be deemed inappropriate for some patients. “We know these tests are valuable, but are they clinically appropriate for specific clinical indications and at a specific time?” he questioned.

“We want to be stewards of our profession,” Hendel continued. “Is there something we can do to practice good medicine but in an economically responsible way?”

It’s a question being asked by other stakeholders, as well. This past summer, Nashville-based MedSolutions launched Outcomes-Focused Cardiac Imaging™ in an attempt to help providers find that balance. The management tool is designed to evaluate imaging options to promote the delivery of the most clinically appropriate tests.

Ultimately, radiology benefits managers (RBMs), payers and a growing number of physicians believe ordering unnecessary or inappropriate tests isn’t practicing good medicine, although the stakeholders often differ on the specific criteria used to determine appropriateness.

Hendel said a chief concern the ACC has with RBMs is a lack of transparency.

“All of them say they base on appropriateness criteria, but we don’t get to see it because it’s ‘proprietary,’” he said. “The not-so-secret mission here is they want to reduce volume.”

Again, he stressed, the goal of the ACC is to reduce unnecessary tests but not at the expense of performing tests that are valuable and necessary.

One of the problems, said Dr. Jennifer B. Meko, western regional medical director for MedSolutions, is there are not a lot of large-scale, head-to-head studies comparing imaging tests in various clinical situations.

“A lot of the published guidelines out there are based on consensus,” explained the cardiothoracic surgeon.

Still, it’s a starting point. MedSolutions created their appropriateness criteria based on guidelines from the American College of Radiology with input from health plan clients, providers and their own medical staff.

“Sometimes we suggest an imaging modality that will give the same answer to the question being asked but is more cost effective,” she said of preauthorization requests. “It’s not always about cost, though,” Meko continued. “Sometimes we suggest more expensive tests if that’s best for the patient.”

The bottom line, she added, is to select the right test to answer the clinical question in the most cost effective manner.

Recently, MedSolutions has focused attention on guidelines for the appropriate use of Coronary Computed Tomographic Angiography (CTA), which has seen a rapid rise in popularity.

“It’s very useful in some particular clinical situations,” Meko said, “but it’s not useful across the board as a screening tool.”

Proponents of CTA say the less invasive screen reduces the need for cardiac catheterization in the diagnosis of coronary artery disease (CAD). However, Meko pointed out, officials with Centers for Medicare and Medicaid Services (CMS) have become concerned over the increasing use of CTA despite a lack of solid clinical evidence demonstrating improved patient outcomes

In June 2007, CMS initiated a national coverage analysis on the topic specifically reviewing available data in regards to using CTA as a substitute for invasive coronary angiography and to evaluate chest pain in the emergency department.

In her comments to the federal agency, Meko urged CMS “to consider coverage with evidence development as the appropriate decision regarding reimbursement.”

She added that with CTA, in particular, the decision to employ this method should be considered in the context of other imaging modalities.

However, Meko also stated in her comments that “CTA is very useful in ruling out coronary disease in patients with equivocal functional stress tests” and “definitely has the potential to contribute greatly to the diagnosis and management of cardiac patients.” Ultimately, she called for a better understanding of the costs, benefits, limitations and appropriateness of CTA in a systemic, evidence-based manner.

In mid-December, CMS posted a national coverage determination for Cardiac CTA for the diagnosis of CAD (www.cms.hhs.gov/mcd/viewtrackingsheet.asp?id=206), which calls for more study but did find promising evidence for two clinical indications leading to coverage with evidence development for those specific situations (symptomatic patients with chronic stable angina at intermediate risk of CAD and symptomatic patients with unstable angina at low risk of short-term death and intermediate risk of CAD).

Hendel noted the ACC, which has already created appropriateness criteria for CTA, is also responding to the CMS decision and will likely suggest a clinical trial and registry to better capture data.

The recent focus on SPECT MPI and Cardiac CTA highlights the need for continuing dialogue between payers, providers and patients. Ultimately, stakeholders hope that practicing sound medicine while being cognizant of fiscal restraint won’t prove to be mutually exclusive endeavors.



February 2008