Have We Downloaded the Latest Drivers?

by: Wayne Webster

About 4-years ago the diagnostic imaging markets were experiencing explosive growth. As we all now know, the market was heading for the same crash as the housing market a year earlier. The growth was fueled by many things. Primarily the advancement of diagnosis, treatment and wealth were the main drivers with increasing wealth being the largest by far.

I was always amazed how the new equipment vendors could take a fairly unusual application, make the imaging device perform the work and then claim it was the next greatest advancement for mankind. I give you Computed Tomography Angiography (CTA).

You may recall there was no reimbursement for CTA in those heady times 4-years ago. Everyone convinced themselves reimbursement was just a matter of time. There was little need to think about the clinical value. CTA had to be better for patients. It wasn’t invasive, CTA would speed throughput, the cardiology practice could own the device, and the doctor would profit mightily when CTA was employed in the practice. If it’s profitable for the doctor, it has to be good for the patient. Who doesn’t understand that concept?

Well, reimbursement never happened and today a Forbes online article by Larry Husten reports from an article in the recent Journal of the American College of Cardiology (JACC) that CTA may not be worthwhile for people with calcium scores of 600 or above. This seems like a no brainer. If you have a high score, you have a lot of calcified lesions in your coronaries. These are created by soft plaques that harden with the deposition of calcium. So you have heart disease if you have a high calcium score. Why do the test?

In the reverse the CTA technology was found less than useful in those with low calcium scores. My question is why would you test someone with low calcium scores? They most likely don’t have heart disease.

There’s more. Beyond the poor utility of the CTA application, the use of the 64-slice CT results in radiation exposure that is 3-7 times more than a standard catheterization. What we have here is an example of what’s wrong with the system. It’s not about the clinical result. It’s about the money.

It’s outcomes like this that motivate payers to try and fix the system. This week I had an opportunity to visit a larger community hospital with a client to support some ongoing discussions. The department manager demonstrated some real angst about the need for new imaging devices and how the doctors and the administration would never approve any request. I thought about the usual reasons; politics, profitability, renovation costs, etc.  I never found the reason on my own.

We all know many studies have been produced that show if a doctor is allowed to own imaging equipment, he may use or over use it to make money. In this case, three of the major area insurers got together and hatched a plan to lower/limit the costs of medical imaging. The plan is simple and effective. Every time a doctor does not order a scan for a condition in which it is approved, the insurer takes an amount equal to 10% of what they would usually pay for the scan if ordered and puts that money in a pot. At the end of the year the money is returned to the hospital for redistribution to the…you guessed it, doctors.

Last year the pot had ~$14 million for redistribution. With one clever move by the payers, who appear to have conspired to bring down the cost of medical imaging or better put limit the availability of medical imaging procedures, the doctors now work to limit the number of diagnostic imaging tests ordered. This total reversal is from a group, the doctors, who couldn’t live without these imaging tests prior to being paid not to order them.

The studies show when doctors own medical imaging devices they order more tests to make money. Now we have an example of what happens when you can make money not ordering the tests. When doctors can make money not ordering a diagnostic imaging test, they will reduce the volume of referrals to maximize their income. This almost sounds like paying a farmer not to grow a crop in order to keep prices from falling.

As we consider our futures in this business we may find it necessary to look at market drivers separately from those being promoted under the Patient Protection and Affordable Care Act (Obama Care), passed in March of 2010.

Here’s the link to the article on-line: http://www.forbes.com/sites/larryhusten/2012/01/19/ct-angiography-found-less-helpful-in-patients-with-high-calcium-scores/

Thankfully, Pogo always knows just what to say.

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