EBCT reimbursement is, at best, dicey
Payers fearful of screening costs
There is a better chance of being reimbursed for a scan by electron beam computed tomography (EBCT) when there’s chest pain and the test is used diagnostically. While the greatest promise of the machine is screening asymptomatic, healthy people, unfortunately that is the least likely to be reimbursed. "If the procedure is done on an asymptomatic, high-risk patient, your success can depend on how you word your request," says Larry Peters, executive director of LifeTech Cardiac Imaging in Atlanta. "If you say, I want to screen this patient for coronary disease,’ they’ll most often deny payment. But if you list the patient’s specific risk factors hyperlipidemia, high blood pressure and say the physician is concerned about coronary disease, your chances are better."
Laurie Givens, RTR, lead CT technologist at HeartScan Imaging in Pittsburgh, agrees. The Pittsburgh area is covered primarily by Blue Cross-Blue Shield, and EBCT coverage is being reviewed. Right now the company is not paying for the procedure. "We’re working hard with them to convince them to pay by supplying them with scientific literature that shows they need to review their policy," says Givens. HeartScan charges $400.
Medicare and commercial insurance companies typically pay 80% to 100% for diagnostic EBCT.
However, Alan Guerci, MD, director of research at St. Francis Hospital in Roslyn, NY, agrees most payers don’t reimburse for this technology, as yet, when it’s used to screen. "Payers say it’s unproven. That’s arguable, but the fact is, despite all the lip service paid to preventive health care, insurance companies are fearful of the costs associated with screening tests. For example, in New York State, it took ten years and an act of the state legislature to require insurance companies to pay for screening mammography."
In the case of EBCT, 10 to 20 million people a year might undergo scanning for reasonable clinical indications. If you multiply 20 million people by $400 for the test, that’s $8 billion per year. Some of the tests would generate more tests, so the associated costs could be $10 billion per year. "People aren’t being promoted in the insurance industry these days for spending more money," says Guerci. "They have to find ways to save money. The psychology of the marketplace is very different from the way it was 15 to 20 years ago. Even though it’s possible that EBCT would end up saving money in the long run, that remains unproved."
Guerci explains by comparing preventive statins to EBCT. Studies have shown, he says, that cholesterol-lowering medications, statins in particular, can reduce coronary events in patients not only with marked elevations, but with mild-to-moderate and normal elevations as well. Reduction in total mortality occurs only in those with very high levels. Nonfatal heart attacks and hospital admissions for chest pain, however, can be reduced in patients with mild-to-moderate elevations, and there’s no adverse effect. It costs a minimum of $1,000 to $1,200 a year to reduce LDL cholesterol to acceptable levels.
Don’t treat unless there’s high calcification
We cannot afford that cost each year, he continues, so why not scan middle-aged patients for whom the physician is contemplating initiation of therapy with one of the statins? "If we ran the EBCT scan first and the score was low, we could save $1,200 a year. Four or five years later, the scan could be repeated. That approach pays for itself if you end up not treating just 7% of the patients. In other words, if 93% of the patients needed cholesterol-lowering therapy, we’d break even."
Isolated hypercholesterolemia is not a powerful risk factor unless it’s very high 350 to 400. It’s when a cholesterol level of 225 to 245 is mixed with factors such as smoking, diabetes, family history, and high blood pressure that your risk goes up substantially.
"You could adopt this approach," says Guerci. "You choose people with normal-to-moderately elevated cholesterol and treat them if they have two or more other risk factors for coronary disease. But if they have none or only one other risk factor, you don’t treat them unless the EBCT shows a high calcification. If you took that approach, it would save huge amounts of money without jeopardizing people’s lives."
"Reimbursement for the coronary artery scan is spotty," says Peters. "It almost seems schizophrenic because we may bill the same insurance carrier with exactly the same codes on five different occasions and get different responses. I think it depends on the individual who processes the claim. Some of the HMOs pay every time for us, and some absolutely refuse to pay."
LifeTech charges $500 for the technical component, then the cardiologist charges another $150 to interpret the result. "Our facility is probably on the high end," Peters says, "but this technology is very cost-effective."
LifeTech’s EBCT costs more than most stress tests, but it costs less then a stress thallium. Stress tests, too, are given both for chest pain and for screening, but they produce information that may be inaccurate and incomplete. If the patient still has pain, whether the stress test is negative or positive, you have to run another test. If you run an EBCT on a patient with chest pain and there’s no coronary disease, you can, with a high degree of confidence, know that the patient doesn’t have a cardiac issue. They may have reflux, hernia, or another noncardiac condition, so no further cardiac testing is necessary. If, on the other hand, there is even a minimal score, the physician will tell the patient he or she has a disease process going on and, although it’s in early stages, he or she needs to take aggressive action. That leads to more long-term cost savings.
"The EBCT is the future of cardiology," says Peters. "Eventually people will realize that if you take preventive action upfront, your long-term savings are tremendous."
"We use EBCT primarily to screen the asymptomatic population for coronary artery disease," says Givens. "Patients have risk factors but no chest pain. The payers see the procedure as a preventive measure, so they won’t pay."
That seems to run against logic since catching someone in the early stages saves the insurance company money in the long run. Armed with information from the EBCT, physicians can encourage patients to change their lifestyles and save the cost of eventual bypass surgery or angioplasty. About 600,000 people undergo bypass surgery each year, and another 900,000 have angioplasties.
They want to know how well they’re doing afterward, but they don’t want to have to submit to yet another highly invasive procedure. "A lot of patients are complaining to their payers urging them to pay," says Givens. "Some of our work is self-referred so patients pay on their own."
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