"Two years ago, when I knew that 64 slice was a reality and that we were going to be getting it, the question we had to answer was, 'Are we going to be able to participate in this?'" —Michael S. Skulski, MD St Vincent’s Hospital

If you are a family practitioner or a doctor of internal medicine at St Vincent's Hospital, Indianapolis, there is a good chance that a radiologist named Michael S. Skulski, MD, is going to stop you in the corridor or outside the reading room. If you give him a few minutes then—or later—he will show you images of coronary computed tomography angiography (CCTA) and tell you about how it can effectively screen your patients with a risk of coronary artery disease (CAD). Oh, and if you are concerned about your patients being able to afford a study that is still considered investigational by most insurance companies, Skulski will tell you about three innovative financing solutions that were designed specifically for CCTA.

"Two years ago, when I knew that 64 slice was a reality and that we were going to be getting it, the question we had to answer was 'Are we going to be able to participate in this?'" Skulski recalls. "As I would talk to [primary care] doctors that came by and show them images on the computers, my first question was 'If I told you I could do this test for you and it had a very high negative predictive value, is it something that's going to help you manage your patients and your practice more effectively?' And the resounding answer was 'Yes.' Those are the people who are taking care of the patients before they ever see a cardiologist."

Skulski and his colleague, radiologist Anthony Zancanaro, MD, have had a vision for how CCTA could help screen CAD patients through primary care physicians (PCPs) for many years. But it has been only since the development of 64-slice technology, and subsequently learning that St Vincent's was purchasing a $1.5 million LightSpeed VCT 64-slice scanner from GE Healthcare, Waukesha, Wis, that Skulski and Zancanaro put their plan into action.

With the confidence that there would be a demand for CCTA by primary physicians, Skulski and Zancanaro asked their group, Northwest Radiology Network, for support in developing a CCTA screening program. The group agreed and gave Skulski and Zancanaro time for professional development at the Radiological Society of North America, the American College of Radiology, and the American Roentgen Ray Society, and a fellowship course at New Jersey's Atlantic Medical Imaging with David Dowe, MD.

After completing training, Skulski and Zancanaro next approached Gary Fammartino, MBA, the senior vice president for ambulatory and outpatient services at St Vincent's, who already was interested in using the new 64-slice CT for cardiac studies.

"I think one of the things that helped us [with the St Vincent's administration] was that we were progressive, we knew 64 slice was coming, and we educated ourselves before it even arrived," Skulski says. "Then, when it arrived, we said, ‘We have people who are trained to do this now, and we want to start doing it. We want your help to get a program together,' and they fully embraced that concept."

Along with Kathy Holton, the administrative director of radiology, Fammartino began to develop a primary care-focused program and marketing strategy with Skulski and Zancanaro, giving them the resources they needed to build the program at St Vincent's.

A Coronary CTA Pilot Program

Part of St Vincent's support was providing the funds to do a trial CCTA pilot screening program at no cost to the test patients. The main goal of the pilot was to optimize the CCTA process and protocol. Fammartino says that GE Healthcare was instrumental in working with the radiologists to design the process and help educate St Vincent's technologists on the CCTA protocols. (See "CCTA Procedure Protocols" for more information.)

The pilot's subjects included about 100 hospital administrators and employees with CAD risk factors, but none of the patients were clinically symptomatic. Patients ranged from 33 to 79 years of age, with a mean age of 48. The test subjects received a CCTA screening with a coronary calcium scoring component.

"I think calcium scoring is helpful in all patients, but most so in younger patients where coronary artery disease likely will be mild or minimal," Skulski says. "Calcium scoring may help the doctors caring for the patients to institute behavior modification and cholesterol-lowering therapies [prior to when they would have done traditionally]."

Among some of the trial subjects were potential referring PCPs in St Vincent's community. Skulski believes that inviting family physicians to have the test can be helpful because it personally demonstrates to them the power and noninvasive nature of the modality.

"These patients became a walking advertisement for our program," Skulski says. "They told their colleagues, friends, and other referring physicians of their experience. I believe this was invaluable."

In the end, Skulski and Zancanaro honed the CCTA procedure so that a patient could complete the entire test in about 2-1/2 hours and be able to return to work.

Of the 100 test patients—all of whom were asymptomatic of CAD at the time of the study—Skulski says that 10% to 15% were discovered to have moderate to severe CAD and, as a result, their clinical management was modified. "(See Patient Management Results.")

Convincing the Payors

Convincing PCPs that a coronary calcium score or CCTA has benefits for high-risk CAD patients may be easier than convincing an insurance company to pay for the studies.

Skulski has made CCTA presentations to Anthem, the area's largest payor, but the insurance company still lists both coronary calcium scoring (CPT code 71250–CT chest without contrast) and CCTA (CPT code 71275) as investigational.

Anthem's rejection has not stopped Skulski from meeting with Medicare and other payors. "I think we're going to need more specific data as time goes forward," he explains, "and show them that they can save money and also take better care of patients."

Skulski's main argument to payors is that CCTA has a high negative predictive value for CAD, which can save insurers the cost of other more expensive nuclear tests, and perhaps the cost of a cardiology referral, for patients found to have minimal to moderate CAD.

"If you get to these patients before they develop serious disease, you won't have to pay for bypass surgery, and they won't have to see a cardiologist," Skulski says. "You'll save on the additional testing that goes along with these things in the future."

St Vincent's administration also is planning to talk to payors through Bernie Emkes, MD, a former family practitioner and currently St Vincent's medical director for managed care.

Emkes shares Skulski's point of view about the cost- and life-saving benefits of CCTA, as well as the advantages for family care practitioners like himself who want to maintain the management of patients who are found to have minimal disease. But Emkes knows it will be a battle to get the test covered by payors. "The dilemma that I have—and I know the insurers will have the same dilemma—is that this cannot be an add-on."

[National Imaging Associates, a benefits management company, is conducting a national study on whether CCTA can be used as an effective replacement for diagnostic coronary catheterizations and nuclear stress tests. Read more about the study online in our October issue's Payor Watch.]

Coronary CTA Pricing

Because St Vincent's recently finished the pilot and began seeing paying patients beginning October 1, 2006, Skulski warns that prices and marketing are likely to be adjusted.

Currently, St Vincent's charges $1,140 for a CCTA, which includes a coronary calcium scoring procedure and a consultation with the radiologist. Skulski believes the consultation can serve as a significant wake-up call to a patient found to have CAD.

"Any time that I sit down with a patient with risk factors, especially smoking, and they have disease, that's a very powerful time to say to them, 'You've just become an ex-smoker,' " Skulski says.

He also is offering a separate coronary calcium score with a consultation. The charge is $500, but the procedure is a portion of an annual physical work-up package offered by a St Vincent's physician's group to corporate executives.

Skulski recognizes that many people cannot afford to pay $500—let alone $1,140—for the full CCTA package and says that he and St Vincent's are working on lower price offerings.

One idea being discussed is a $300 to $350 coronary calcium scoring package that includes cholesterol screening, which may contain a brief consultation with the radiologist. Skulski notes that if the calcium score shows disease, it may lead to the patient getting a full CCTA.

Financing Program

The hospital administration's commitment to the CCTA program is evidenced by its three financing options that were specifically designed for CCTA procedures.

• The first option is from Personal Finance Company and gives patients/guarantors a contract that allows free financing for up to 12 months. The balance must be $200 or greater, however, and requires a credit application and approval.
• The second financing option is offered through a local branch of Fifth Third Bank, Cincinnati. This program is an installment loan agreement and allows the patient/guarantor to make monthly payments according to the contract. The balance must be greater than $1,000, and the interest rate varies monthly based on the prime rate, although it will not exceed 13%. All patients are approved, regardless of credit history.
• The third program, through CSI Financial Services, San Diego, currently is offering a 12% rate for financed procedures. The balance must be greater than $50, and the guarantor must make a monthly payment of 4% of the balance due. This last option does not require a credit application or approval, but it does require hospital approval.

Skulski also believes that as medical savings accounts become more prevalent, those with a high risk of CAD may use the money in their accounts for CCTA. The real challenge is finding those potential patients.

Out of the View Box

Although some patients can pay $1,140 cash for the CCTA, few are aware of the procedure. Consequently, Skulski, Zancanaro, and St Vincent's are on a mission to educate PCPs, the public, Rotary clubs, office managers—almost anyone with a heartbeat—about the negative predictive value of CCTA and its benefits.

"Radiologists need to get out of the view box and talk to patients and groups of people," Skulski says. "We're very involved in the technologies, but we must be better at communicating with the patients. All they know is that we're on the first bill that shows up, so they just see a doctor's name that they don't identify with. We need to give ourselves a face and a voice with patients, with physician groups, and, ultimately, with the leaders of the communities that we live in."

Skulski is using that out-of-the-view-box philosophy with CCTA and coronary calcium scoring by constantly talking to physicians in the hospital.

"When I'm down in the reading room and physicians are walking by, I show them the images," Skulski says. "I pull up a case and say, ‘I just did this one today; take a look at this. You can see the negative predictive value of this examination; you can see how it can help you.' Or, if it's a cardiologist or vascular person, I say, ‘This is what's problematic for me in this case. Do you have any thoughts about that?' Because we really want to build that collegiality. The best-case scenario for [CCTA] is that we do this together."

When Skulski is not grabbing a physician in the reading room, he is on his way to a primary care group's executive council, where he makes a CCTA presentation. At the end of the presentation, he always asks the physicians about their points of view and how he can effectively relay his information to their group's physicians.

Skulski also is invited to speak at Indianapolis physician associations, which consist of physicians that have quarterly forums. There, he can directly speak to 60 to 90 PCPs in one room. After a 15-minute presentation, he hands out information packets about St Vincent's program and how to order a CCTA, and he provides the name of St Vincent's physician liaison.

Additionally, Skulski is beginning to market directly to groups of high wage earners, setting appointments with big law practices and local corporations that might offer CCTA as a benefit to their executives. These market segments also are mostly likely to have employees contributing to a medical savings account.

Perhaps Skulski's most surprising educational patient outreach is his talks at Kiwanis clubs, Rotary clubs, and other leadership organizations. "You say that's not the greatest use of your time," Skulski says, "but you know what? Those are people who are leaders in their community, and the more people we can talk to who are leaders in their community, the quicker this test is going to be adopted, and the better we're going to be able to take care of patients." At these meetings, Skulski says that his presentations are less technical than at his PCP meetings. In addition to explaining the procedure in lay terms, he stresses the value of peace of mind that a person with a high risk of CAD can have by undergoing a CCTA.

Aside from Skulski's physician outreach, St Vincent's marketing department is working on writing stories about the program for its internal newsletters and promotional magazines, as well as health features on local television news broadcasts. Other future marketing efforts include:

• DVDs to explain CCTA to physicians and patients;
• dinner meetings with a CCTA educational component for PCPs; and
• Calcium-Scoring Saturdays," where a large group of patients can receive a calcium score, radiologist consultation, and cholesterol screening at perhaps $300 to $350.

"Calcium scoring is inexpensive in relation to CCTA because it's a very quick examination," Skulski says. "Probably the total time a patient has to be in your department is 15 minutes. ...And if you really want to help people be preventive, you have to give them a chance to do it—set the price where people will pick you up on it."

Skulski hopes that CCTA can benefit cardiologists as well as radiologists and PCPs, believing that all of the disciplines can use their skills to complement each other. But it remains to be seen how the modality becomes part of the standard of care.

Tor Valenza is a staff writer for  Imaging Economics. For more information, contact
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