A cardiac CT battle is won, but struggle has just begun

Medicare's decision against a national coverage determination for cardiac CT 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 CCT will not turn into a multibillion-dollar debacle. 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 an estimated 2000 cardiac CT-capable scanners in the field and the record-breaking acceptance of CCT by local Medicare carriers in 50 states must have raised red flags at Medicare. Its evaluation for a CCT national coverage determination revolved around the modality's clinical efficacy, but you can be sure that its fiscal implications were considered as well.In the end, CMS set aside its objections because of compelling research data and assurances from the coalition of imaging societies that a tsunami of CCT utilization would not follow.

In combination, the societies possess the administrative mechanisms to hold back that 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 CCT are sure to complain. But these steps are necessary to assure that CCT is properly applied and that payers remain receptive to the introduction of future imaging technologies.