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How much does it cost to offer Cardiac PET?

Posted on: 09.13.18

As imaging technology continues to advance, Cardiac PET MPI is gaining more awareness in today’s clinical market. In recent years, the modality has seen growth and is generating interest among cardiologists.

While the diagnostic benefits of Cardiac PET are clear, it’s important to understand the financials and investments needed to offer the service before making a commitment. In this post we’ll explore five aspects to consider as you evaluate Cardiac PET.

1. Equipment Requirements

If you decide to offer PET imaging, you’ll need to choose between the purchase of a new imaging system, or refurbished. It’s common for pre-owned options to be 8-10 year-old traditional PET cameras that have been refurbished to factory standards for technology and performance.

Many of these older cameras use line sources to perform attenuation correction. Generally, the camera and attenuation correction sources are considered the acquisition component. It’s often bundled with a new processing workstation that employs some of the latest cardiac processing features, including coronary flow information.

Depending upon the manufacturer, a refurbished system can cost between $350,000 and $450,000, but because there is limited availability in the secondary market, they’re also subject to the law of supply and demand.

An additional factor in the equipment equation should be your maintenance and repair costs, which, for a pre-owned system, will typically range from $80,000 -$85,000 annually.

If you’re considering a refurbished model, it’s important to do business with a reputable company. Keeping quality and service in mind, a trustworthy organization will help you find the best fit for your investment.

The alternative option is to purchase a new PET MPI camera. Most modern PET imagers include a CT component that provides attenuation correction. Most new PET/CT imagers cost over $1,500,000 and are a significantly higher investment than the cost of a refurbished model.

New cameras come with various levels of CT sophistication, some of which can perform calcium scoring and coronary vessel imaging. If you’re contemplating the larger investment, you might want to consider purchasing the most sophisticated camera your budget can afford, and offset the cost by the additional tests you can offer your patients.

It’s important to remember that regardless of which new PET/CT model you choose, you’ll need to spend 10-12% of the purchase price for annual repair and maintenance costs.

Many cardiology practices choose the refurbished route. When you do the math, depreciating $350,000 over 72 months is a lot easier to digest than $1,500,000 over the same time period. The sticker shock alone prevents some practices from considering the more sophisticated tests.

2. Radiopharmaceutical Expenses

The radiopharmaceuticals used with PET MPI are a significant component of the monthly cost in offering the modality. If you’re using the Rubidium-82 radiotracer, you can expect to pay between $40,000 and $45,000 each month, depending upon your study volume, the size of your generator, and the length of your contract. Supply contracts are generally a minimum of 1 year but are typically negotiated for 3-year terms.

13n-ammonia is an alternative radiotracer, but its practicality and cost make it prohibitive. A unit dose solution, however, is known to be in clinical trials, which may or may not lead to commercial availability within 3-5 years.

3. Staffing Considerations

If your practice is offering SPECT imaging in-house, your current nuclear technologist should have the educational background and licensing required to perform PET studies as well. While they may not have direct PET/CT expertise, your technologists can easily be trained. The only procedural difference between SPECT and PET MPI is the type of stress imposed on the patient. SPECT imaging includes both chemical and mechanical while PET includes only chemical stress. It does not require the use of a treadmill.

When you purchase a PET camera, the manufacturer will include applications training, as will the generator or cyclotron company.

Depending upon your volume, one technologist may be able to manage the workflow. You might also consider adding an assistant if an additional technologist isn’t warranted. Generally, adding PET MPI to your services should not affect your staffing, unless, of course, your volume is such that both your SPECT and PET imaging are significant enough to require an additional team member.

4. Facility Requirements

Adding a PET camera to your office may require some site planning considerations. The PET camera is significantly larger than the typical SPECT camera. Since you’ll be keeping your SPECT camera, you’ll not only need additional space, it will also have to be larger than what you have allotted for your SPECT camera. A 15’x20’ – 20’x30’ room could accommodate a PET camera, depending on the manufacturer. The space will also need to be lead-lined for radiation shielding. If your office square footage is tight, consider building an addition or even acquiring other real estate either in your current building or at another location.

5. Regulatory Expenses

Some states in the U.S. require physicians to apply for a Certificate of Need (CON)to install a PET camera. The goal of the CONprogram is to control health care facility costs and facilitate the coordinated planning of new services. Approval is not guaranteed as they reserve the right to determine the necessity of an additional PET camera in a particular area. If you live in one of these states, be sure to factor in the cost and time of submitting your application.

There may also be additional taxes or fees assessed by some states for high-end imaging. In that case, a percentage of the revenue from your PET studies may be payable to the state government.

Four important ways Cardiac PET Perfusion Imaging can affect your profitability

Posted on: 08.02.18

In today’s economic climate, practices are looking for additional services that will benefit their patients while also positively affecting their bottom line. Some cardiologists are exploring the idea of offering PET imaging at their facility. While convenient, in-house PET scans may not be the right fit for every practice. The smartest and most informed decision should take into account these four important factors.

1. Radiopharmaceuticals

Consumables for cardiac PET are unlike those used for SPECT imaging. The two commonly available radiopharmaceuticals for the modality include a 13N ammonia based product and 82Rubidium.

The exceptionally short half-life of the advanced ammonia-based radioactive tracers used for PET imaging, 15O water and 13N ammonia, is a significant challenge that in almost all cases, requires an on-site cyclotron.

Most providers offering PET use a 82Rubidium tracer, which can be produced by an on-site generator. While it delivers similar results and is less costly than the ammonia-based tracer, it’s still a considerable investment, often costing more than $40,000 a month for the rental of the generator.

2. Preauthorization Considerations

An often cited dynamic of Cardiac PET is that it does not require Medicare preauthorization. While this makes the ordering process more manageable, it’s important to remember that there is a critical distinction between pre-authorization and pre-approval.

Pre-authorization is not necessarily a green light for payment approval. All the existing rules still apply and, once evaluated, Medicare has to agree with the clinical validity of the decision. As the procedure becomes more popular, Medicare and payers will continue to increase their scrutiny and regulations surrounding reimbursement.

3. Patient Volume

Patient volume is a critical factor when evaluating Cardiac PET. Statistically, 20-30% of SPECT patients receive inconclusive results and clinically qualify for a PET scan for future follow ups. In order to cover the overhead, a set number of scans will need to take place each month.

If your volume is in the gray area after factoring in the 20% referral rate, it’s worth carefully looking at the numbers. Given their higher patient population, large organizations, universities, and hospitals are typically a good fit. But again, the total reimbursement must also be considered.

If the organization is not a free-standing clinic, the Medicare reimbursement code is written so that only the cost of the study is reimbursed. Expenses related to the 82Rubidium generator are excluded from hospitals, and they are only allowed to bill for the procedure.

In this ever-changing regulatory environment, rules and reimbursement rates will be modified over time. In calculating your expectations, whether it’s patient volume, cost, or reimbursement rates, you also assume the risk of change…for better or for worse.

4. Exchanging SPECT for PET

Remember, too, that your estimated PET studies per month will ultimately reduce your SPECT study volume. It’s essential that you accurately forecast your SPECT and PET revenue since an increase in one will inversely affect the other. Double counting the number of scans is a mistake some Pro Forma’s make and ultimately leads to unmet expectations after the financial commitment has been made.

The Bottom Line

While financials are a critical consideration, the value of a PET scan in a patient’s diagnosis and the outcome is also significant. While SPECT is a vital part of any cardiology practice, the ability to offer a PET scan could confirm or deny the need for invasive surgery. For the right cases, it saves money, time, and unnecessary risk for patients, surgeons, and insurers across the board.

It’s not an easy decision, by any means. There’s no denying that PET adds clinical value, but the financial aspect is also a practical consideration in any business. If it’s not financially feasible in your practice, and your recommended course of action is a PET scan, referring a patient to the local hospital is still the smart option. It could be a simple solution to a complex problem, and one that ultimately supports the highest level of care for your patients.

How to know if Cardiac PET makes sense for your practice

Posted on: 03.22.18

Cardiac PET has been used as a diagnostic imaging tool for a number of years, but has recently seen an increase in interest among cardiologists. When evaluating a considerable investment, such as Cardiac PET, it’s critical to look beyond the buzz and know for sure if it’s the right choice for your practice. Let’s take a look at Cardiac PET and some ways to see if it makes sense for you and your practice.

The Basics of Cardiac PET

Although most commonly used when imaging certain Oncology patients, PET cameras can potentially be of benefit to cardiologists for a segment of patients needing myocardial perfusion imaging. Supporters of PET MPI suggest higher diagnostic accuracy when compared to SPECT MPI, especially when Attenuation Correction is not available on the SPECT system.

Cardiac PET imaging must be performed on a PET or PET/CT system as SPECT imaging systems cannot image these higher energy agents. Instead of using readily available unit doses of Thallium or Technetium based MPI agents, Cardiac PET utilizes a Rubidium (Rb 82) Generator or an Ammonia (N-13) cyclotron for onsite production of the patient doses. Rubidium generators and Ammonia cyclotrons require a significant and ongoing investment, so a considerable volume of patients is necessary to support the overhead.

The working assumption is that PET MPI can reduce downstream costs by creating less false positives. While reducing false positives can lower costs, the total expense of providing PET MPI testing is considerable to both the practice and the patient.

Benefits of Cardiac PET

Cardiac PET is an excellent tool to diagnose patients who may have CAD. PET MPI benefits patients with a high likelihood of interventional needs because of its ability to calculate estimated blood flow and flow reserve. For patients who fit this profile, data from a PET MPI scan can be used to gauge the potential success of intervention (angioplasty, CABG, etc).

Images from Cardiac PET cameras typically offer excellent clarity and resolution due to the high-count rates and high Kev level of the PET MPI agents. Additionally, PET systems all have Attenuation Correction (either source based or CT based), further increasing reader confidence when interpreting images.

Though Cardiac PET is a useful tool in diagnosing coronary artery disease, a very small percentage of cardiac practices own a PET imaging system. The most recent estimates suggest less than 200 dedicated Cardiac PET facilities are operational in the U.S.

Drawbacks and Risks of Cardiac PET

One of the limiting factors in the growth of Cardiac PET is the cost of offering the modality. PET systems, whether refurbished, used, or new, are significantly more expensive than SPECT systems in terms of purchase price and in terms of ongoing repair, maintenance, and upkeep.

Outside of the known camera costs, the ongoing expenses and consumables are a considerable jump from SPECT. The nature of the radiotracers requires costly, long-term contracts that must be committed to before the first scan is provided.

For practices and hospital systems with the right panel size, Cardiac PET can be a profit center that offers a real benefit to patients. However, for groups that have clinical volume in the gray area, it can be a financial burden.

Because of this dynamic, it’s essential to know what imaging volume is needed to cover your overhead. While vendors may provide a pro forma, they often minimize cost factors, so the decision requires more due diligence as compared to other modalities.

Additionally, there is growing uncertainty about the future of reimbursement for Cardiac PET scans. Today, Medicare does not require prior authorization or pre-certification in order to be reimbursed for performing PET MPI. This stance on PET reimbursement has driven very modest growth over the last 18 months. Most Medicare Advantage plans currently require the same prior authorization or pre-certification for payment as is mandated by private insurance payers. The scrutiny will undoubtedly increase as study volumes grow. Even a slight change in reimbursements could move the camera from being a profit producer to a financial loss.

The Bottom Line

There is no question that Cardiac PET imaging offers high-quality images, may increase reading confidence for interpreting physicians, and provides information that may prove invaluable for some patients. Current estimates are that between 15% and 25% of MPI studies may be more appropriately performed as PET MPI rather than SPECT MPI (if PET MPI is available).

Even considering possible reimbursement instability, with the right panel size it’s a beneficial modality to add to your diagnostic imaging department. That said, it should be explored with a mindful approach that takes the full cost into account.

Ultimately, you want to perform the right test, for the right patient, at the right time, and for the right reason. Gaining a thorough understanding of the required investment, technology, and reimbursement dynamics is the first step in the process to determine if and how a Cardiologist might add PET MPI to their diagnostic toolkit.

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