The business side of nuclear cardiology is becoming increasingly critical as the field has changed significantly with new healthcare payment models, shrinking reimbursements and new priorities under growing ownership by private equity firms. Cardiology as a whole emerged from the COVID-19 pandemic in a state of concern over how to better manage business priorities as profit margins become increasingly smaller. Insurance payers have increased the red tape involved in getting prior authorizations, and Medicare payments continue to inch closer to not being worth accepting medicare patients.
This has prompted most cardiology societies to refocus sessions at their annual meetings and webinar training on the business aspects of running cardiac imaging departments. This is a change from the previous primary focus on clinical concerns with patients. Another sign of this growing concern and need to refocus on the dollars and cents of running cardiology as a business can be seen with the American College of Cardiology (ACC) incoming president being a cardiology business management expert, not a cardiologist.
The American Society of Nuclear Cardiology (ASNC) is the latest society to focus more on the business side of cardiology. ASNC hosted a series of business related sessions at its 2023 meeting that aimed to help practitioners navigate the complexities of modern practice.
Robert Hendel, MD, professor of medicine and radiology at Tulane University, former president of ASNC and a former ACC board member, moderated some of these sessions and spoke to Cardiovascular Business about the growing concerns of managing cardiac imaging departments.
"We took a different direction this year. ASNC just celebrated its 30th year and we have had about 26 different meetings in the past, but this year's meeting represents the first time that we had sessions on the nonclinical competencies of nuclear cardiology. There was a big focus on business and how to operationalize your laboratory, how to maximize what you're doing and how to provide the best quality care, not just in terms of the latest science, but just in the practicality of running a lab," Hendel explained.
The changing business landscape of nuclear cardiology
Discussions at the ASNC meeting examined several key business-related considerations for nuclear cardiology practices. Topics included how to grow your new nuclear cardiology lab; diversity, equity and inclusion session; and how to get start a positron emission tomography (PET) imaging program. Hendel said PET is the way of the future for nuclear cardiology because it offers better imaging and additional information on microvascular blood flow while it enables imaging for new types of cardiac conditions. He said PET offers advantages well beyond what is possible from single photon emission computed tomography (SPECT), the current workhorse nuclear cardiology technology.
"The business aspects included an update on coding and reimbursement issues and how to develop a pro forma and recognize new expenses," Hendel said. "I think the average nuclear cardiologist, especially those just maybe starting out and growing their laboratory, really haven't been exposed to that. So this was sort of an introduction to at least give them some background."
While cardiologists are trained to diagnose, treat and care for patients, he said the transformation of the American healthcare system in recent years requires managers of cardiology departments to better understand the business side of operations. This is something most clinicians are not taught at universities.
Addressing the squeeze on margins in cardiology
One of the key drivers behind the focus on business aspects in nuclear cardiology is the evolving healthcare landscape in the United States. Reimbursements for cardiovascular imaging have been steadily declining, placing a financial squeeze on practices. There also have been major shifts in ownership of cardiology practices in recent years.
"We've watched it transform from private practice to hospital based and hospital owned. And now we have a lot of private equity firms and venture capital dollars going in, which really transforms the landscape in terms of nuclear cardiology business profiles," he explained.
The pressure to maintain quality patient care while navigating these financial challenges has led to a growing interest in understanding how to maximize resources, optimize laboratory operations and reduce costs.
"I think there's a big squeeze. The margins, especially for cardiovascular imaging, have been drastically reduced. Some would say it's not really worthwhile anymore. And also the transition from the reimbursement levels that let's say a private practice got versus a hospital owned practice that's different. And now with private equity, it's a whole new ballgame," Hendel said.
While patient care is paramount, he said cardiology is also a business, so resources cannot be wasted and departments cannot spend unnecessarily. There are also concerns in nuclear cardiology, where surveys of ASNC members have shown some practices are still using imaging systems and technology from the 1990s. New technology has greatly improved computed tomography (CT), echocardiography and cardiac MRI, but nuclear cardiology is being left behind with poorer imaging quality, less valuable clinical information and high radiation doses.
Hendel said one standout presentation at ASNC was on the venture capital infusion of dollars and private equity firms because they are willing to make the initial investments to modernize nuclear cardiology departments to keep them competitive. He said these changes taking place in ownership may offer opportunities to improve the imaging technology.
"That's really been a tough point for a lot of small practices and even small hospitals to go out and spend another half a million or a million or more for new equipment. But in terms of being able to afford a capital investments, it certainly does provide opportunities," Hendel said.
Coding and reimbursement challenges in nuclear cardiology
One of the areas of concern discussed at the ASNC meeting was coding and reimbursement. While coding in nuclear cardiology has not seen significant changes in recent years, the reimbursement landscape has evolved, where it is expected that the levels of reimbursement between office-based imaging and hospitals will see more equalization.
The session also stressed the importance of accurately completing American Medical Association (AMA) Specialty Society Relative Value Scale Update Committee (RUC) surveys they are sent. Hendel said these surveys tend to have very low participation, but are the tool used to determine reimbursement levels for physician relative value units (RVUs).
"If people just throw the surveys out and don't pay attention to them, we're going to get what you expect, which is very little or it's going to be negative. So you can't whine about something if you don't participate. So if you get a RUC survey, even though it seems pretty straightforward, please go ahead and do it, and do it fairly, so that we can maximize what we think is fair reimbursement," Hendel explained.
He said this can include explaining the time to teach techs on how to do a better scan, reviewing the image processing, and watching the quality of your lab by performing cath correlations with nuclear cardiology studies. He said that should all be accounted.
Prior authorizations and appropriate use criteria
The challenges posed by prior authorizations have been another significant concern for nuclear cardiology practices. While prior authorizations aim to ensure the appropriate use of studies, they also can create administrative burdens. In response to these concerns, some states have implemented "gold carding" programs to exempt high-performing practices from the burdensome prior authorization process. At the federal level, the Protecting Access to Medicare Act (PAMA) is currently on hold, with uncertainty about its future. This hold is because the Centers of Medicare and Medicaid Services (CMS) found requiring pre-authorization for all imaging exams created more work for doctors and was adding cost and frustration for hospitals.
"A number of states have already moved forward with gold carding where if a practice or an individual is doing well and they're performing at a high level with appropriate use of the studies and the technologies, then they don't have to go through prior authorization every single time. And that's what we've been advocating for a long time, and we're seeing that now has traction," Hendel said.
When prior authorization requests are denied, there is an appear and peer review process where a nurse or doctor from the insurance company discusses the patient case with the cardiologist to have them explain why they feel the patient needs a test.
"We all hate it. It's terrible to have to get involved in. Sometimes I had to get on the phone call with first a nurse, and then it gets to a clinician who's usually not a cardiologist. And sometimes it is a cardiologist, but they're certainly not well versed in cardiac imaging or nuclear cardiology. Honestly, I've never had a study turned down after I've done a peer review. But it's just painful," Hendel stressed.
Cardiologists are generally concerned with providing the best care possible, so creating a new focus on the business side and making sure physicians acknowledge the costs involved may raise some eyebrows, but ASNC sees it as a necessity.
"I don't want to put dollars and cents ahead of quality of care. We've got to be careful there because we could cut corners, we could use lousy equipment, we could do short protocols that provide lousy images. We won't upgrade our equipment. There's a lot of ways to cut corners and save dollars, but that's at the penalty of patient care. So what we're really looking to do is to try to have a transformation to a more efficient laboratory by providing optimization," Hendel said.
A lot of time was spent in the ASNC sessions talking about new software that is available to improve efficiencies or image quality without the need to buy new equipment. Accreditation was another highlight, because it provides a bar by which everyone should rise to and provide the highest care. This can foster a wider use of modern imaging techniques, reduce radiation exposure and help practices provide as much value as possible.