Jan. 28, 2008

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Will Anyone Pay for Cardiac CTA?

Medicare Cuts Support for New Noninvasive Imaging Technology

Graham Ramsay Joseph Ladapo

In a stunning move, Medicare recently proposed a coverage policy for cardiac computed tomography angiography (CTA) that would severely limit reimbursement for this new and popular imaging test. Though cardiac CTA is widely accepted as a promising technique, many physicians have highlighted potentially harmful and costly consequences associated with its application, and it is precisely these cons that have provided the basis for Medicare’s decision.

Altogether, the agency’s policy proposal serves as a blow to many of the radiologists and cardiologists who are spirited proponents of the procedure. But its greatest significance may be the precedent it sets for other emerging—but unproven—innovations. Indeed, it may mark the beginning of a period of greater restraint and tougher decision-making from Medicare.

Cardiac CTA is a procedure in which the coronary arteries are imaged noninvasively. Made possible by advances in CT technology—namely the development of the 64-slice multidetector CT—the imaging test gives physicians a high-resolution view of the coronary arteries. Beautiful in its rendering of clinically relevant anatomy, cardiac CTA with the 64-slice CT has become a focus of intense attention among physicians interested in detecting coronary heart disease. The procedure was all the buzz at the 2006 annual meeting of the American College of Cardiology and has also made its rounds through media circles. Time magazine touted the technology with a picture of a CT-imaged heart on the front cover, adorned with the headline: “How to stop a heart attack before it happens.” Even Oprah Winfrey praised the 64-slice CT in a 2005 airing of her show, exalting it as a major medical breakthrough and undergoing the procedure herself.

But cardiac CTA with the 64-slice CT has some serious drawbacks, too. It can expose patients to a high dose of radiation, which raises the risk of cancer, especially in young patients and in women. It has also raised eyebrows on the cost side: physicians performing cardiac CTA are discovering incidental anatomical findings in their patients, many of which require costly follow-up tests. Most of these findings, which include lung nodules, liver lesions, and breast masses, are ultimately found to be benign or clinically unimportant, making the tests a waste of time and money. Since cardiac CTA is still a mixed bag of as many potential benefits as potential drawbacks, its overall impact on health outcomes and costs is entirely uncertain.

Medicare initially chose not to institute a national coverage decision for the procedure and instead relegated the determination to local Medicare carriers. For reasons not well understood, many of these carriers quickly offered to reimburse cardiac CTA, despite the uncertainty surrounding its use. By 2006, approximately 24 states covered the procedure, and several more joined their ranks in 2007. Not long thereafter, cardiac CTA became a reimbursable procedure in every state in the nation.

Medicare’s recent coverage policy proposal will supersede local carrier decisions and only cover cardiac CTA when the procedure is performed on patients enrolled in a clinical trial approved by the Centers for Medicare and Medicaid Services. By doing so, Medicare guarantees that ultimately cardiac CTA will only be covered on a national level if these trials demonstrate a net positive impact on health outcomes.

Medicare’s decision will undoubtedly constrain the growth of cardiac CTA, but its decision to take such a firm stance on a popular and promising—but unproven—technology may be the biggest take-home message. It stands in the face of the welcoming atmosphere that usually characterizes medicine’s posture toward technological innovations. Whether or not cardiac CTA will ultimately prove to be a technology that offers incremental value is only a small piece of the puzzle. The bigger mystery is whether Medicare will be willing to challenge other popular but unproven and potentially costly technologies in the future.

—Joseph Ladapo is a Harvard medical student and a PhD student in health policy.

The opinions expressed in this column are not necessarily those of Harvard Medical School, its affiliated institutions, or Harvard University.

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Copyright 2007 by the President and Fellows of Harvard College