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Ideas in Hospital-Based Imaging |
MRgFUS Master Plan
Material Assets
Mobile Scanner Reduces Risk for ICU Patients
JCR Partners to Offer Quality and Safety Web Conferences
MRgFUS Master Plan
Houston’s SightLine Health pursues a reimbursement change, hoping that payors will recognize the benefits of this uterine fibroid treatment
By Renee DiIulio
MR-guided focused ultrasound (MRgFUS) is not new—the ExAblate 2000 system from InSightec, Dallas, was given FDA approval in fall 2004. But with just over 2 years on the market, the system isn’t old either. As is the case with many infant technologies, payors have not yet begun to reimburse the procedure for uterine fibroids. This factor has limited MRgFUS’s use, despite such advantages as noninvasiveness, minimal side effects, and cost-efficiency. But the reimbursement climate may soon change.
SightLine Health LLC, Houston, which offers the service, has begun discussions with three major medical insurance companies to initiate reimbursement, according to T.J. Farnsworth, SightLine president and CEO. “MRgFUS can be expensive but is more cost-effective when compared to surgical methods,” he says. “Payors are realizing that the procedure can be completed in 3 hours with no anesthesia versus a 2- or 3-day hospital stay and 2 weeks of bed rest and pain medication.”
He notes that the methodology already has two CPT3 tracking codes: one for simple procedures (0071T) and a second for complex (0072T). “Our fee schedule is in the $17,000 to $25,000 range for complex procedures,” Farnsworth explains, noting that patients typically pay $10,000 to $17,000 cash, depending on procedure length and complexity as well as fibroid size.
The cost has limited the number of women who decide to undergo MRgFUS. “The procedure is not cheap, which has been a major hurdle. But we knew this going into it and are trying to overcome it now,” Farnsworth says, referring to the reimbursement discussions.
Farnsworth’s argument is bolstered by positive research data. He estimates that more than 2,500 women have opted for the procedure throughout the United States since its introduction. “We’ve found about a 5% recurrence rate in commercial applications of MRgFUS,” he says, comparing it to about 17% for uterine arterial embolization. Myomectomy patients show even higher recurrence rates.
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| A patient undergoes MRgFUS at SightLine Health in Houston. |
Hybrid Technology
The hybrid system incorporates MR and ultrasound. Real-time MR provides guidance and temperature mapping; ultrasound is the ablation tool. Currently, ExAblate 2000 is the only device approved by the FDA for this use.
“The system uses a lens to focus the hundreds of transducers in the array to a specific pinpoint, which can be as small as a grain of rice or as large as a jelly bean. The sound waves heat the tissue to necrosis,” says Farnsworth, who likens the process to that of a child burning leaves with a magnifying glass. The precision avoids the destruction of collateral tissue that occurs with radiation.
The beam is guided by real-time MR imaging, which identifies tumors and verifies dead tissue. “We are able to measure temperature changes in real time to confirm the tissue has been destroyed,” Farnsworth says.
The ExAblate system has been approved for use only with 1.5T and 3T MR systems from GE Healthcare, Waukesha, Wis.
Though the procedure can take up to 4 hours for very complex cases, it does not require anesthesia, and patients generally are able to return to work within a day. There is no consistent use of medications, radiation, or hormones. There also are no associated surgical risks, such as infection, blood loss, and adverse reaction to anesthesia. Farnsworth notes that it can be challenging to remain still in the MR machine for 3 hours, but patients are typically given mild sedatives, not painkillers, to relax.
The procedure, however, is not for everyone. “MRgFUS is typically recommended for patients with six or fewer larger symptomatic fibroids,” he says. It would not be recommended for women with five to 30 small fibroids, 1 to 2 cm in size; pedunculated fibroids; fibroids suspected of being cancerous based on the prescreening MR examination; or those less than 4 cm from the sacral nerve.
The procedure also is recommended only for women who do not plan to become pregnant—but this too may change. According to Farnsworth, the FDA is currently evaluating whether to remove this specification. “A clinical trial, slated to begin in about 6 months, has been designed not only to confirm a positive decision, but also to examine whether the procedure should be recommended for women who wish to become pregnant,” he says.
During the procedure, practitioners take care to assure the beam path is clear. “We cannot treat through scars, surgical clips, or the bowel,” he explains, noting that mitigating steps, such as filling the bladder to migrate the bowel, can be taken.
Group Benefits
Patients are not the only ones who benefit from MRgFUS. SightLine was formed specifically to offer the service to patients; the organization partners with radiology and gynecology groups. “We are not interested in the diagnostic side. We go into imaging centers with the ablation equipment and perform our surgery on site,” Farnsworth says. If one center does not have an approved MR machine, SightLine will lease time on a GE Healthcare MR in another facility to treat the first center’s patients.
Radiology groups benefit from prescreening MR examinations and leased MR time. “MRgFUS brings in a significant number of billable study referrals,” he says. “We refer to our radiology group anywhere between 40 and 70 pre- and post-contrast MRIs on a monthly basis.” Because SightLine owns the ablation equipment, no capital expenditure is required from the physician group.
SightLine also handles the marketing. Because there is not yet standard reimbursement, the organization markets directly to patients. Depending on the city, this may take the form of billboards, television, print, radio, and/or Internet marketing.
As a result, centers offering MRgFUS often become women’s “health hubs.” OB/GYNs who refer MRgFUS to patients expand to other services. “The radiology group we partner with in Houston is performing therapies that it did not do before,” Farnsworth explains.
Should payors decide to reimburse MRgFUS, more patients are likely to opt for the procedure.
Renee DiIulio is a contributing writer for Axis Imaging News. For more information, contact .
Material Assets
Behind the scenes, materials management professionals ensure smooth equipment purchases
By Dana Hinesly
The miracles of modern medicine would not be possible without the innumerable machines, applications, and accessories filling the halls and treatment rooms of health care organizations across the country. Putting these products in place takes oversight and, in most organizations, falls under the purview of the materials management group.
To what extent these teams are involved varies by location. Some handle specific departments, and others oversee multisite systems. In either situation, imaging purchases make up a considerable amount of the work, primarily due to the dollars involved with these assets.
“We spend more time on a major investment than we do on a routine purchase [of products], because in many cases, we already have a standard established on those products,” explains Jan P. Lea, vice president of materials management at Methodist Health System, Dallas. She developed a New Technology Committee for her hospital system, which reviews purchase requests. “We attended a health care advisory board session where they discussed this type of approach, giving examples of hospitals that bought technology that didn’t make sense, and we realized it is exactly what we needed.”
As its moniker implies, this committee specifically addresses new items, engaging in an extensive review process to ensure that the system does what it promises, is a good fit for the clinicians, and will provide a return on investment.
Contract Negotiations
In the past few years, Lea’s committee has been put through the paces as the hospital system added a third hospital campus. “It was great getting to build a new hospital because it gave us a lot of leverage,” she says. “When you’re buying that much imaging equipment at one time, you definitely get everybody’s attention.” Using this to its advantage, Methodist extended negotiations to meet more than just the immediate demands of the hospital. “I was able to lock in the price for all imaging purchases scheduled for the next 2 years at our two existing campuses,” Lea says.
Virtually every aspect of the contract was on the table, including service, how many days of training the vendor would provide, payment terms, and the required deposit.
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| Jan Lea |
“The standard contract asks for a down payment, typically of 20%,” Lea says. “Twenty percent of an MRI is a lot of money, so we negotiate to waive that, because in some cases, we are buying imaging equipment and cutting a purchase order 2 years before it will be delivered—and that would be a lot of time for [the vendor] to have the use of our funds.”
Negotiations are one of the last steps in the acquisition process, which begins either with a request from a clinician or as a result of publicized advancements in available systems.
“I review all requests for imaging equipment before they are presented to senior management for approval,” says Clark Saylor, consultant for radiology and asset management at Universal Health Services Inc, King of Prussia, Pa. “Our model is to have the end users define a performance spec, which, in many cases, takes the form of a proposal from a vendor. Our responsibility at corporate is to determine that the spec is consistent with the stated strategic direction and the financial goals of the facility.”
However it is initiated, Lea believes that it is vital for her team to be part of the process from the start. “Some of my peers get pulled into the process too late,” she says. “They are then in the position of trying to negotiate when it’s already clear to the vendor reps that they have the deal. If that’s the case, then there isn’t much that can be done at that point; your hands are tied.”
To avoid such instances, the materials management team at Methodist stays in close communication with the radiology director on each campus, staying informed about what is working for the radiologists, discussing where they would like to see improvements, and contacting vendors to address concerns when necessary.
Providing the best possible environment for the medical personnel is a top priority for Lea and others in her field, which means that they often are involved in virtually all areas of planning.
“Probably the biggest piece of my job that people are not aware of is working directly with the architects. It’s really important that we are able to plan the layout to achieve the desired result,” Lea says, noting that these decisions often have to be made 2 years in advance of the groundbreaking ceremonies. “We are involved with all of the design development from the very beginning. We plan everything from the lockers all the way down to every chair. It is our responsibility to buy everything that goes into the facility, and the architects design based on what we provide.”
Tech Considerations
It is likely no surprise that improvements in technology have made the biggest impact on how materials managers approach their duties.
“In the past, you checked for available power HVAC [heating, ventilation, and air conditioning] capacity and sometimes water and drain requirements,” Saylor says. “Today, you must consider network connections, bandwidth requirements, data storage, and interfaces to other systems.”
Obtaining this perspective requires that materials teams work closely with others in the organization, including biomedical engineering and the IT/IS staff, to achieve the best result for the hospital. It also necessitates that the teams be aware of advancements and innovations.
“The New Technology Committee has evolved into looking at technology of the future and being proactive to identify the top 10 trends that we should be investigating,” Lea says. “The rapid changes in technology demand that we focus on what’s coming next, to see what new technologies hold promise and to determine if it makes sense to bring them into one of our facilities.”
Dana Hinesly is a contributing writer for Axis Imaging News. For more information, contact .
Mobile Scanner Reduces Risk for ICU Patients
Bedside CT avoids the complications of moving neuro patients to radiology
By Renee DiIulio
When a physician needs to perform a CT scan of a patient’s head, the patient typically must go to the CT scanner located in the radiology department. For some patients, it’s a long trip; for others, a risky one. If the trip is too risky, a physician may decide to forego the scan. But if the scanner can be brought to the patient, then benefits in patient care, workflow, and efficiency can be realized.
Until this past December, patients in the neurology ICU of the Cleveland Clinic traveled from the sixth floor to the basement to have CT examinations performed. The trip involved transporting not only the patient, but also the staff and equipment—including drips, ventilators, and ventricular drains—needed to provide care.
“Simple scans become a fairly big production because there is some risk involved,” says Tom Masaryk, MD, director of neuroradiology at the Cleveland Clinic. Physicians may decide to skip the scan if they are reluctant to send the patient out of the ICU.
Because of the complexity of these cases, the scans take longer to complete. “They tie up a lot of time on the scanners, which are otherwise very efficient and able to scan more patients, who are less sick, in the same time period,” Masaryk says.
The desire to improve this situation led the hospital to the CereTom, a cordless, wireless, mobile head-and-neck CT scanner from Neurologica, Danvers, Mass. The 8-slice scanner is 5 feet tall, 4 feet wide, and 29 inches long and weighs roughly 750 pounds. Motorized wheels help to transport the device to patients’ bedsides, where it acquires 1.25 mm slice per rotation and operates with battery or wall-outlet power. The device communicates wirelessly with a laptop that rests on a separate stand.
At the Cleveland Clinic, the instrument is stored in an alcove and brought out for brain scans on acutely ill patients. The size of the gantry limits the CereTom to head and neck scans, but permits greater geometric efficiencies, requiring less power to rotate, thus enabling high-quality images. “The image quality is surprisingly very good,” Masaryk says.
The Clinic is performing some CT angiography and a bit of perfusion imaging with the CereTom, according to Masaryk. Features of the scanner include nonenhanced spiral CT, CT angiography, CT perfusion, and xenon CT. “[The CereTom] has a lot more capability than just a simple CT scanner,” says Masaryk, who also acknowledges that comparisons of the CereTom to 64-slice fixed scanners are unfair.
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| NeuroLogica’s CereTom is a cordless, wireless, mobile head-and-neck CT scanner. |
“We questioned whether the ICU would embrace it or continue to drag patients downstairs,” Masaryk says. To assure buy-in, ICU personnel and techs were included in the decision-making process. “We brought someone from the ICU as well as the techs to look at the scanner,” Masaryk says. “They thought they would prefer it over transporting patients to radiology.”
The team now performs eight to 10 of these scans a day. “The nurses prefer having the equipment bedside over moving the patient,” Masaryk says. The user-friendly scanner, which is shared between two floors, can be prepped in 15 minutes or less, and the clinic has someone trained to use it on every shift.
“The team was willing to try things a different way and saw the advantages of [the CereTom],” Masaryk says. He notes that other scans, such as for the abdomen and chest, still must be performed in radiology, but that the neuroradiology needs are great enough to justify the scanner.
Renee DiIulio is a contributing writer for Axis Imaging News. For more information, contact .
JCR Partners to Offer Quality and Safety Web Conferences
On January 24, Joint Commission Resources (JCR), Lombard, Ill, an affiliate of the Joint Commission, announced its partnership with GE Healthcare, Waukesha, Wis, to market and distribute a series of Web conferences on quality and safety. Since January 25, the Joint Commission Resources Quality and Safety Network has been presenting its 12 original satellite, live Web, and Web archive programs.
“These teleconferences not only provide updated education on Joint Commission standards, but they also provide the ability to learn what other health care facilities are doing to meet and exceed the standards,” Yosef D. Dlugacz, PhD, of North Shore-Long Island Jewish Health System explained in a press statement. “The sharing of these ‘best practices’ is very useful in developing strategies to improve patient care. These teleconferences provide excellent explanations of the standards and examples in terms of applicability.”
Featuring opportunities to interact with industry experts, as well as demonstrative case studies from hospitals across the country, the programs center around such topics as “National Patient Safety Goals,” “Creating a Culture of Safety,” and “Strategies to Help Prevent Infection.” The faculty will be composed of Joint Commission representatives and national health care experts.
Trinity Healthforce Learning, a division of TWL Knowledge Group Inc, Carrollton, Tex, will team with GE Healthcare to distribute the series. “This educational offering is a convenient, cost-effective learning method that enables our customers to improve the quality of care and focus on the safety of their patients,” said Richard Nuccio, GE Healthcare education marketing manager.
The programs are intended for all members of the health care enterprise, particularly administrators, managers, or organization leaders; continuing education credit is available. The next seminar, “Enhancing Communication and Teamwork,” will be held on April 26 at 1:30–3 pm EST; subsequent programs will take place on May 24, June 28, July 26, August 23, September 27, October 25, November 15, and December 20. For more information, visit www.twlk.com/healthcare/JCR/ or call (877) 438-4788.
