Cardiac CT and coronary CTA: early Medicare claims analysis of national and regional utilization and coverage.

PURPOSE: The aim of this study was to assess trends in utilization and Medicare coverage of cardiac CT and coronary CT angiography (CCTA). METHODS: Medicare claims for cardiac CT and CCTA were identified for the first 3 complete years for which Current Procedural Terminology(®) tracking codes existed (2006-2008). The frequencies of billed and denied services were extracted on national and regional bases, along with reporting physician specialty and site of service. RESULTS: Total annual claims for cardiac CT and CCTA services for Medicare fee-for-service beneficiaries increased from 58,124 to 95,269 (+64%) between 2006 and 2008. The overall percentage of denied claims decreased from 34% to 21% (20,014 of 58,124 to 20,062 of 95,269, P < .001), with the highest denial rate for calcium scoring studies (declining from 82% to 61%) and the lowest rate for CCTA (29% to 14%). Annual overall regional denial rates ranged from 8.9% to 80.6%. Of all 254,672 base services, 138,136 claims (54%) were submitted by cardiologists, 90,767 (36%) by radiologists, and 13,445 (5%) by others. In 12,324 cases (5%), provider specialty was undetermined. Two-thirds (67%) of services were reported in the office setting (170,511), followed by the outpatient hospital (64,008 [25%]), inpatient hospital (15,922 [6%]), ER (1,577 [1%]), and all other (2,654 [1%]) settings. CONCLUSION: Most cardiac CT and CCTA services are reported by cardiologists and most takes place in private office and outpatient hospital settings. During the first 3 years of Current Procedural Terminology tracking codes, the utilization of cardiac CT and CCTA by Medicare fee-for-service beneficiaries increased by 64%. Despite perceptions that new technology tracking codes are rarely payable, a large majority of all examinations are reimbursed by Medicare. Coverage varies regionally but overall has improved, setting the stage for expanded patient access.

Clinical microsystems, Part 4. Building innovative population-specific mesosystems.

BACKGROUND: In 2005, the Geisinger Health System (Danville, Pennsylvania) developed ProvenCare, first applied to coronary artery bypass graft (CABG), as an innovative provider-driven quality improvement program to promote reliable delivery of evidence-based best practices. A new mesosystem is created for each ProvenCare model, integrating the care delivery process between contributing microsystems and defining new mesosystem leadership. The approach has been expanded to many patient populations, including percutaneous coronary intervention (PCI). A NEW PCI MESOSYSTEM: In 2007 clinical microsystem thinking was applied to PCI: understanding the current processes and patterns, assembling the frontline professionals to redesign the processes, and using a beta-test phase to measure the changes and adjust accordingly, until the best process was established. A new mesosystem team was created to ensure that the right care is delivered at the tight time. REFINING IMPLEMENTATION: In the course of developing the CABG initiative, Geisinger established role definitions to keep teams on track; a comprehensive plan from design through execution and follow-up; and guiding principles established for the teams engaged in designing, developing, and implementing ProvenCare programs. PRELIMINARY EXPERIENCE: For the 40 measurable process elements in the PCI mesosystem pathway, as of month seven (July 2008) of the beta-test phase, 55% of the patients received 100% of the identified process elements. CONCLUSION: Geisinger Health System has joined different microsystems to form an innovative mesosystem capable of producing reliable, evidence-based care for patient subpopulations. This approach to embedding evidence-based care into routine care delivery can be adapted by others.