“Two years ago, when I knew that 64 slice was a reality and that we were going to be getting it, the question we had to answer was, ‘Are we going to be able to participate in this?'”
—Michael S. Skulski, MD
St Vincent’s Hospital

If you are a family practitioner or a doctor of internal medicine at St Vincent’s Hospital, Indianapolis, there is a good chance that a radiologist named Michael S. Skulski, MD, is going to stop you in the corridor or outside the reading room. If you give him a few minutes then—or later—he will show you images of coronary computed tomography angiography (CCTA) and tell you about how it can effectively screen your patients with a risk of coronary artery disease (CAD). Oh, and if you are concerned about your patients being able to afford a study that is still considered investigational by most insurance companies, Skulski will tell you about three innovative financing solutions that were designed specifically for CCTA.

“Two years ago, when I knew that 64 slice was a reality and that we were going to be getting it, the question we had to answer was ‘Are we going to be able to participate in this?'” Skulski recalls. “As I would talk to [primary care] doctors that came by and show them images on the computers, my first question was ‘If I told you I could do this test for you and it had a very high negative predictive value, is it something that’s going to help you manage your patients and your practice more effectively?’ And the resounding answer was ‘Yes.’ Those are the people who are taking care of the patients before they ever see a cardiologist.”

Skulski and his colleague, radiologist Anthony Zancanaro, MD, have had a vision for how CCTA could help screen CAD patients through primary care physicians (PCPs) for many years. But it has been only since the development of 64-slice technology, and subsequently learning that St Vincent’s was purchasing a $1.5 million LightSpeed VCT 64-slice scanner from GE Healthcare, Waukesha, Wis, that Skulski and Zancanaro put their plan into action.

With the confidence that there would be a demand for CCTA by primary physicians, Skulski and Zancanaro asked their group, Northwest Radiology Network, for support in developing a CCTA screening program. The group agreed and gave Skulski and Zancanaro time for professional development at the Radiological Society of North America, the American College of Radiology, and the American Roentgen Ray Society, and a fellowship course at New Jersey’s Atlantic Medical Imaging with David Dowe, MD.

After completing training, Skulski and Zancanaro next approached Gary Fammartino, MBA, the senior vice president for ambulatory and outpatient services at St Vincent’s, who already was interested in using the new 64-slice CT for cardiac studies.

“I think one of the things that helped us [with the St Vincent’s administration] was that we were progressive, we knew 64 slice was coming, and we educated ourselves before it even arrived,” Skulski says. “Then, when it arrived, we said, ‘We have people who are trained to do this now, and we want to start doing it. We want your help to get a program together,’ and they fully embraced that concept.”

Along with Kathy Holton, the administrative director of radiology, Fammartino began to develop a primary care-focused program and marketing strategy with Skulski and Zancanaro, giving them the resources they needed to build the program at St Vincent’s.

Patient Management Results from St Vincent’s CCTA and Coronary Calcium Scoring

In St Vincent’s CCTA pilot program, every patient that received a CCTA also received a coronary calcium scoring. Approximately 100 patients with a median age of 48 participated in the program, and 10% to 15% were found to have some level of coronary artery disease (CAD).

Calcium Scoring Patient Management Protocols. According to Michael S. Skulski, MD, of St Vincent’s Hospital, there is no generally acknowledged algorithm for patient management as a result of coronary calcium scoring. The scoring software on GE Healthcare’s LightSpeed VCT scanner breaks down patients by age and sex in comparison to similar patients. For example, a 40-year-old man with a coronary calcium score of 4 would be in the 75th percentile for his age group and sex; therefore, he would benefit from behavior modification and cholesterol-lowering therapies. However, a 72-year-old man with a calcium score of 40 would be in the 10th percentile of his age group. He is doing well with his current treatment. Coronary calcium scores can range from 0 to 2,000 and higher.

“Coronary calcium is an indication of coronary artery disease,” Skulski notes. “So, if you have any coronary calcification, that would be more information to [enable you] to go in and say, ‘You probably need to have a CCTA.'” At the very least, when a patient is in a higher percentile in comparison to the peer group, Skulski uses the calcium score as a motivating factor to institute behavior modification and cholesterol therapies.

CCTA Patient Management Protocols. Along with Anthony Zancanaro, MD, Skulski divided the pilot patients’ CCTA results into seven classifications: normal, minimal, mild disease, mild to moderate disease, moderate disease, moderate to severe disease, and severe disease.

Skulski referred patients who had mild to moderate disease (stenosis of less than 50%) back to their primary care physicians (PCPs) for behavior modification and cholesterol therapies. In each of these cases, the images and findings were discussed with the patient. Their primary care doctor also was notified of the information with possible clinical modifications.

“I believe that the normal, mild, mild to moderate, and moderate disease patients likely will be able to be treated by PCPs,” Skulski says. “In some cases, moderate-diseased patients will go on to further studies, such as a nuclear medicine stress test. Depending on patient results, they could be managed by their primary care doctor or, if their primary care doctor chooses, they may refer the patient to a preventive cardiologist.”

For patients with moderate to severe disease (moderate defined as stenosis greater than 50%; severe as stenosis greater than 70%), Skulski recommended a cardiology referral. Of this group in the pilot cohort, four patients had cardiac catheterization. In two of these patients, coronary stents were placed, and none of the patients went on to coronary artery bypass surgery.

—T. Valenza

A Coronary CTA Pilot Program

Part of St Vincent’s support was providing the funds to do a trial CCTA pilot screening program at no cost to the test patients. The main goal of the pilot was to optimize the CCTA process and protocol. Fammartino says that GE Healthcare was instrumental in working with the radiologists to design the process and help educate St Vincent’s technologists on the CCTA protocols. (See “CCTA Procedure Protocols” for more information.)

The pilot’s subjects included about 100 hospital administrators and employees with CAD risk factors, but none of the patients were clinically symptomatic. Patients ranged from 33 to 79 years of age, with a mean age of 48. The test subjects received a CCTA screening with a coronary calcium scoring component.

“I think calcium scoring is helpful in all patients, but most so in younger patients where coronary artery disease likely will be mild or minimal,” Skulski says. “Calcium scoring may help the doctors caring for the patients to institute behavior modification and cholesterol-lowering therapies [prior to when they would have done traditionally].”

Among some of the trial subjects were potential referring PCPs in St Vincent’s community. Skulski believes that inviting family physicians to have the test can be helpful because it personally demonstrates to them the power and noninvasive nature of the modality.

“These patients became a walking advertisement for our program,” Skulski says. “They told their colleagues, friends, and other referring physicians of their experience. I believe this was invaluable.”

In the end, Skulski and Zancanaro honed the CCTA procedure so that a patient could complete the entire test in about 2-1/2 hours and be able to return to work.

Of the 100 test patients—all of whom were asymptomatic of CAD at the time of the study—Skulski says that 10% to 15% were discovered to have moderate to severe CAD and, as a result, their clinical management was modified. “(See Patient Management Results.”)

Convincing the Payors

Convincing PCPs that a coronary calcium score or CCTA has benefits for high-risk CAD patients may be easier than convincing an insurance company to pay for the studies.

Skulski has made CCTA presentations to Anthem, the area’s largest payor, but the insurance company still lists both coronary calcium scoring (CPT code 71250–CT chest without contrast) and CCTA (CPT code 71275) as investigational.

Anthem’s rejection has not stopped Skulski from meeting with Medicare and other payors. “I think we’re going to need more specific data as time goes forward,” he explains, “and show them that they can save money and also take better care of patients.”

Skulski’s main argument to payors is that CCTA has a high negative predictive value for CAD, which can save insurers the cost of other more expensive nuclear tests, and perhaps the cost of a cardiology referral, for patients found to have minimal to moderate CAD.

“If you get to these patients before they develop serious disease, you won’t have to pay for bypass surgery, and they won’t have to see a cardiologist,” Skulski says. “You’ll save on the additional testing that goes along with these things in the future.”

St Vincent’s administration also is planning to talk to payors through Bernie Emkes, MD, a former family practitioner and currently St Vincent’s medical director for managed care.

Emkes shares Skulski’s point of view about the cost- and life-saving benefits of CCTA, as well as the advantages for family care practitioners like himself who want to maintain the management of patients who are found to have minimal disease. But Emkes knows it will be a battle to get the test covered by payors. “The dilemma that I have—and I know the insurers will have the same dilemma—is that this cannot be an add-on.”

[National Imaging Associates, a benefits management company, is conducting a national study on whether CCTA can be used as an effective replacement for diagnostic coronary catheterizations and nuclear stress tests. Read more about the study online in our October issue’s Payor Watch.]

Coronary CTA Pricing

Because St Vincent’s recently finished the pilot and began seeing paying patients beginning October 1, 2006, Skulski warns that prices and marketing are likely to be adjusted.

Currently, St Vincent’s charges $1,140 for a CCTA, which includes a coronary calcium scoring procedure and a consultation with the radiologist. Skulski believes the consultation can serve as a significant wake-up call to a patient found to have CAD.

“Any time that I sit down with a patient with risk factors, especially smoking, and they have disease, that’s a very powerful time to say to them, ‘You’ve just become an ex-smoker,’ ” Skulski says.

He also is offering a separate coronary calcium score with a consultation. The charge is $500, but the procedure is a portion of an annual physical work-up package offered by a St Vincent’s physician’s group to corporate executives.

Skulski recognizes that many people cannot afford to pay $500—let alone $1,140—for the full CCTA package and says that he and St Vincent’s are working on lower price offerings.

One idea being discussed is a $300 to $350 coronary calcium scoring package that includes cholesterol screening, which may contain a brief consultation with the radiologist. Skulski notes that if the calcium score shows disease, it may lead to the patient getting a full CCTA.

Financing Program

The hospital administration’s commitment to the CCTA program is evidenced by its three financing options that were specifically designed for CCTA procedures.

  • The first option is from Personal Finance Company and gives patients/guarantors a contract that allows free financing for up to 12 months. The balance must be $200 or greater, however, and requires a credit application and approval.
  • The second financing option is offered through a local branch of Fifth Third Bank, Cincinnati. This program is an installment loan agreement and allows the patient/guarantor to make monthly payments according to the contract. The balance must be greater than $1,000, and the interest rate varies monthly based on the prime rate, although it will not exceed 13%. All patients are approved, regardless of credit history.
  • The third program, through CSI Financial Services, San Diego, currently is offering a 12% rate for financed procedures. The balance must be greater than $50, and the guarantor must make a monthly payment of 4% of the balance due. This last option does not require a credit application or approval, but it does require hospital approval.

Skulski also believes that as medical savings accounts become more prevalent, those with a high risk of CAD may use the money in their accounts for CCTA. The real challenge is finding those potential patients.

Out of the View Box

Although some patients can pay $1,140 cash for the CCTA, few are aware of the procedure. Consequently, Skulski, Zancanaro, and St Vincent’s are on a mission to educate PCPs, the public, Rotary clubs, office managers—almost anyone with a heartbeat—about the negative predictive value of CCTA and its benefits.

“Radiologists need to get out of the view box and talk to patients and groups of people,” Skulski says. “We’re very involved in the technologies, but we must be better at communicating with the patients. All they know is that we’re on the first bill that shows up, so they just see a doctor’s name that they don’t identify with. We need to give ourselves a face and a voice with patients, with physician groups, and, ultimately, with the leaders of the communities that we live in.”

Skulski is using that out-of-the-view-box philosophy with CCTA and coronary calcium scoring by constantly talking to physicians in the hospital.

“When I’m down in the reading room and physicians are walking by, I show them the images,” Skulski says. “I pull up a case and say, ‘I just did this one today; take a look at this. You can see the negative predictive value of this examination; you can see how it can help you.’ Or, if it’s a cardiologist or vascular person, I say, ‘This is what’s problematic for me in this case. Do you have any thoughts about that?’ Because we really want to build that collegiality. The best-case scenario for [CCTA] is that we do this together.”

When Skulski is not grabbing a physician in the reading room, he is on his way to a primary care group’s executive council, where he makes a CCTA presentation. At the end of the presentation, he always asks the physicians about their points of view and how he can effectively relay his information to their group’s physicians.

Skulski also is invited to speak at Indianapolis physician associations, which consist of physicians that have quarterly forums. There, he can directly speak to 60 to 90 PCPs in one room. After a 15-minute presentation, he hands out information packets about St Vincent’s program and how to order a CCTA, and he provides the name of St Vincent’s physician liaison.

Additionally, Skulski is beginning to market directly to groups of high wage earners, setting appointments with big law practices and local corporations that might offer CCTA as a benefit to their executives. These market segments also are mostly likely to have employees contributing to a medical savings account.

Perhaps Skulski’s most surprising educational patient outreach is his talks at Kiwanis clubs, Rotary clubs, and other leadership organizations. “You say that’s not the greatest use of your time,” Skulski says, “but you know what? Those are people who are leaders in their community, and the more people we can talk to who are leaders in their community, the quicker this test is going to be adopted, and the better we’re going to be able to take care of patients.” At these meetings, Skulski says that his presentations are less technical than at his PCP meetings. In addition to explaining the procedure in lay terms, he stresses the value of peace of mind that a person with a high risk of CAD can have by undergoing a CCTA.

Aside from Skulski’s physician outreach, St Vincent’s marketing department is working on writing stories about the program for its internal newsletters and promotional magazines, as well as health features on local television news broadcasts. Other future marketing efforts include:

  • DVDs to explain CCTA to physicians and patients;
  • dinner meetings with a CCTA educational component for PCPs; and
  • Calcium-Scoring Saturdays,” where a large group of patients can receive a calcium score, radiologist consultation, and cholesterol screening at perhaps $300 to $350.

“Calcium scoring is inexpensive in relation to CCTA because it’s a very quick examination,” Skulski says. “Probably the total time a patient has to be in your department is 15 minutes. …And if you really want to help people be preventive, you have to give them a chance to do it—set the price where people will pick you up on it.”

Skulski hopes that CCTA can benefit cardiologists as well as radiologists and PCPs, believing that all of the disciplines can use their skills to complement each other. But it remains to be seen how the modality becomes part of the standard of care.

Tor Valenza is a staff writer for  Axis Imaging News. For more information, contact

CCTA Procedure Protocols

1) Before the procedure, each patient receives a “What to Expect When Having a CCTA” form in the mail. The form describes the CCTA and what to do and not do, such as not using any tobacco products and not consuming caffeine 12 hours before the procedure, and drinking 16 ounces of water an hour before the procedure. The document then goes on to briefly describe the procedure, and reminds patients to resume their normal diet and drink fluids after the procedure.

2) The patient arrives, registers, and fills out a patient health profile form.

3) A staff member explains the procedure, discusses the effects and side effects of medications given (metoprolol, nitroglycerin [NTG], and contrast material), and answers any questions. Afterward, an informed consent form is signed.

4) An RN reviews and documents the patient’s history and medications.

5) Vital signs and a cardiac rhythm strip are obtained from the patient.

6) The patient’s medications and history are reviewed with a physician, who prescribes the amount of beta-blocker to be given based on the patient’s heart rate (HR). The targeted HR for examination is the low 50s.

  • For HR 70 or greater, metoprolol 100 mg PO is given.
  • For HR 60-70, metoprolol 50 mg PO is given.
  • For HR low 50s, metoprolol 25 mg PO is given.

7) The patient also may be given metoprolol IV 1-15 mg over 15 minutes to achieve targeted HR.

8) Acetaminophen 325 mg tablet x 2 is given PO to help prevent headache from NTG.

9) 18g 1-1/4-inch IV is established in antecubital fossa (preferably left).

10) A calm atmosphere is provided with decreased stimuli for patient to aid in HR reduction.

11) Twenty to 40 minutes after the beta-blocker is given, the patient’s HR is checked. If it is in the targeted range, the patient is taken to the examination room in a wheelchair or on a cart.

12) When the patient is on the CT table, a blood pressure cuff is placed on the arm opposite the IV site; nasal cannula at 2–3 L/min, O2 saturation monitor, and heart rate monitor (lead 2) are placed.

13) The patient is given an opportunity to again ask questions and voice any concerns.

14) When baseline vital signs are again obtained, NTG 1/150 grain or 0.4 mg sublingual is given.

15) The IV is then connected to the power injector, side effects of contrast are again reviewed, and the examination is performed per CT technologists. (The procedure should last about 20 minutes.)

16) The patient’s vital signs are rechecked at 5-minute intervals and documented; the patient is observed closely during examination.

17) After the examination is completed, the patient is placed on a cart, and vital signs are checked again.

18) The patient is then monitored for 30 to 60 minutes, given a snack and caffeinated drinks (if tolerated), and gradually progressed through sitting and standing to determine tolerance of beta-blocker and NTG.

19) If desired or advised, hydration may be given: normal saline 250-500 mL IV.

20) When stable, the patient is released after 30 to 60 minutes.