Making Colonoscopy Pay

I was going through the MD Buyline database and found that endoscopy technology costs have been increasing at a rate of 3 to 4% per year.  Add this to the 1.5% increase in labor costs and it becomes apparent that you need to keep a close eye on your GI lab budget.

The good news is reimbursement has been tracking closely with the increasing costs.  In 2007, CMS reimbursed $538 (APC 0143) per colonoscopy.  Now it is $636, a 15% increase.  But, when I ran the costs and reimbursement levels in a ROI calculator, the margins were just about the same.  So, what can a hospital do differently to increase their margins?  As in most healthcare cases, it boils down to cutting costs and increasing volume.  

Each year, there are approximately 14 million colonoscopies performed in the U.S. and about half are for screening. The aging population and the improved outcomes from screening (screening decreases colon cancer by 17%-54%) should continue to increase utilization. 

Additionally, there is a wide range of negotiable costs that include both capital and consumables.  Discounting for capital can vary by 10%; consumables, 10 to 30%.  With these numbers, your margins increase $30 per procedure.  Although that doesn’t sound like a lot, over three years, that’s $230,000.

Nanoshells in Cancer Therapy

Just when you think the rapid growth of nano technology has leveled off, scientists take another step with gold nanoshells as a therapeutic device. 

Gold nanoshells are hollow structures that have been previously used for diagnostic tests.  Along with their small size, gold nanoshells have a unique characteristic that allows them to be used as a therapeutic tool for cancer.  The combination of a gold shell and hollow sphere gives them the ability to absorb near infrared light.  The light is then converted to heat energy, which selectively destroys cancer cells from within. 

Currently, several companies are developing laser-activated drug delivery systems.  One early study using a 4 watt, 810-nm near infrared laser produced 93% tumor necrosis and regression in cancer cells.  A more recent study using nano bubbles and a 532-nm laser caused over 95% destruction in cancer cells while sparing healthy tissue.

Studies are underway targeting head and neck cancers, and other potential applications include lung, colorectal, and prostate cancer.  These are cancers that are accessible to a laser fiber, making them excellent targets for photo thermal modulated cancer drugs such as nanoshells.    

It may be several years before the technology becomes main stream, but the idea of a noninvasive cancer therapy with no side effects is pretty exciting!  And, gold nanoshells are just the beginning.  Scientists have also developed nanoshells coated with antibodies and other therapeutic drugs.  Nanoshells could change the way we think about drug delivery.

Electrically-enhanced chemotherapy has produced exciting clinical results.  The technology offers the promise of a safer, quicker therapy with lower costs from fewer agents and treatment sessions.  The NovoTTF system was recently FDA approved in the U.S. for patients suffering from end-stage glioblastoma and has been in use in Europe for several years.  Further studies are also underway for skin, breast, and early-stage brain tumors, three of the deadliest and most costly cancers to treat. 

Chemotherapy has been in use as a treatment for cancer since the early 20^th century.  Since then, it has grown to a $42 billion world market.  Electrically-enhanced chemotherapy uses a pulsed electrical field to increase the cell membrane’s permeability.  This allows the anticancer drug molecules that previously could not pass cells’ membranes to be absorbed directly in to the tumor.

The NovoTTF system consists of a pulse-generating device, skin electrodes, and the chemotherapy agents, such as bleomycin, cisplatin, and temozolomide.  The treatment process starts by administering the chemotherapy agent with through an IV or locally directly to the tumor.  Afterwards electrodes are applied on the skin.  Once in place, the electrical pulses are applied and depending on the form of cancer, treatments may last several weeks.

Clinical trials have shown that by exposing the cancer to an electrical field, it increases the sensitivity to chemotherapeutic treatment 1-3 orders of magnitude.  This increased the overall survival of glioblastoma by over 39 months.  Early studies have also shown that it is a very safe technology, which is supported by the FDA’s approval.  

I asked Dr. Bentley Thrasher, oncologist at the VA Medical Center in Kansas City, KS, about the advantages of chemotherapy.  Dr. Thrasher said, “The ‘gold standards’ of treating most cancers are either surgery or radiation, but not all cancers are operable.  For some cancers, chemo therapy is an effective tool.  However, brain cancer and other aggressive cancers can be difficult to treat with chemo because some compounds cannot pass through the cell membranes.”

What a concept: using a relatively simple, low-cost technology to enhance cancer therapy.  In today’s environment, you would expect science to have come up with a multimillion dollar machine or an expensive drug regimen.  With the cost of healthcare rising each year, this is an excellent new development.

Electrically – Enhanced Chemotherapy – Simple and Effective

Electrically-enhanced chemotherapy has produced exciting clinical results. The technology offers the promise of a safer, quicker therapy with lower costs from fewer agents and treatment sessions. The NovoTTF system was recently FDA approved in the U.S. for patients suffering from end-stage glioblastoma and has been in use in Europe for several years. Further studies are also underway for skin, breast, and early-stage brain tumors, three of the deadliest and most costly cancers to treat.

Chemotherapy has been in use as a treatment for cancer since the early 20^th century. Since then, it has grown to a $42 billion world market. Electrically-enhanced chemotherapy uses a pulsed electrical field to increase the cell membrane’s permeability. This allows the anticancer drug molecules that previously could not pass cells membranes to be absorbed directly in to the tumor.

The NovoTTF system consists of a pulse-generating device, skin electrodes, and the chemotherapy agents, such as bleomycin, cisplatin, and temozolomide. The treatment process starts by administering the chemotherapy agent with through an IV or locally directly to the tumor. Afterwards electrodes are applied on the skin. Once in place, the electrical pulses are applied and depending on the form of cancer, treatments may last several weeks.

Clinical trials have shown that by exposing the cancer to an electrical field, it increases the sensitivity to chemotherapeutic treatment 1-3 orders of magnitude. This increased the overall survival of glioblastoma by over 39 months. Early studies have also shown that it is a very safe technology, which is supported by the FDA’s approval.

I asked Dr. Bentley Thrasher, oncologist at the VA Medical Center in Kansas City, KS, about the advantages of chemotherapy. Dr. Thrasher said, “The gold standards of treating most cancers are either surgery or radiation, but not all cancers are operable. For some cancers, chemo therapy is an effective tool. However, brain cancer and other aggressive cancers can be difficult to treat with chemo because some compounds cannot pass through the cell membranes.

What a concept: using a relatively simple, low-cost technology to enhance cancer therapy. In today’s environment, you would expect science to have come up with a multimillion dollar machine or an expensive drug regimen. With the cost of healthcare rising each year, this is an excellent new development.

19% Increase for Breast Reconstruction, CMS Shows Support

A 19% increase in reimbursement for DRG 585 is pretty exciting, especially if your inpatient surgery department is performing open biopsies, local excisions, or reconstruction surgeries of the breast for 2011.  In the last three years, DRG 585 (Breast Biopsy, Local Excision & Other Breast Procedures WO CC/MCC) has seen a 25% increase in reimbursement.  

There has been a whole range of exciting advancements in outpatient percutaneous biopsy procedures.  According to an AHRQ report comparing the effectives of open surgical biopsies against core-needle, stereotactically guided vacuum-assisted core-needle biopsies have a sensitivity of 99.2%.  Still, open breast biopsies are the only procedure that’s 100% sensitive to cancer.  Interestingly, both have similar effectiveness; but, to date, only 62% of breast biopsies are performed minimally invasively.

Also, depending on how much tissue is removed, it may leave the breast deformed.  One study showed that breast reconstruction is important to the patient’s quality of life.  So much so, in fact, that the “Women’s Health and Cancer Rights Act” (WHCRA) was signed into law over 10 years ago, which gave women with breast cancer the right to choose to have their breast reconstructed after a mastectomy.  This has allowed the rate of inpatient breast surgeries to increase steadily over the years.

Options for breast cancer surgery have evolved rapidly with skin sparing, areolar sparing, and nipple sparing approaches becoming more common with reconstruction.  Although effective, they add time and cost to the procedure.  So, it appears that CMS is telling us they support breast reconstruction after cancer.

Oncology: Optical Biopsy Sheds Light on Cancer

The use of light as a medical diagnostic modality has been evolving since the pulse oximeter was first invented.  The recent FDA approval of the optical coherence tomography imaging system (OCTIS) has taken the use of light as a diagnostic tool another step.  OCTIS is designed to use multiple wavelengths of light to provide magnified cross-sectional images of a suspicious pathology.  This, combined with its 1-mm catheter, will enable it to be a viable tool for lung and GI tract cancers. 

Historically, advanced imaging technologies, such as CT and MRI, are used to detect suspicious nodules as small as 1 mm; however, to confirm or rule out cancer, an invasive biopsy is performed. Still, 99% of biopsied lung lesions are negative for cancer.

I spoke to Armin Ernst, MD, pulmonologist and chief of the Division of Pulmonary, Critical Care and Sleep Medicine at St. Elizabeth’s Medical Center in Brighton, MA, and a noted researcher in the field of pulmonary medicine, about what OCTIS technology adds to the cancer diagnosis process.  He said, “A CT and an MRI can only really tell us if something is there; they can’t really tell us what it is.  A technology like OCTIS helps us with the next step, finding out what is there.  This is what differentiates it from the others.”

Studies have shown that optical coherence tomography (OCT) offers resolution of up to 30 µm, which allows it to detect tumors as small as 500 µm.  Early trials indicated that the 3D OCT images closely matched histological images viewed under a microscope.  In addition, they offer added multiple magnified cross-sectional in vivo images that cannot be obtained with a biopsy.  Another study found that OCT resolution is 10-25 times better than with high-frequency ultrasound imaging.  In comparison, endobronchial ultrasound has an accuracy rate of 69% for diagnosing peripheral lung lesions.

It will probably be years before any technology completely replaces the gold standard of diagnosing cancer by viewing a tissue sample under a microscope.  But, now physicians have a tool that acts like a tomographic microscope and can reach the peripheral regions of the lungs.  This will allow for a quicker and more patient-friendly means of ruling out cancer in real time.

Cancer ID in Five Minutes? Read on

Just think of the advantages to being able to confirm a cancerous pathology in less than five minutes.  Researchers at the Beckman Institute for Advanced Science and Technology at the University of Illinois in Urbana-Champaign have developed nonlinear interferometric vibrational imaging (NIVI), a light-based technology that offers the promise of quick and accurate cancer diagnosis.

Using light to identify a pathology is not a new concept.  Several companies already have systems on the market that use either near-infrared (NIR), optical coherence tomography (OCT), or multimodal hyperspectral imaging (MHI) to diagnose vulnerable plaque or cancer.  What makes NIVI technology unique is the use of pulse light to vibrate the tumor cells.  This allows the technology to identify the composition of the cell at the molecular level along with a magnified image, resulting in a color image that distinguishes healthy from cancerous tissue.

Currently, the only exact method to determine any form of cancer is to examine the cells under a microscope.  But, published studies revealed that NIVI technology can indentify cancer with 99% accuracy and define cancer boundaries within 100 ?m.  In comparison, leading-edge confocal laser scanning microscopy (CLSM) has an accuracy rate of 94.0% in live tissue.

Although still in the development stage, it can be presumed that the accuracy of NIVI technology will only improve.  When I spoke to Dr. Wilbur A. Franklin, MD, professor, Department of Pathology at the University of Colorado Health Science in Center Aurora, Colo., and a well-published author on early cancer detection, he commented on the additional advantages of optical imaging.  He stated, “Confirming cancer requires a sample of the tissue processed in a lab and then examined under a microscope by a trained pathologist.  This is a time consuming process and there is a risk in that the tissue still needs to be biopsied and, depending on the size of the mass or nodule, 99% turn out negative for cancer.  One goal has been to develop advanced imaging techniques that will help lower the rate of biopsies and speed the process.  This is especially important if the tissue is obtained during an open surgical procedure.” 

When I spoke to an engineer, he explained that the current design is just the tip of the iceberg.  Eventually they hope to miniaturize the technology to work with an endoscope or on the tip of an instrument.  Think about it: cancer diagnosis and the ability to indentify healthy margins in real time.  This will change the way cancer is diagnosed and treated, proving a positive impact in patient flow for the provider.  Additionally, the relief of knowing your results in minutes instead of hours or days is invaluable.  This is one technology that informed patients will be asking for.

PET = Personalized Cancer Therapy

Additional reimbursement is great news from CMS for Positron Emission Tomography (PET) and for improved cancer outcomes.  Historically, CMS has only covered a FDG PET study either for the initial diagnosis or a follow-up staging for solid tumors and myeloma.  Because of the high cost of PET, its use has been limited for further follow up staging, an important tool in evaluating the effectiveness of the therapy.  

When I spoke to Claudia Henschke, MD, professor of radiology at Weill Medical College, attending radiologist, chief of the division of Chest Imaging, and chief of the division of Health Care Policy and Technology Assessment at New York Hospital-Cornell Medical Center, New York, NY, she commented on the advantages of PET and stated, “PET is another technology for detecting cancer, but it is usually not effective in detecting very small nodules.  Its primary advantage is in determining an active cancer.” 

Clinical trials support the advantages of using PET technology for determining the effectiveness of a therapy.  One study demonstrated that PET has 95.9% accuracy in restaging cancer for patients after a first-line therapy, revealing that PET is very effective in grading tumors and measuring its tissue response to treatment. 

The drawbacks of PET are high capital costs ($1.6 million plus) and its consumable tracer FDG (18F fluorodeoxyglucose) can range from $200 to over $800 per patient.  This, combined with labor and overhead ($800 to $1,000), leaves little room for positive margins under existing reimbursement practices (APC 308 – $1100 per study).  At a cost of approximately $1,000 per patient, any unreimbursed procedure would put all but the most active programs under a financial strain. 

It doesn’t take a major financial evaluation to determine that additional reimbursement for an imaging study is good news.  Studies have shown that this form of personalized cancer therapy is cost effective.  When a basic round of external radiation therapy starts at $100 and chemo at $200, providers can spend tens of thousands of dollars on cancer treatments that may have a limited effect.  So, any technology that keeps them from wasting time and expense is good news. When CMS offers a financial incentive to practice good medicine, maybe they are trying to say something.