It's a frustrating situation for a doctor or clinician: A new method, technique or technological innovation promises to greatly improve patient care, but it doesn't yet have a CPT code, so they cannot get paid for using it. The hospital or health system has to self-fund it -- if it has the financial resources to do so at all.
That puts health systems in a bit of a bind, forcing them to make tough choices about what equipment and methods they'll fund and which ones they won't. It also puts smaller hospitals at a disadvantage, as they typically don't have the requisite pocketbooks to stay at the forefront of medical innovation.
Radiology is a prime example of a field whose ambitions outreach the ability to pay. Dr. Daniel Podberesky, chair of radiology at Nemours Children's Health System, did things in residency that are now outmoded due to new methods and innovations that have taken place over the last 15 to 18 years. Tech evolves rapidly, and a system can fall behind if it doesn't stay on top of things.
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Take, for instance, the 3-D printing of medical imaging. Imagers are used to looking at 3-D structures on a 2-D computer monitor, or even 3-D reconstructions on a 2-D monitor (which lend themselves better to digital manipulation). The sense of three dimensions is, of course, an illusion, a virtual trick the computer is performing.
By taking data sets and printing actual three-dimensional models, a radiologist can examine things in a unique way, and in some cases alter their approach to tackling the problem. A surgeon can more comfortably plan her approach to a procedure, and more effectively communicate to the patient and family what the problem is and what the medical response will be.
"But there is absolutely no reimbursement for it whatsoever," said Podberesky. "It's being primarily funded through some grant support and philanthropic effort, and internal investments Nemours puts into this research as well.
"My gut feeling is the system will catch up with these innovations and we'll see reimbursement for these things, but it could take years and years," he said. "You're looking at five, six, seven, eight years of doing things with no reimbursement whatsoever. It's a big cost to us, and a big cost to the system."
One of the issues at play is that once a specialty organization, like the American Academy of Pediatrics, asks for a new CPT code, it takes a lot of time to get it approved, especially with insurance companies involved in the process. And even if a CPT code is approved, there's no guarantee it will be deemed reimbursable. Ultrasound elastography has a CPT code, but until a committee decides it's reimbursable, the code is only applied for tracking purposes.
Podberesky said that some organizations may try to direct a patient to a certain imaging exam or diagnostic technique because it's cheaper than the alternative. Likewise, insurance companies may deny reimbursement for some things but approve it for cheaper approaches.
"Serving children is the right thing to do even if we're not reimbursed," said Podberesky, "but what if the child doesn't live in the catchment area of a hospital with that mindset, and you go to a local community hospital? They may not have the same mindset of innovation."
Even a system with resources like Nemours can struggle to fund certain innovations. Podberesky would personally love access to HIFU, or high-frequency ultrasound, with is used to treat tumors in a noninvasive way via imaging guidance. But it's so cost prohibitive that the system simply can't justify putting the manpower and financial resources into it at this point.
Artificial intelligence is another area that would be helpful in radiology, as well as big data management for the system in general, but again -- it's not reimbursed.
"The leadership team, the research wing, they have very difficult decisions to make," said Podberesky. "In some sense, there is a competitive process to it. You apply for funding or pitch your case to the leadership that this is a potentially impactful new innovation you're pursuing. Then you have to weigh which of those is going to be the most impactful in the shortest period of time."
The good news is that there are a number of different funding avenues. The National Institutes of Health funds a lot of research. Various societies, focusing on things like cystic fibrosis and sickle cell, are also helping to advance innovation.
"Most of those big organizations have their own sort of organizational infrastructure that includes things like advocacy and innovation, but many have their own funding mechanisms as well," said Podberesky.
Ultimately, the only way to get new innovations reimbursed is to conduct research and publish findings demonstrating that certain techniques or technologies do, in fact, work. Podberesky said it's the only way to truly move the needle when it comes to achieving reimbursable status for a new innovation.
"My gut feeling is that something has to change," he said. "As a physician, our mission and our values and the way we approach this sort of thing is almost sort of easy. We just do what's best for the child and we use the resources allocated to us, and find ways to squeeze every drop to support that mission. It's more difficult for the accountants, the administrators, the finance people. They're having to figure this whole thing out and navigate this."
Focus on Innovation
In September, we take a deep dive into the cutting-edge development and disruption of healthcare innovation.