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New bill calls for changing reimbursement for radiopharmaceuticals

por John R. Fischer, Senior Reporter | July 24, 2019
Molecular Imaging
A new bill that would ensure adequate Medicare reimbursement for procedures that use radiopharmaceuticals has been introduced before the U.S. Congress.

Issued by Representatives Scott Peters (CA-D.), Bobby Rush (IL-D.) and George Holding (NC-R.), the Medicare Diagnostic Radiopharmaceutical Payment Equity Act of 2019 is expected, if passed, to extend patient access to highly-targeted, precision diagnostic procedures for more accurate diagnoses and treatment of diseases, such as Alzheimer’s and Parkinson’s, by changing the way in which reimbursements for such exams are carried out.

“Current CMS policy only allows for separate payment of diagnostic radiopharmaceuticals in the hospital setting during the two- to three-year transitional pass-through period. After the transitional pass-through period, the payment for the radiopharmaceutical becomes bundled with many others in the procedure payment,” Terri Wilson, senior director of patient access and healthcare policy at Blue Earth Diagnostics and current chair of the MITA PET Group, told HCB News. “When this happens, hospitals are significantly underpaid for newer precision diagnostic radiopharmaceuticals, and some may stop offering the service, thereby limiting patient access. HR 3772 would correct this issue.”

Since 2008, the Centers for Medicare and Medicaid Services (CMS) has treated diagnostic radiopharmaceuticals as supplies, bundling or “packaging” them with the cost of the procedure in hospital outpatient settings. Critics argue that the structure is unfair and inefficient, due to Medicare paying for diagnostic radiopharmaceuticals separately as drugs in clinician office settings and the FDA classifying them as drugs and needing to approve them for use.

While often successful, the bundling of radiopharmaceuticals with multiple generic products that are broadly indicated does not significantly move payment amounts. This prevents many hospitals from obtaining reimbursements high enough for them to justify performing the exam, especially those using newer precision diagnostic radiopharmaceuticals which are often indicated for a single disease state.

The bipartisan legislation aims to ensure providers receive reasonable reimbursement through Medicare to cover high-value, low-volume diagnostic radiopharmaceuticals used in nuclear medicine exams for patients. It is also budget neutral, ensuring the change comes at no expense for taxpayers.

“It is critical that patients have access to the health services they need, to ensure they receive the right treatment at the right time,” said Rep. Rush. “In my home state of Illinois, many hospitals have chosen, and are continuing to choose, not to provide access to diagnostic radiopharmaceuticals because Medicare reimbursement rates are lower than the cost to perform the test.”

The announcement of the bill has been met with a flurry of support within the medical imaging community, including by Society of Nuclear Medicine and Molecular Imaging (SNMMI), which plans to start a letter-writing campaign upon introduction of the bill and is asking patients and the nuclear medicine and molecular imaging community to participate in it.

“Diagnostic radiopharmaceuticals are incredibly effective in the diagnosis of a number of different diseases, including prostate cancer, Alzheimer’s and Parkinson’s disease, and others,” said SNMMI president Vasken Dilsizian during a Capitol Hill briefing on the subject of the bill. “We’ve really only scratched the surface of potential with these technologies, and I expect we’ll see future improvements in these diagnostic tools if policy is adjusted to better reflect patient need.”

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