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Assessing the reimbursement challenges facing radiopharmaceuticals

por Gus Iversen, Editor in Chief | June 25, 2021
Molecular Imaging
From the June 2021 issue of HealthCare Business News magazine

We have also been working with commercial payers to reverse their non-coverage policies regarding PET/CT and have been successful for oncologic indications, mirroring Medicare. We continue our efforts for SPECT/CT and PET/CT coverage of cardiac and neurologic indications into 2021.

HCB News: Tell us about the Facilitating Innovative Nuclear Diagnostics (FIND) Act of 2021 and how it's poised to impact the reimbursement landscape.
MG: Much like H.R. 3772 but with a catchier name, the FIND Act of 2021 seeks to level the playing field when it comes to reimbursing precision diagnostic radiopharmaceuticals. Therapeutic radiopharmaceuticals are reimbursed separately, as are diagnostic radiopharmaceuticals in physician offices and independent diagnostic testing facilities (IDTFs). However, in the outpatient hospital setting, CMS arbitrarily treats diagnostic radiopharmaceuticals as supplies and bundles their reimbursement with the scan. We need to fix that to promote human health and longevity.

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The FIND Act targets those drugs approved by the FDA since 2008 with a mean cost per day of $500 or above. Currently, this list involves eight diagnostic radiopharmaceuticals, including three for Alzheimer’s, but the list is expanding. Precision diagnostic radiopharmaceuticals for diagnosis of breast, prostate and neuroendocrine cancer will lose pass-through payment in 2-3 years and be subject to bundling. The bill is also budget-neutral and contains a no-copayment clause for Medicare beneficiaries.

HCB News: Did you have a role in developing the FIND Act? If so, can you tell us a bit about that?
MG: As chair of SNMMI’s Government Relations Committee and SNMMI vice president-elect, obtaining separate payment for diagnostic radiopharmaceuticals in the outpatient hospital setting has been at the top of my list. I strategized with our government relations team and lent a hand whenever I could, including in the naming of the bill. Although Capitol Hill was closed due to COVID-19, I participated in various virtual fly-ins and communicated with members of Congress in my home state of New Jersey.

HCB News: Coming off a year in which cancer screening was largely delayed, reimbursement for those scans seems more important than ever. Do you expect the pandemic to shape reimbursement going forward in any way?
MG: With enhanced financial pressure due to the COVID-19 pandemic, hospitals may be reluctant to offer innovative nuclear medicine services because of inadequate reimbursement imposed by existing Medicare policy payment methodologies. Hospitals are going to be less likely than ever to continue providing these services at a loss if the reimbursement issues are not addressed soon.

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