Fair And Adequate Reimbursement Is Vital To Developing Life-Saving Medical Treatments

Main Category: Medicare / Medicaid / SCHIP
Also Included In: Health Insurance / Medical Insurance;  Medical Devices / Diagnostics;  Radiology / Nuclear Medicine
Article Date: 18 Jun 2008 - 5:00 PST

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Reimbursement of molecular imaging and therapies - leading to the early detection and diagnosis of many life-threatening diseases - remains an urgent and critical need as consumers face ever-increasing healthcare costs. The Centers for Medicare and Medicaid Services (CMS) needs to provide fair and adequate reimbursement for effective diagnostic techniques and life-saving medical therapies - yet currently, diagnostic radiopharmaceuticals are not adequately reimbursed. To address this pressing problem, SNM has issued proposed recommendations and rationale for reforming radiopharmaceutical reimbursement under Medicare.

Despite statutory language in the Social Security Act clearly defining radiopharmaceuticals as "specified covered outpatient drugs," CMS recently reclassified diagnostic radiopharmaceuticals as "supplies" instead of "drugs." This distinction has bundled payment for diagnostic radiopharmaceuticals into the payment for nuclear medicine procedures, thus threatening Medicare and other patient access to these critical diagnostic drugs.

"Treatments exist today that can radically improve the prognosis for patients suffering from many devastating diseases, and yet reimbursement by CMS for these drugs is sometimes less than half the actual cost of producing them," said 2008-09 SNM President Robert W. Atcher, Ph.D., M.B.A. "As we develop new therapeutic radiopharmaceuticals that have the potential to dramatically change disease outcomes, we need to ensure that they will be adequately reimbursed in order to be effectively utilized."

To address this issue and to ensure that Medicare beneficiaries continue to have access to diagnostic radiopharmaceuticals, SNM has issued the following recommendations:

• 1. All radiopharmaceuticals should be recognized and treated as drugs, not supplies.
  
  
• 2. CMS should continue to reimburse radiopharmaceuticals at charges reduced to cost in 2008 while working with the nuclear medicine industry (nuclear pharmacies and manufacturers) to develop standard payment methodology based on the average radiopharmaceutical invoice price at the distributor or nuclear pharmacy level (patterned after the average sales price model for drugs).
  
  
• 3. All radiopharmaceuticals should qualify for the same bundling threshold in 2008 ($60.00) as all other drugs.
  
  
• 4. CMS should accept and utilize external data sources to identify and appropriately reimburse radiopharmaceuticals under HOPPS, as the agency does for all other drugs. The most accurate sources of radiopharmaceutical cost data are nuclear pharmacies and manufacturers.

Nuclear medicine procedures are safe, painless and cost-effective techniques used to diagnose and treat disease. These imaging techniques are essential to the management of many serious diseases, including heart disease and cancer, as they provide specific information about physiologic, metabolic and other functional activities in the body or its pathology and allow for highly effective targeted therapy. For more information on SNM's policy statement on reforming radiopharmaceutical reimbursement under Medicare, please visit http://www.snm.org/cmspolicy.

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About SNM - Advancing Molecular Imaging and Therapy

SNM is an international scientific and medical organization dedicated to increasing understanding and sound practice of molecular imaging throughout the medical community and with the public. Due to the work of SNM members, molecular imaging is a vital element of today's medical practice, adding an additional dimension to diagnosis that can change the way common and devastating diseases are understood and treated.

Our more than 16,000 members set the standard for molecular imaging practice by creating procedure guidelines, sharing information through our Journal and meetings, and leading advocacy on key issues that affect imaging research and practice. For more information visit http://www.snm.org/.

Source: Amy Shaw
Society of Nuclear Medicine

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