On October 18, 2019, an opinion piece that NorCal CarciNET Community’s Josh Mailman opinion article (“CMS policy shouldn't penalize those with rare disease”) was published by The Hill, The opinion piece highlighted the challenges with the current method that Medicare/CMS use to pay for radiopharmaceuticals. This webpage provides more information on how this will impact NET patients and providers along with a tool for those that are interested in taking action.
The Medicare Diagnostic Radiopharmaceutical Payment Equity Act of 2019 (H.R. 3772), which many in the nuclear medicine community are working on to help improve, will impact Medicare payments for imaging only. This bill is not looking at broader medical payment, billing or cost issues.
In 2008, Medicare/CMS simplified how CMS paid for PET Imaging. The simplification reduced an infinite combination of supplies and tracers to a few PET bundles based on tracer cost. These bundles allowed a provider to bill for all PET imaging in a simplified manner. The most expensive bundle is ~ $1,400 (there are some regional adjustments).
To accommodate new imaging agents, Medicare allowed a provider (hospital) to bill new agents outside the bundle and be paid for separately as a drug for a period of 3 calendar years. The provider would be paid the average selling price + 6% for the imaging agent. After 3 years the imaging agent is no longer billed separately and is added to one of the various bundles with the idea that some agents would be cheaper and some more expensive and it would average out.
Then innovation happened - several imaging agents have come to market that cost thousands of dollars. After the 3-year period when Medicare paid for these agents separately expired, 2/3 of the facilities offering scans with these new agents stopped providing the scan. This could happen to NET patients. On Jan 1, 2020, NETSPOT (Ga68 DotaTate PET/CT) will no longer be paid for separately and while Medicare will still cover the scan (as appropriate) at the highest bundle level (~$1,400), this reimbursement will be less than the cost of the imaging agent (~$3,200).
What will likely happen if we don't get Congress to act?
It is likely that there will be fewer places that will offer a Ga68 DotaTate scan for patients with NETS and those that do will potentially have to make up the losses in other areas of their NET program. That is why getting The Medicare Diagnostic Radiopharmaceutical Payment Equity Act of 2019 (H.R. 3772) passed is important.
For the best opportunity for this bill to pass, letters should focus on imaging and Medicare.
If you would like to write your Congressional representatives about this topic - makes this process easy. All you need to do is enter your zip code to determine who the letter will be sent to. Democracy.io will not track your information. You will be asked for your contact information at the end of the process as well as the topic (“health”) that will be passed to your congressperson.
You may use the sample language below as well as a personal story if you wish.
Subject: In Support of Medicare Diagnostic Radiopharmaceutical Payment Equity!
Diagnostic radiopharmaceuticals are drugs necessary for all nuclear medicine imaging studies to diagnose and determine the severity of the disease. Nuclear medicine studies image an organ’s anatomy and determine organ function. This optimizes a physician’s ability to evaluate and determine the most effective treatment pathway for patients suffering from Alzheimer’s disease, Parkinson’s disease, cardiovascular disease, some forms of cancer, and other diseases.
*Insert your testimony here on how Nuclear imaging has impacted your care. Please try to keep the letter to a page.*
Diagnostic radiopharmaceuticals are statutorily regulated as drugs but are arbitrarily treated differently by the Centers for Medicare and Medicaid Services (CMS), which has packaged them into procedural bundles, known as Ambulatory Payment Classifications (APCs), since 2008.
This has proved to be problematic, as diagnostic radiopharmaceutical costs may vary widely within a nuclear medicine APC. At times, the costs exceed the whole APC payment. This translates into a strong disincentive for hospitals to utilize innovative targeted radiopharmaceuticals, serves to discourage investment in and research for new precision diagnostic radiopharmaceuticals, and impacts patient access to the most appropriate and innovative diagnostic tools at readily-accessible healthcare locations. In addition, this can result in an inaccurate diagnosis and possibly inappropriate treatment plans.
I believe that CMS should be directed to pay separately for those diagnostic radiopharmaceuticals with a per-day cost that exceeds $500, which will safeguard access to the most appropriate diagnostic radiopharmaceuticals for detection and treatment.
I am pleased to support the Medicare Diagnostic Radiopharmaceutical Payment Equity Act of 2019.