SNMMI Press Releases
June 10, 2013
SNMMI Position Statement on Adequate and Appropriate Reimbursement for Nuclear Medicine and Molecular Imaging Radiopharmaceuticals
SNMMI released a position statement on adequate and appropriate reimbursement for nuclear medicine and molecular imaging procedures at its 2013 Annual Meeting in Vancouver, British Columbia.
- How are nuclear medicine and molecular imaging radiopharmaceuticals currently reimbursed in the hospital outpatient setting?
- Why is the nuclear medicine and molecular imaging industry hesitant to invest in new technologies for the creation of domestic supply of Molybdenum-99 (Mo-99), the parent isotope of Technitium-99m (Tc-99m)?
- How does the conversion of Mo-99 produced with highly-enriched uranium (HEU) to Mo-99 produced with non-HEU impact reimbursement rates for nuclear medicine and molecular imaging procedures.
Currently, reimbursement for radiopharmaceuticals used in nuclear medicine and molecular imaging in the hospital outpatient setting is bundled with procedure reimbursements, treating radiopharmaceuticals as supplies rather than drugs. This often results in radiopharmaceuticals not being reimbursed adequately and appropriately.
In addition, the reimbursement rates are calculated from data that lag at least two years behind current costs. Increases in production costs are not recognized early enough for updated bundled payments for at least two years—and sometimes three or more—within the current system. As such, hospitals and clinics are faced with the choice of not being fully reimbursed for radiopharmaceuticals, using less desirable diagnostic tools, or not offering the procedure at all.
In the near future, reimbursement for radiopharmaceuticals will become a more pressing issue. The world’s two primary sources of molybdenum-99 (Mo-99)—which produces Tc-99m that is used in more than 40,000 medical procedures each day—will be phased out of commercial isotope production beginning in 2016. The High Flux Reactor in the Netherlands is expected to transition its production to the PALLAS reactor, also in the Netherlands. The National Research Universal reactor in Canada, which provides 40 percent of the world’s supply, will no longer produce Mo-99.
This will require the United States to secure a new, reliable supply of Mo-99 that is in accordance with the United States nuclear nonproliferation program, which will require all radiopharmaceuticals to be produced with non-HEU. Given the uncertainty of market conditions, industry is hesitant to invest in new technologies and facilities.
SNMMI believes that the Centers for Medicare and Medicaid Services (CMS) should utilize its authority to reform the Hospital Outpatient Prospective Payment System (HOPPS), which designates the reimbursement rates for nuclear medicine and molecular imaging procedures. CMS should consider new and unique options for bundled payments for these unique drugs, using current data—rather than two-year-old data—for setting current rates.
In addition, the U.S. government should take steps to ensure that new production facilities will be available to create a reliable domestic supply of Mo-99. This can be accomplished by providing adequate reimbursement for new non-HEU technology.
Although CMS authorized an additional $10 reimbursement per dose for Tc-99m produced by non-HEU methods used in a diagnostic procedure for hospital outpatient departments, there is no concrete estimate for the true cost of 100 percent conversion to Tc-99m created with non-HEU. It is uncertain whether or not the true realized full cost can be absorbed into the bundled HOPPS payment. Further, this $10 reimbursement does not apply to physician’s offices or independent diagnostic testing facilities, which represent a large segment of Tc-99m users. Third party payers are have also not yet adopted this additional $10 payment.
Removing these payment obstacles will ensure that patients continue to receive the most appropriate, cost-effective treatments and diagnostic services available. In the absence of adequate Mo-99—and thus the Tc-99m supply produced from it—patients will be imaged using procedures that are less accurate, have a higher cost and a higher radiation dose, and could possibly lead to increased morbidity and mortality.