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Radiopharmaceuticals: Should reimbursement rule treatment options?

by Gus Iversen, Editor in Chief | June 18, 2015
Molecular Imaging
From the June 2015 issue of HealthCare Business News magazine

The annual meeting of the SNMMI draws about 5,000 attendees from around the world. The interests and expertise among that crowd is varied and, as this year’s meeting in Baltimore gets closer, there should be no shortage of timely issues worth discussing. In terms of radiopharmaceuticals, much of the conversation has revolved around effectively managing and facilitating the tracer’s transition from academic laboratories into meaningful and economical clinical usage.

Whether trying to usher a new tracer into the market, or improve the cost and clinical understanding of a tracer that’s already there – illustrating problems and solutions to CMS is key. The society works extensively in partnership with the government to communicate new findings and facilitate innovation.

Alongside the Alzheimer’s Association and a group of experts they brought together called the Amyloid Imaging Taskforce, the society submitted an AUC statement seeking reimbursement for amyloid imaging in 2013. CMS did not see sufficient evidence to fully reimburse the procedure, so the AUC outlined scenarios where those imaging outcomes could improve patient care.

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With other tracers, CMS sees sufficient evidence for reimbursement – but the model they use for providing it sometimes becomes outdated. Medicare’s Hospital Outpatient Prospective Payment System (HOPPS) needs to be modified as new tracers are developed and introduced to the market, and the old ambulatory payment category (APC) options no longer always leave room for the hospitals to recoup their expenses. Meanwhile, other tracers may become over-reimbursed with time, thus creating inappropriate care incentives for providers. The SNMMI is working with CMS to solve those problems too.

Amyloid imaging: how valuable is knowing?
According to the World Health Organization, 47.5 million people worldwide suffer from some form of dementia, and an additional 7.7 million cases are reported annually. The neurodegenerative failure associated with diseases like Alzheimer’s can turn a loved one into a stranger, and represents a costly problem for the health care industry that’s only getting worse.

A study published last year in the New England Journal of Medicine estimated the cost of care for a dementia patient to be around $41,000 to $56,000 a year. In part because of the aging population, it projects the total cost of dementia care to the industry will more than double by 2040, reaching upwards of $400 billion annually.

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