Bundled payments are intended to lower healthcare spending and achieve value-based care, but what happens when the reimbursement is a fraction of the cost to the provider?

This is a problem being faced concerning many radiopharmaceuticals today, and some experts believe that the consequences extend beyond patients receiving compromised care to actually damaging the adoption and development of better, emerging tracers.

Since different radiopharmaceuticals can cost anywhere between $20 and $3,000 per unit dose, bundling them into the same category means a facility will lose money performing an exam with expensive “supplies”.
For instance, if there is an average bundle package of $700 for a certain procedure and the radiopharmaceutical costs $1,200 then the hospital loses $500. And that doesn’t even factor in the cost of technology, salaries and radiologist reading fees.

“In this model, they are not able to account for huge differences in the costs from one radiopharmaceutical to another,” said Dr. Munir Ghesani, associate professor of radiology at NYU Langone Medical Center, and a member of the government relations committee at the SNMMI. “As a result, a lot of physicians do not use the expensive radiopharmaceuticals.”

Although technically drugs, CMS classifies radiopharmaceuticals as supplies so it can incorporate them into bundled payments under Ambulatory Payment Classifications (APCs) in the Medicare Hospital Outpatient Prospective Payment System (OPPS).

“The reason for that is cost savings,” said Ghesani. “When you bundle things together, it usually saves money.”

And generally speaking, bundled payments are a great thing, he added, but he and his peers believe packaging radiopharmaceuticals with procedures may be doing more harm than good.

In addition to preventing Medicare patients from receiving the nuclear medicine procedures they require, the current reimbursement situation may also hinder innovation because companies don’t want to spend money on the development of a radiopharmaceutical that hospitals won’t purchase.

“That is a major concern and part of the reason why some of the major players in this field have backed out of developing radiopharmaceuticals,” said Ghesani.

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