A tale of two provider types
The radiopharmaceutical Octreoscan, which is used to visualize hormone-producing tumors in the nervous and endocrine systems, costs between $1,200 and $1,400. However, it is not being reimbursed anywhere close to that amount.

Octreoscan procedures are more likely to be provided by large healthcare institutions where cost concerns are less of a factor than at their smaller hospital counterparts. In addition to that, large health systems or academic hospitals are more likely to offer any procedure that it FDA-approved in the interest of maintaining recognition and reputation.


Reclassifying from “supplies” to “drugs”
In March, SNMMI, the Medical Imaging and Technology Alliance (MITA), the Council on Radionuclides and Radiopharmaceuticals Inc. (CORAR), and patient advocates met on Capitol Hill to lobby for a bill that would require CMS to reclassify diagnostic radiopharmaceuticals as drugs.

“Lo and behold, in the budget bill there is a provision telling CMS to reverse its decision to take a number of radiopharmaceuticals off of the pass-through list on January 1 of this year, and mandating a Government Accountability Office (GAO) study [to investigate] the problems and come back to them with recommendations,” said Powell.

The pass-through list consists of items that are not bundled into the Medicare Payment Group Methodology. Those items are paid for separately – usually on the same basis that approximates their cost. In addition, the ruling doesn’t apply to radiopharmaceuticals that are already off the pass-through list and those that will go off before January 1.

The GAO study, which is scheduled for completion in 2021, will evaluate whether classifying radiopharmaceuticals as supplies is a patient harm issue. Those findings will likely play a major role in determining whether or not the agents are reclassified.

Ghesani believes that part of the problem is that patient rights groups aren’t aware of this issue. Getting more people involved in the discussion and encouraging patients to lobby their representatives are necessary steps to impact legislation.

“The patients may not even be aware that this very crucial test that they would otherwise need is not being performed because of the bundling issues,” he said. “I think if there is enough awareness, it will really inspire people to make that change by reaching out to their congress member or even going to some of the committees that are eventually responsible for giving guidance to CMS.”

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