Cardiac PET MPI, with its accuracy, efficiency, and safety, has become the preferred imaging modality for diagnosing heart disease. Providers rely on reimbursement from Centers for Medicare & Medicaid Services (CMS) and private insurers to cover the costs of the procedure and help recoup the significant investment required to start and maintain their cardiac PET programs. CMS sets the annual government contribution rate for medical procedures including cardiac PET, a figure that provides the basis for many private insurers. In 2019, CMS proposed a major reduction in the Physician Fee Schedule payment affecting cardiology practices and independent diagnostic testing facilities that could have drastically reduced the availability of cardiac PET across the U.S.
What does it take to start a cardiac PET program?
Cardiac PET providers will likely need to purchase a PET or PET/ CT scanner, which can range from $500,000 to $3.5 million. Depending on the facility, there may be considerable costs to build space for the scanner and purchase other equipment. They also must pay for the cardiac PET tracers and staff time once their program is running. Those investments and ongoing costs must be recouped for programs to be viable. Reimbursement is crucial because it covers the imaging studies that physiciansdo to help diagnose and treat patients, but it should also help cover initial startup costs.
Why was reimbursement for cardiac PET threatened in 2019?
Each year, hospitals report their costs for every procedure, which is how Medicare sets pricing in the hospital setting (HOPPS). For the physician practice, CMS either leaves it to the individual Medicare Administrative Contractors (MACs) to establish pricing which, in many cases, mirrors the national HOPPS rate, or they establish a payment based on the Relative Value Unit (RVU) of the procedure. In 2019, CMS conducted a reassessment survey of cardiac PET for private practices that resulted in an inappropriate and unsustainable proposed payment rate, 82% less than the previous payment. The results did not accurately reflect utilization rates of the equipment, costs that go into providing the procedure, and the upfront costs for implementing a cardiac PET program.
The proposed payment rate would have been devastating for patients and providers. Physician practices would not have been able to afford to provide cardiac PET imaging, and many would have had to end their programs, immediately removing access for about 70% of patients.
What did Bracco do to prevent the cut from taking place?
Bracco initiated collaboration between private companies, physicians’ advocates and societies like the American Society of Nuclear Cardiology (ASNC), American College of Cardiology (ACC) and the Society of Nuclear Medicine and Molecular Imaging (SNMMI) that support the cardiac PET industry. We implored our customers to get involved, be engaged and write letters to their local congressional representatives. A significant part of our effort was to work with all involved to develop and convey a unified, consistent and thorough message to CMS that encompassed the concerns of all stakeholders. Bracco, in addition to leaders at ASNC, SNMMI and ACC, met with CMS and provided comments and accurate data that reflected the true costs to start and run a cardiac PET program. Bracco provided actual procedure data to CMS that directly addressed the inappropriate utilization rate used in setting the payment. For example, CMS data reflected a 90% utilization rate of a PET scanner, but we had data from our sites that showed only about a 50% utilization rate. Considering that difference alone almost doubles the payment rate. We were able to stop that payment cut from going into effect. The payment remained stable from last year and is appropriate. It was a huge relief, but we know CMS could implement payment adjustments for any procedurein the future.
How will you navigate these issues in the future?
This experience revealed a significant issue with the process that CMS uses to establish payments. Their process does not have the capability to incorporate all the variables that are unique to cardiac PET, some of which are essential to determine appropriate reimbursement. For example, we learned they have no way to appropriately include and consider direct buildout costs for a startup cardiac PET suite, one of the most significant costs.
This process helped us forge a better relationship and open dialogue with offcials at CMS that will serve providers and patients in the long run. Our goal now is to continue providing CMS with data on the clinical relevance of the cardiac PET procedure and accurate costs to provide a cardiac pet study. It is incredibly important for us to remain at the forefront, so CMS does not propose another drastic cut like this again.
What can healthcare providers do to ensure access to cardiac PET?
Bracco gave providers the tools to effectively communicate the value of the cardiac PET procedure. Healthcare provider involvement, producing quality studies and engaging with CMS and their local lawmakers will be critical moving forward.
To learn more about the best stress test during a pandemic, listen to the MedAxiom HeartTalk podcast below. Guests Christopher Douglas, MD, FACC, Interventional Cardiologist, and Jamie Branch, Lead Imaging Technologist, from Heart & Vascular at Hattiesburg Clinic discuss PET imaging, stress testing, and how work gets done safely in the midst of a pandemic.