A CMS proposal to expand Medicare coverage of PET scans that are used to diagnose and determine the stage of a cancer may provide a clinical boon to patients and some increased reimbursement opportunities for physicians and hospitals, but providers arent likely to rush out and buy the equipment should the proposal prevail, according to healthcare experts.
This proposal is good news, says Tonya Sanders, diagnostic imaging portfolio executive for group purchasing organization Novation. But its definitely not going to be one of those things where just because CMS makes the announcement (providers) go and purchase the equipment. Dollars are way too tight to make that kind of jump.
The coverage expansion would allow Medicare to automatically reimburse providers for PET-scan services when the technology is used as an initial diagnostic tool to determine tumor size, whether lesions are benign or cancerous and whether a cancer has metastasized.
The proposed expansion would not cover prostate, breast and melanoma cancers, however. Currently, Medicare will only pay for diagnostic PET scans when the tests are registered and performed under the Coverage with Evidence Development, or CED, programs National Oncologic PET Registry observational study, which collects data on PET-scan usageand its impact on treatment of cancer patients. Data from the registry found that results of PET scans often changed the treatment plans oncologists prescribed for their patients.
Public comment on the proposed regulations ends Feb. 5, with a final rule expected in April.
But while the new rule would no longer require providers to register their patients with the CED study in order to receive Medicare reimbursement, the number of diagnostic PET scans being performed is likely to increase only nominally under a new coverage rule, radiology experts say. The CMS coverage proposal is only for a limited number of cancers from the registry; not for all, notes Pam Kassing, senior director of economics and health policy for the American College of Radiology.
Barry Siegel, M.D., director of nuclear medicine for the Mallinckrodt Institute of Radiology at the Washington University School of Medicine, St. Louis, was among the CMS advisory committee members who recommended expansion of diagnostic PET scans. His center also is among those that reported PET-utilization data reviewed by the committee. The group found that on average, providers only increased their Medicare reimbursement of cancer-diagnostic PET scans by 10% to 15% by participating in the CED study.
Such an increase is probably not enough to encourage wide adoption and purchase of PET technology among providers, Siegel says. I anticipate a bit of a bump (in usage) because now well have doctors who just didnt want to bother with the paperwork performing PET diagnostic scans, Siegel says. But, bottom line, this new ruling is not going to double or triple the number of scans being performed in the U.S.
Karsten Grabski, M.D., head of the nuclears that most providers using PET technology to diagnose and determine the stage of a cancer could accommodate substantially higher patient loads. As a result, he doesnt anticipate hospitals purchasing the technology or training and hiring staff strictly as a result of the CMS proposed coverage decision. If I look at PET usage here, Id have to say locally we probably have enough coverage, because I could see more patients, says Grabski, who estimates he sees roughly 24 patients weekly for cancer-related PET scans.
Whether private insurers also expand coverage of diagnostic PET scans is still questionable and a significant consideration for providers as well. UnitedHealthcare has issued comments in support of the CMS proposed coverage expansion, and the insurer already covers PET scans for the staging of cancer, according to spokeswoman Cheryl Randolph. Other insurers, however, are still deciding their response to the proposal, acknowledges Robert Zirkelbach, spokesman for the trade group Americas Health Insurance Plans Were currently soliciting feedback from our members and then we plan to respond to the CMS, he says.
To submit a letter to the Modern Physician Reader Blog, click here. Please include your name, title, company and hometown. Modern Physician reserves the right to edit all submissions.