Today, CMS
released its FY25 proposed rule on the Hospital Outpatient Prospective Payment System (OPPS), and it
included adjustments to an existing packaging policy for diagnostic
radiopharmaceuticals established in 2008.
CMS stated, “We
propose to pay separately for diagnostic radiopharmaceuticals with per day
costs above a threshold of $630, which is approximately two times the volume
weighted average cost amount currently associated with diagnostic
radiopharmaceuticals. We also propose to update the $630 threshold in CY 2026
and subsequent years by the Producer Price Index (PPI) for Pharmaceutical
Preparations.”
SNMMI
enthusiastically supports this change to the current OPPS bundling system. CMS’
reimbursement of higher-priced diagnostic radiopharmaceuticals with per-day
costs above a $630 threshold will allow patients access to new, more advanced
diagnostic nuclear medicine procedures. The change will also align CMS’
radiopharmaceutical reimbursement policy with those for many other drugs
included in the OPPS.
This would
replace a system wherein diagnostic radiopharmaceuticals are treated as
“supplies” and reimbursed through a packaged payment system. The methodology
averages the higher cost of these specialized products with more general and
widely used lower-cost radiopharmaceuticals, thus overpaying for the low-cost
products and underpaying for the higher-cost products. This results in healthcare institutions not
being able to provide these services. creating a significant barrier to patient
access to the newer, more precise generation of diagnostic nuclear imaging
drugs.
The proposed
rule is published annually and will have a 60-day comment period, which will
end on September 9, 2024. The final rule will be issued in early November and will
take effect January 1, 2025.
SNMMI continues
to analyze the entire proposed rule and will develop a more comprehensive
summary in the coming days. The Society plans to send comments to CMS for
consideration in the FY25 Final Rule.
We are excited
to celebrate this win for patients and the greater nuclear medicine community!