Imaging Under Fire: Radiology Seeks to Rebound from Reimbursement Reductions

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Clinical images courtesy of (clockwise) OrthoView, TeraRecon, Amicas, Amicas, MIMvista

By any measure, 2009 has been a rough year for medical imaging. The U.S. House of Representatives passed legislation that could change Medicare payments for advanced diagnostic imaging procedures, such as MRI, CT, PET and nuclear medicine, through an increase in the equipment utilization rate assumption from 50 percent to 75 percent.

This could lower the technical component payments for these services. The bill also seeks to increase the payment reduction on contiguous body parts from its current 25 percent to 50 percent. Both of these provisions would become effective Jan. 1, 2011.

In November, the U.S. Preventive Services Task Force reversed course from its 2002 recommendations and issued new guidelines against routine screening mammography in women aged 40-49 years. In addition, it suggested that biennial screening mammography was sufficient for women aged 50-74 years. Industry debate continues. (See story, page 16)

However, PET proponents scored major victories when the Centers for Medicare & Medicaid Services (CMS) expanded the exams for which it will reimburse use of the modality. Also, some cardiac PET studies saw an uptick in their reimbursement rate, a bright spot in a year of double-digital cuts to CT and MR payments in 2010.

Health Imaging & IT checked in with leaders from SNM, ACR, RSNA and ARRS and got their reaction to events of the past year and thoughts on what the future may hold for imaging.

Making it molecular
Molecular imaging got some good news earlier this year on the reimbursement front for imaging several new cancer types. And to validate imaging biomarkers for use in streamlining the development and registration of investigational therapeutics, the SNM Clinical Trials Network was introduced.

“There are two reasons we created the network: the first is to support pharmaceutical companies that are using PET imaging in clinical trials and are having trouble with obtaining reliable, quantitative imaging,” says Michael Graham, MD, PhD, SNM president and professor of radiology and director of nuclear medicine at the University of Iowa Carver College of Medicine. “The second is to provide a platform supporting uniform trials for new imaging agents that are in the public domain, such as the fluorothymidine (FLT) marker for DNA synthesis, and fluoromisonidazole (F-MISO) for imaging hypoxic tumor tissue.

“To test new therapies early on, determine whether to go ahead with larger-scale trials, and accumulate data for FDA approval, a large, centralized effort is necessary,” Graham explains. “Because these agents are generic, there is no profit motive for an individual pharmaceutical vendor to do it; it has to be done by an economically disinterested group such as the SNM.”

A growth area for nuclear medicine is the assessment of response to therapy and the development of personalized medicine. “Nuclear medicine physicians are helping to test chemotherapy agent effectiveness and tailor therapy for individual patients after only a few doses. They save money and time by figuring out in the first week or two if the course of therapy is really working,” says Graham. One example of this is customizing the dosage of new agents directed against receptors on tumors, such as Gleevec.

Isotope supply concerns
One great challenge to nuclear medicine over the past couple of years has been the threat to the supply of the oft-used molybdenum-99 (Mo-99)—the parent isotope of technetium-99m (Tc-99m)—the most widely utilized radioisotope in the world for molecular and nuclear diagnostic imaging studies. Approximately 80 percent of worldwide clinical nuclear medicine is dependent on the availability of Mo-99. Currently used reactors are 40 to 50 years old, and are experiencing downtime related to aging, leading to instability in the supply. This is a global issue being addressed locally.

Shortages have resulted from the unexpected and scheduled shutdowns of the largest—albeit aging—producers of Mo-99: the National Reactor Universal (NRU) reactor in Chalk River, Ontario, and the High Flux Reactor (HFR) in Petten, Netherlands.

Together, these reactors produce two-thirds of the world’s Mo-99 supply. In August, the shutdown of NRU was extended into the first quarter of 2010. To date, based on their proximity, the U.S. and Canadian medical communities have been most affected by the current shortage. In fact, about 91 percent