RSNA: PET Reimbursement: The NOPR Effect

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CHICAGO--Eight years after the Centers for Medicare & Medicaid Services (CMS) first covered PET for an oncologic application, molecular imaging’s main modality is edging toward more comprehensive coverage. That journey has been a long, slow ride, recalled Valerie Cronin, CNMT, chief operating officer of DENT Neurologic Institute in Buffalo, N.Y., during Tuesday morning’s Molecular Imaging: Here to Stay educational session at the Radiological Society of North America (RSNA) conference.

After witnessing the economic and political fallout associated with other high-end imaging modalities like CT and MRI, CMS took a very cautious approach to PET. Further exacerbating the PET reimbursement challenge is the modality’s dependence on FDA approval of tracers beyond FDG. That is, the clinical value of PET/CT will improve with new tracers; however, moving new tracers from development to clinical practice has been slow.

In the early days of PET reimbursement, payment decisions were left in the hands of third party payors’ technology assessment panels. Few panels had sufficient knowledge of PET, so most followed the ultra-cautious approach of CMS. CMS adopted a piecemeal model, steering clear of coverage for broad applications and instead considered specific applications of specific cancers such as staging of thyroid cancer. The problem, said Cronin, is that the tight requirements made it very difficult to acquire data about the utility of PET for low-incidence cancers.

A new model: NOPR
In 2006, CMS changed course and took an aggressive step with the launch of National Oncologic PET Registry (NOPR). NOPR covers cancers neither specifically covered nor non-covered by CMS and requires the provider to collect data about the role of PET in disease management.

“CMS covered PET during evidence development, allowing us to provide clinically appropriate care during data collection,” summed Cronin.

The objectives of NOPR were fairly clear. CMS aimed to assess the effect of FDG-PET on patient management plans. Participating providers were required to complete a five question form that stated the reason for the study, cancer site and type, disease stage and summary, performance status and intended patient management plan. A post-PET form also addressed intended patient management.

NOPR concluded on Aug. 31, 2008, with nearly 90 percent of all PET facilities participating in the program. The results showed that 36 percent of the time PET changed the physician’s intended management of the disease.

“This is an exciting registry with several important strengths,” shared Cronin. NOPR collected real world, timely data in a large patient population. Conversely, NOPR is not without limitations. It did not collect information about actual patient management, and it is too soon to tell if PET changed long-term patient outcomes.