Medicare Payment and Reimbursement

Healthcare News of Note: With new treatments emerging, Medicare increases coverage of PET screening for Alzheimer’s disease

October 26, 2023 3:43 pm
  • CMS is withdrawing restrictions on coverage of PET scans for detecting Alzheimer’s disease, saying coverage determinations can be made on a case-by-case basis.
  • Women under 50 years old continue to have a higher incidence of lung cancer than men of the same age, and the trend now extends to middle-aged adults as younger women with a high risk of the disease enter older age.
  • Hospitals reached their highest customer satisfaction score in one survey since 2018, driven by a 5% rise in outpatient satisfaction.

Over the past few weeks, I have found these industry news stories that should be of interest to healthcare finance professionals.

1. CMS updates Medicare coverage of PET scans as a screening tool for Alzheimer’s disease

CMS recently moved to expand Medicare coverage of screening for a primary marker of Alzheimer’s disease, a key step in enhancing access to newer pharmaceutical therapies such as Leqembi.

The decision, posted Oct. 13, ends restrictions on coverage of positron emission tomography (PET) imaging for beta amyloid. Beneficiaries previously would be covered for only one such screening for as long as they were on Medicare. As described in a 2013 decision, the screening also had to take place in the context of a clinical study that met certain criteria.

CMS agreed in 2022 to cover Alzheimer’s disease (AD) medications such as Aduhelm that target beta amyloid plaque in the brain for patients in the early stages of the disease, as long as the treatment was furnished in a clinical study. Stakeholder feedback noted that coverage of PET imaging should be expanded because study protocols may dictate that more than one PET scan be provided to a patient as a means to monitor the course of their disease. After the release of Leqembi, which is in the same class of drug as Aduhelm, CMS earlier this year adjusted its treatment coverage policy to apply to any scenario in which the provider participates in an authorized registry.

In the new decision memo, CMS said the removal of the prior screening coverage policy “will allow appropriate coverage of amyloid PET scans and will greatly reduce provider and patient burden from the existing requirements and test limitation. Stakeholders and patients have particularly emphasized the constraints on choice of treatments and appropriate management of proven anti-amyloid treatments due to the once-in-a-lifetime limitation.”

Ending national guidelines

Under the new policy, there no longer will be a national coverage determination (NCD) for PET screening for beta amyloid. Instead, Medicare administrative contractors (MACs) will make coverage determinations.

“As new treatments directed against amyloid for patients with AD are developed and approved by the FDA, the MACs are able to promptly respond to the evidence on proven treatments for individual patients,” the decision memo states.

Other guidelines to consider

In a July interview with HFMA, Ronald Hirsch, MD, vice president of the Regulations and Education Group at R1 RCM, emphasized that a 2005 NCD on coverage of PET scans for patients with dementia remains pertinent.

“If you have physicians starting to order PET scans for dementia, you [should] very carefully look at the national coverage determination,” Hirsch said during an episode of the Voices in Healthcare Finance podcast. “It has quite a long list of requirements that must be fulfilled in order for Medicare to cover that PET scan for the patient with dementia. There has to be significant documentation available to the hospital or the imaging center prior to that scan being done, or there’s going to be a high risk of denial.”

— Nick Hut, HFMA senior editor

2. Lung cancer incidence in women grows again for those younger than 50 and now extends to middle-aged women as well

A new study confirms higher lung cancer incidence in women than men younger than 50 years old in the United States, as first noted in a 2018 study. The disparity now extends to middle-aged adults as younger women with an elevated risk of the disease enter older age.

The findings, which were published in a research letter Oct. 12 in JAMA Oncology, also included:

  • A higher incidence of lung cancer in women ages 35 to 54 is due to the declines in the incidence rates being greater in men than women between 2000-2004 and 2015-2019.
  • Among individuals ages 50 to 54, the rate per 100,000 person-years decreased by 44% in men and 20% in women, which resulted in the female-to-male incidence rate ratio increasing from 0.73 during 2000-04 to 1.05 during 2015-19.
  • Among individuals ages 55 and older, however, lung cancer incidence rates continued to be lower in women, although differences became increasingly smaller. Among persons ages 70 to 74, for example, the female-to-male incidence rate ratio increased from 0.62 during 2000-04 to 0.81 during 2015-19.

“Cigarette smoking cessation efforts should be intensified among younger and middle-aged women, and lung cancer screening encouraged among eligible women at both health care professional and community levels,” wrote the authors.

Proactive smoking cessation program results

Interestingly, a study published Oct. 14 in the American Journal of Preventive Medicine also advocates for proactive smoking cessation outreach and treatment. The data analysis included 10,683 patients in a smoking registry from 2017 to 2020.

Results of the trial, which employed both “electronic health record prompts during primary care visits and certified tobacco cessation specialists [offering] proactive outreach and smoking cessation treatment to patients,” included:

  • An average $42 decrease per patient per month in acute healthcare costs
  • An incremental cost-effectiveness ratio of $628 per person who quit smoking and $905 per quality-adjusted life year gained

“Implementation of a comprehensive and proactive smoking cessation outreach and treatment program for adult primary care patients who smoke meets typical cost-effectiveness thresholds for healthcare,” wrote the authors.

3. Hospitals and health insurers see better customer satisfaction scores, per the American Customer Satisfaction Index

Customers are more satisfied with their health insurance and with outpatient healthcare, according to results of the latest American Customer Satisfaction Index (ACSI) Insurance and Health Care Study (registration required).

The findings, published Oct. 17 in a news release, were based on interviews conducted October 2022 to September 2023 with 12,849 customers. Key takeaways include:

  • Health insurance satisfaction saw an increase of 4% “to a record-high score of 76.”
  • Health insurers saw “widespread policyholder satisfaction gains,” with all but one insurer seeing increased ACSI scores, including industry leader Humana, up 6% for a score of 82.
  • Hospitals reached their highest ACSI score (74) since 2018, driven by a 5% rise in outpatient satisfaction. The inpatient score increased 4% from 71 in 2022.
  • Satisfaction with nonhospital care jumped 11% to 81 as “patients find the post-pandemic medical office experience far better than the previous two years.”

HFMA bonus content

Read the Oct. 24 article “Hospital, physician advocates disagree over the role of physician-owned hospitals as policymakers ramp up focus,” by Nick Hut.

Read the October issue of hfm magazine, including the Jill Geisler column “6 things good leaders don’t do when delivering bad news,” the Ken Perez column “How homelessness and healthcare are inextricably linked,” and the Chapter News feature “Maryland Chapter event focuses on inclusion and equity,” by Crystal Milazzo.


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