Cardiac PET hums; cost calls the tune

May 20, 1992

A positron emission tomography utilization model developed bythe American Hospital Association indicates a strong clinicalrationale for PET. On the flip side, while some private payersreimburse the procedure, the modality's high cost and a reluctanceon

A positron emission tomography utilization model developed bythe American Hospital Association indicates a strong clinicalrationale for PET. On the flip side, while some private payersreimburse the procedure, the modality's high cost and a reluctanceon the part of Medicare and most insurers to jump on board continueto restrain the PET market.

The AHA model anticipates healthy clinical demand for PET overthe long haul. Although no time period is provided, the modelpredicts a need in the U.S. for 1.1 to 1.8 million clinical PETscans. About 20,000 clinical PET scans were performed last year,according to the Institute for Clinical PET, an industry/physicianPET advocacy organization.

Utilization models are useful for administrators in helpingto gauge whether to make the approximately $5 million investmentin a PET camera, cyclotron and related personnel and siting costs.

The AHA model pinpoints current clinical applications for PET,which include cardiology (64%), neurology and psychiatry (31%),and oncology (5%). Use of PET in all three applications is expectedto increase substantially as the technology gains acceptance.

While PET may fly in theory, its high cost has forced somehospitals to put off purchasing the equipment indefinitely. Othersare hammering out collaborative agreements to share PET systems.

In mid-1991, about 51 centers were using PET, but only halfwere using it in a clinical fashion, according to ICP. Between30 and 45 more centers are predicted to sprout this year.

While demand projections are critical to PET purchase decisions,so is the potential for reimbursement. So far, private insurersand the Health Care Financing Administration remain unconvincedthat the technology is worth a premium price.

Insurers are taking a more proactive role in assessing newtechnologies--and they're starting with PET, according to JohnCova, director of medical technology for the Health InsuranceAssociation of America.

"We're looking at new technologies and determining whetherthey are safe and effective before they're widely available,"he said.

Only a handful of insurers cover PET, and then only under limitedcircumstances. Blue Cross of California (Woodland Hills), Floridaand Nebraska pay for cardiac studies and brain studies in epilepticpatients. PET screening for heart disease is not covered.

HCFA reviewed PET in 1980 and 1986, but on both occasions rejectedthe approval due to insufficient clinical evidence. Results ofanother review, conducted by the Office of Health Technology Assessmentin 1989, are still pending. A separate review of PET radiopharmaceuticalsby the Food and Drug Administration is also needed prior to approval.