The American Medical Association (AMA) Board of Delegates approved a policy calling on payers to reimburse for the drug regadenoson (Lexiscan) and not to employ payment policies that push for cardiologists to change the drug they use for pharmacologic stress for one that is considered less safe. The policy was adopted at the AMA 2022 meeting last week.
Many cardiologists prefer to use regadenoson as a vasodilator for pharmacologic stress test imaging as opposed to adenosine. Regadenoson is usually used as a pharmacologic stress agent for radionuclide myocardial perfusion imaging (MPI) in patients unable to undergo adequate exercise stress. In positron emission tomography (PET), pharmacologic stress is the only way cardiac patients can be imaged under stress because of the 75 second half life of the standard radiotracer used.
There are fewer patient side effects from regadenoson that can lead to admissions, and it is easier to administer via string rather than IV bolus. However, many payers will not reimburse the higher cost of the drug agent.
The new policy, adopted by the AMA House of Delegates, calls for insurance payers to cover the reimbursement costs of the more expensive drug, because it can save money downstream if a patient has complications and is a better drug for patient care.
"It is faster, easier to use, has less side effects and has less of a chance for complications, such as bradycardia or asthma attacks, but it costs more," explained Stephen Bloom, MD, director of clinical research, Midwest Heart and Vascular Specialists, Overland, Kansas, and an AMA delegate from the American Society of Nuclear Cardiology (ASNC).
The New York delegation brought the resolution to the floor of the AMA because the reimbursement for regadenoson is lower than the actual cost of the drug itself.
"It essentially was a disincentive from the payers in attempts to push us to use adenosine instead of regadenoson," explained Nishant Shah, MD, assistant professor of medicine, Brown University, and an ASNC AMA delegate. "From our point of view, this is not a test substitution, but it is a drug substitution on the part of the payers through a sort of back-door mechanism. This started with regadenoson, but it is really about the notion that all drugs should be reimbursed at a minimum at cost, as opposed to being purposeful reimbursed at a lower rate to drive clinicians to select other drugs."
Bloom said he had run into similar issues at hospitals he works at in Kansas City, where to save money the pharmacy was asking the cardiologists to switch to adenosine. He said the cardiologists resisted this effort because there are good reasons to use the more expensive agent.
"It's not always about saving money, it's about using an agent that is easier to use and has less chances of complications," Bloom said. "I feel a lot better using a drug that is safer."
He noted it also takes less staff and procedure time to administer regadenoson.
"What a pharmacist advocating for a change like this may not understand based on a cost-benefit analysis is that there are costs associated with the complications, and that mitigates some of the cost difference," explained Shah.
He said this is more pronounced if a center is performing a lot of cardiac exams and sees more complications over time as a result.
"The main issue is that we do not want to see a third-party payer influencing clinical decision-making around what is best for that specific patient at that particular time," Shah said. "The resolution was really just a gateway for AMA to discuss this issue, and regadenoson and adenosine were just the examples brought forward for the discussion by the New York delegation."
Challenges in cardiac telemedicine discussed at AMA
There was also discussion of telemedicine at the cardiovascular medicine council meeting at AMA, made up of delegates from the cardiovascular subspecialties. A primary discussion centered on issues involving cross-state licensing of cardiologists who are using telemedicine to speak with physicians in neighboring states. This is an issue frequently seen at hospitals in larger border cities, or closely packed regions like New England, where many patients from Maine, New Hampshire and Vermont often are treated by specialists at hospitals in Boston, Massachusetts.
"We learned a lot about telemedicine use during the pandemic, and there are a lot of issues centered around licensing and regulations," Shah explained. "I don't think we have come to any sort of consensus yet on these issues as a specialty in cardiology or in the AMA House of Medicine."
Shah said licensing also becomes a problem when patients travel to second homes in other states during the winter. He said many patients want to have telehealth consultations with him who are physically out of state. "There are patients who want have a telehealth visit specifically with me, but there are questions whether or not I can actually treat that patient when they are physically located in Florida," Shah said.
No resolution was put forward at the 2022 AMA meeting, but Shah expects this will be a subject of discussion and further policies at future AMA meetings.
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