A 340B View of Pluvicto (Lutetium Lu 177 Vipivotide Tetraxetan): Financial Misalignment in Radioligand Therapy

This analysis offers an in-depth view of the financial potential and hurdles of radioligand therapies (RLTs) for health care institutions covered under the 340B Drug Pricing Program. Using Pluvicto (lutetium Lu 177 vipivotide tetraxetan) as a case study, we aim to highlight the economic misalignment between health care institutions and radiation oncologists.

We provide an overview of the 340B program and perform a financial analysis of Pluvicto. This was achieved by identifying acquisition and reimbursement costs and comparing the wholesale acquisition cost with the calculated 340B ceiling price using Health Resources and Services Administration formulas. In addition, we compared physician work incentives by analyzing Medicare work relative value unit (wRVU) generation for a standard 6-dose course of Pluvicto versus a 20-fraction external beam radiation therapy plan.

This analysis discovered that under the 340B program, covered entities can acquire Pluvicto at a discount of approximately 31.7% below the wholesale acquisition cost ($34,970.71 vs $51,168.13 per dose). This was shown to generate a potential gross margin of over $101,000 for a full 6-dose course. Even with the large gross margin generated, we discovered that physician compensation remains disproportionately low. A full course of Pluvicto generates approximately 20.6 wRVUs compared with 47 wRVUs for a standard external beam radiation therapy course. This creates a "wRVU trap" where radiation oncologists are financially penalized for the time-intensive training and management required for RLT.

The 340B program offers significant revenue opportunities for hospitals administering RLTs like Pluvicto. However, current physician compensation models do not align with the clinical effort required. To ensure sustainable RLT adoption, health systems must leverage 340B margins to develop alternative incentive models that adequately compensate radiation oncologists for their role in this precision therapy.