FEATURE tion , and any coverage granted is usually retroactive ,” Dr . Majhail explained . “ You do a procedure , submit a claim , and the MACs decide whether or not they are going to pay for that service . In that setting , it becomes problematic for an institution to take on the financial risk of doing an expensive procedure like transplant without the confidence that the procedure will be covered and paid for .”
Even for the conditions that receive Medicare coverage , hospitals and patients are often left dealing with expensive bills .
“ If a patient is referred for transplant we do a benefit check upfront to see if the transplant will be covered at our institution ,” said Dr . Majhail . “ If they have a commercial payer and we are given prior authorization , we are often paid in phases .”
Patients who have commercial insurance typically receive more comprehensive coverage for transplant that includes services received during all phases of the transplant , from preparative regimen days (“ minus days ”), to the transplant procedures (“ day zero ”), to post-transplant recovery ( days 30-60 +).
“ Commercial contracts are confidential , and rightfully so , but most use a case rate that covers a set number of days or a full transplant episode ,” Ms . Farnia said . “ I would estimate that reimbursement on the commercial side is typically somewhere between $ 200,000 and $ 400,000 for the transplant episode .”
If a patient gets sick and is admitted to the intensive care unit for a complication related to the transplant or conditioning regimen , institutions can ask for additional reimbursement . Once a patient is discharged , commercial payers continue to cover that patient ’ s follow-up care .
For its covered indications , Medicare also pays per episode , but only for the inpatient stay , Dr . Majhail explained . “[ Compared with Medicare ,] commercial payers pay at a rate that is closer to the actual costs that we incur ,” he said .
In 2015 , the current Inpatient Payment Base for transplant was :
• $ 64,432 for alloHCT ( diagnosis-related group [ DRG ] 014 )
• $ 34,477 for AHCT with major complication or comorbidity or a complication or comorbidity ( MCC / CC ; DRG 015 )
• $ 24,402 for AHCT without MCC / CC ( DRG 017 )
These reimbursement rates are “ not even close to covering what it costs for the inpatient stay ,” Dr . Majhail said . “ They do not reflect the actual costs for providing treatment to these patients .”
According to Dr . Giralt , performing an allo-HCT for Medicare patients is , on an economic level , a moneylosing proposition – particularly because Medicare coverage does not include any “ minus days ” and does not accurately cover the cost of obtaining the donor marrow . “ CMS covers the procurement of all transplant organs except for bone marrow ,” he noted .
That means that a hospital will spend a good portion of time “ in the red ” before an individual even checks into the hospital , Ms . Farnia added .
“ If a patient is getting marrow from an unrelated donor , the hospital is already incurring somewhere between $ 30,000 to $ 50,000 to identify donor cells , get the cells , and get them ready for transplant ,” she explained . Another coverage issue relates to the cost of drugs needed during and after transplantation . “ We have had patients on Medicare who , for a multitude of reasons , suddenly can ’ t afford to take their immunosuppression medications or antibiotics to prevent infection ,” Dr . Giralt said . “ This is a serious problem . It is really shooting yourself in the foot to cover the whole transplant but not cover life-sustaining medication to prevent graft-versus-host disease ( GVHD ).”
Many Medicare beneficiaries will incur substantial costs to undergo a bone marrow transplant for one of the approved indications , and they will spend weeks or even months in the hospital after undergoing transplant . 5 Patients with standard Medicare Parts A and B coverage with a Medicare Supplement Insurance ( or “ Medigap ”) plan – a policy sold by private companies to help pay some of the health-care costs that standard Medicare plans don ’ t cover – will incur the least out-of-pocket costs , according to Ms . Farnia . However , those patients with Parts A and B without a Medigap plan must pay deductibles with no out-of-pocket maximum .
“ CMS [ could ] come up with a coverage process that is more appropriate for a procedure like transplantation , where good evidence tells us that it is effective and safe in the older population .”
— NAVNEET MAJHAIL , MD , MS
Under current Medicare policies , for days one through 60 of any inpatient hospital time within a given calendar year , beneficiaries pay nothing for coinsurance . However , from days 61 to 90 , they pay $ 322 in co-insurance per day and , for each “ lifetime reserve day ” after day 90 in each benefit period ( up to 60 days over their lifetime ), they pay $ 644 in co-insurance per day . For any hospital time beyond the lifetime reserve days , beneficiaries pay all costs . 6
Advocating for Change
What is the future for transplant coverage , and how can the transplant community help to enact policy changes ? The first step to changing the coverage system is to continue to gather data about the efficacy of transplant , according to Dr . Giralt .
“ The transplant community is blessed in that all allo- HCT procedures in North America have to be reported to the registry managed by the CIBMTR ,” Dr . Giralt said . “ It gives us a data repository , which is essential for any research we want to do .”
For example , there is little likelihood that there would ever be a phase III trial comparing outcomes for patients with myelofibrosis who received transplant with those who received no transplant . However , with data in the CIBMTR registry , a trial could compare transplant outcomes with those of patients in the registry who chose not to undergo transplant , he explained .
From a legislative perspective , Dr . Majhail said that there are a variety of actions that lawmakers and hematologists can take to advocate for improvements in CMS ’ coverage of transplant .
“ Lawmakers could encourage CMS to come up with a coverage process that is more appropriate for a procedure like transplantation , where there is good evidence telling us that it is effective and safe in the older population ,” he said .
In 2015 , Dr . Majhail and Ms . Farnia were involved in the publication of a guideline by the American Society for Blood and Marrow Transplantation ( ASBMT ) that spelled out the appropriate indications for AHCT and alloHCT , including transplantation in older adults . 7 Discussing age in the guideline , ASBMT wrote :
“ Age by itself should not be a contraindication to transplantation in patients who may benefit from this procedure . Selected older patients with limited comorbidities and good functional status can safely receive HCT with a relatively low and acceptable risk of non-relapse mortality . Instead of chronologic patient age , evaluations such as functional status , HCT-specific comorbidity index score , [ European Group for Blood and Marrow Transplantation ] risk score , and Pre-Transplantation Assessment of Mortality risk score can assist in determining risks of non-relapse mortality and transplant candidacy for individual patients .”
“ We have to encourage CMS to consider coverage of transplantation that reflects how the transplantation community practices ,” Dr . Majhail said .
It is also critical that hematologists work with associations like the American Society of Hematology and ASBMT to advocate for these changes so that older patients can be cared for in an appropriate manner .
Dr . Burns acknowledged that the community of transplanters is a small one , especially in comparison with larger groups like physicians who treat patients with breast cancer , so it will require help from the larger community of health-care professionals who care for transplant recipients . “ I would ask hematologists who are not transplanters , but who take care of patients prior to and after transplant , to support our efforts for change ,” Dr . Burns said .— By Leah Lawrence ●
REFERENCES
1 . Pasquini MC , Zhu X . Current uses and outcomes of hematopoietic stem cell transplantation : CIBMTR Summary Slides , 2015 . Accessed October 1 , 2016 from http :// www . cibmtr . org .
2 . Centers for Medicare & Medicaid Services . Decision Memo for Allogeneic Hematopoietic Stem Cell Transplantation ( HSCT ) for Myelodysplastic Syndrome ( CAG-00415N ). Accessed September 22 , 2016 from https :// www . cms . gov / medicare-coverage-database / details / ncadecision-memo . aspx ? NCAId = 238 .
3 . McClune BL , Weisdorf DJ , Pedersen TL , et al . Effect of age on outcome of reduced-intensity hematopoietic cell transplantation for older patients with acute myeloid leukemia in first complete remission or with myelodysplastic syndrome . J Clin Oncol . 2010 ; 28:1878-87 .
4 . Centers for Medicare & Medicaid Services . Decision Memo for Stem Cell Transplantation ( Multiple Myeloma , Myelofibrosis , and Sickle Cell Disease ) ( CAG-00444R ). Accessed September 22 , 2016 from https :// www . cms . gov / medicare-coverage-database / details / nca-decision-memo . aspx ? NCAId = 280 .
5 . National Heart , Lung , and Blood Institute . What to Expect During a Blood and Marrow Stem Cell Transplant . Accessed September 20 , 2016 from https :// www . nhlbi . nih . gov / health / health-topics / topics / bmsct / during .
6 . Medicare . gov . Your Medicare Coverage : Inpatient hospital care . Accessed September 20 , 2016 from https :// www . medicare . gov / coverage / hospital-care-inpatient . html .
7 . Majhail NS , Farnia SH , Carpenter PA , et al . Indications for autologous and allogeneic hematopoietic cell transplantation : guidelines from the American Society for Blood and Marrow Transplantation . Biol Blood Marrow Transplant . 2015 ; 21:1863-69 .
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