Blood and marrow transplantation compensation: Perspective in payer and provider relations

Abstract

The high cost per patient of hematopoietic cell transplantation (HCT) causes this therapy to be the focus of much controversy, given the competing societal demands to provide all possible therapy to preserve life while simultaneously limiting global health care expenditures. Treatment and eligibility decisions for HCT often are heavily scrutinized by both governmental and private payers and not simply determined by physicians, facility providers, and the patient. In an effort to control costs, payers have administrative infrastructure to review resource utilization by these patients. Additionally payers have developed payment methodologies, usually in the form of a case rate payment structure, that place facilities and physician providers of HCT at financial risk for adverse patient financial outcomes in an effort to promote optimal utilization and selection of patients for HCT. As providers enter into such financial risk arrangements with payers, the providers need to understand the true cost of care and be able to identify predictable and unpredictable outlier risks for the financial consequences of medical complications. HCT providers try to protect themselves from excessive financial risk by having different payment rates for different types of transplant, eg, autologous versus HLA or genotypically matched related versus HLA mismatched transplants. Because at certain times in the HCT process risk is more unpredictable, HCT providers require different payment system strategies for the different time periods of care such as evaluation, pre-transplant disease management, harvesting, and cell processing, as well as short- and long-term follow-up. Involvement by clinicians is essential for this process to be done well, especially given the rapid changes technological innovation brings to HCT. Constant dialogue and interaction between providers and payers on these difficult financial issues with HCT is essential to preserve patient access to this potentially lifesaving therapy.

Predictability of hematopoietic stem cell transplantation rates

“…However, HSCT is a high-cost procedure and can present a financial challenge for patients and health care systems in any country. [5][6][7] A correlation between the economic strength of individual countries and transplant rates, i.e. the number of transplants per number of inhabitants, was reported earlier by the European Group for Blood and Marrow Transplantation (EBMT).…”

National Institutes of Health Blood and Marrow Transplant Late Effects Initiative: The Healthcare Delivery Working Group Report

“…From a care delivery model and coverage perspective, the HCT episode can be divided into several phases. 15, 16 These include: (1) Evaluation phase, during which services required to assess and evaluate whether a patient, and in the case of allogeneic HCT the donor, are suitable for the transplantation procedure, (2) Pre-transplant care phase, that includes care provided from the time a patient is identified as a candidate for HCT and includes all related care until the initiation of conditioning regimen, (3) Transplant phase, which usually begins with the start of the conditioning regimen and can last 30 to 120 days post-transplant; this phase covers the stem cell infusion and the transplant hospitalization and often includes graft procurement, stem cell mobilization and processing, and (4) Followup care phase, that starts on completion of the transplant phase and can extend until the patient is discharged from routine transplant center follow-up care. Survivorship care is considered to be part of this last phase.…”

Hematopoietic stem cell transplants for chronic myeloid leukemia in Europe—Impact of cost considerations

“…[1][2][3][4] Still, HSCT is a high cost procedure and can present a financial challenge for patients and health-care systems in any country. [5][6][7] The impact of the economic strength of individual countries on HSCT has been reported earlier in detail by the European Group for Blood and Marrow Transplantation (EBMT). 8,9 It explained the differences in numbers of transplants between Eastern and Western European countries.…”