costs, charges and reimbursements in bmt: is there any good news for the future??? costs, charges...
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Costs, Charges and Reimbursements in BMT:
Is there any Good News for the Future???
John Kersey MD
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2009 ASBMT Corporate Council Meeting
• Status of Health Care Reform in the US– Will insurance coverage be mandatory??
• Massachusetts “Romneycare” as model
– Insurance Exchanges?– Increase in government as payor (Medicaid and
Medicare)?– What about reimbursement limits?
• My 2009 predictions vs reality
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2011 Phoenix Meeting
• Reimbursements– Changing Payer Mix– Reimbursements for Clinical research
• Dr. Keith Sullivan
• Costs– Current Inpatient Costs
• How will we reduce costs in the face of decreasing reimbursements??
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Payer Mix in Minnesota BMT Program in 2010
Medicaid Medicare Non-government
Pediatric 20% 2% 78%, largest Blue Cross
Adult 16% 16% 68%, largest Optum/URN
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Increase in Medicaid patients in Minnesota BMT Program in 2010
• We had 34 vs 21 average in previous years–A significant increase compared to the
2007-2009 period
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Government Payors
• Medicare, Medicaid and other government-sponsored programs – Pay a predetermined, fixed rate (e.g. DRG) for
inpatient services and a fee schedule for outpatient and physician services
– Payment rates are usually low and often below cost
– EXPECTATION FOR GOVERNMENT PROGRAMS (ESPECIALLY MEDICAID) TO INCREASE UNDER AFFORDABLE HEALTH CARE ACT Of 2010(OBAMACARE)
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Reimbursement Issues
• Medicaid cases are increasing relative to commercial payers in part due to unemployment and the economy
• Medicaid reimbursements are as low as 10% in some states
• Network participation of BMT programs increases reimbursements
• National organizations (such as OptumHealth and Life link) are increasing used by insurers for payment and eligibility issues
_____________________• Payers have difficulty risk-adjusting reimbursements
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BMT Programs have relied on Commercial Payers to Maintain Margins
• Blue Cross, Aetna and other contracted payers– Designated transplant centers networks in their
network– Case rates and days covered in the global period are
different in every contract– BMT centers must rely on “outlier reimbursements”
maintain margins
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When reimbursements fall, how do we reduce costs to maintain margins?
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Minnesota Study of Cost of Adult BMT
Majhail/ Weisdorf Biol.Blood Marrow Transplant 2009:15,84
• Consecutive adult (≥18 years) allogeneic BMT recipients (2004-2006)
–294 patients
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Four groups of patients in Minnesota Cost Study
• Myeloablative Matched Related Donors (MA MRD• Myeloablative Umbilical Cord Blood (MA UCB)• Non-myeloablative Matched Related Donors (NMA
MRD)• Non-myeloablative Umbilical Cord Blood (NMA
UCB)
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Multivariate Analysis for SurvivalVariablesa Relative-risk
(95% confidence intervals)
P-value
Transplant type
MA MRD 1.0 0.59
MA UCB 1.1 (0.7-1.6) 0.85
NMA MRD 0.8 (0.5-1.2) 0.21
NMA UCB 1.0 (0.6-1.5) 0.98
Graft failure
No 1.0 <0.001
Yes 3.6 (2.2-5.9)
Dialysis
No 1.0 0.001
Yes 2.1 (1.4-3.3)
Mechanical ventilation
No 1.0 <0.001
Yes 4.4 (3.1-6.2)aOther variables considered in the model included age at transplantation, gender, KPS score, disease risk, history of
previous transplant, CMV status, HLA match, graft source, acute GVHD and occurrence of hepatic VOD
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Methods: Cost Information
• Obtained cost info from day -30 through day +100– Both direct and indirect costs– Cost categories:
• Graft acquisition• Laboratory services• Radiological investigations• Pharmacy services• Room and board• Blood components• Other services
– Information not available for:• Physician charges• Patient intangible costs
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Costs Higher in Myeloablative and MRD cases
• Total costs by conditioning (first 100 days)– MA HCT = $137,112– NMA HCT = $84,824– P<0.001
• Total costs by graft source– UCB HCT = $137,564– MRD HCT = $83,583– P<0.001
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Cost PredictorsVariablesa,b Relative-risk
(95% confidence intervals)
P-value
Transplant type MA MRD 1.0
MA UCB 1.3 (1.1-1.5) 0.05
NMA MRD 1.0 (0.9-1.2) 0.82
NMA UCB 1.0 (0.8-1.2) 0.96
Graft failure No 1.0
Yes 1.8 (1.7-1.9) <0.001
Dialysis No 1.0
Yes 1.3 (1.1-1.5) 0.05
Mechanical ventilation
No 1.0
Yes 1.3 (1.2-1.4) 0.004
Hospital stay, tertilesc <32 days 1.0
32-48 days 1.0 (0.8-1.2) 0.98
>48 days 2.1 (1.9-2.3) <0.001a Other variables considered: age, KPS score, disease risk, previous transplant, CMV status,
acute GVHD, hepatic VOD and total medical encounters in days (by tertiles)b Excluding costs of graft acquisitionc Total hospital stay in first 100 days post-transplantation
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0
250
500
750
1000
1250
1500
1750
2000
2250
MA MRD MA UCB NMA MRD NMA UCB
Medi
an C
ost
Per
Day
Sur
vive
d, $
Other
Radiology
Blood components
Laboratory
Pharmacy
Room/Board
33%
32%
4%11%
18%
2%
31%
30%
5%
14%
17%
2%
40%
27%
6%
13%
12%
3%
38%
36%
11%
3% 7%5%
$1023
$2082
$612
$1156
Costs Per Day Survived
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Conclusions from Minnesota Study
• Umbilical Cord Blood transplants are available to patients lacking a matched related donor.
– However, costs are higher than matched related donor transplants (both myeloablative and nonmyeloablative)
• Severe post-transplant complications and prolonged hospital stay are critical determinants of cost
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What’s Next? How will we reduce costs?
• Standardization of protocols is likely to be the most important–Avoid non-proven labs and
radiology–Reduce pharmacy, hospital stay–More research protocols designed
to reduce complications
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Costs, Charges and Reimbursements in BMT:
Is there some good news for the future???
Yes, our field has high costs but costs will be (hopefully rationally) reduced
based on: a) standardized protocols b) research progress