Many of us have never been touched by blood diseases. But tens of thousands of Americans diagnosed with leukemia and lymphoma each year are not so lucky. Those individuals—as well as their friends and loved ones—understand the ceaseless struggle with disease. They understand the heroism of survivors. And, with heavy hearts, they too often understand the sadness that accompanies loss of life.
Fortunately, there is more hope than ever for those facing blood disease diagnoses, and the primary reason is increased access to bone marrow and cord blood transplants. As a physician and the CEO of National Marrow Donor Program® (NMDP)/Be The Match®, I have witnessed great progress in the treatment of these diseases. Since our organization’s Be The Match Registry®was created by an act of Congress almost 30 years ago, our organization has facilitated more than 74,000 life-saving transplants. Thanks to the selflessness of donors in the United States and around the world our reach continues to grow; Be The Match now stands ready with more 27 million potential marrow donors and 680,000 cord blood units to deliver to patients in need.
Despite this, one of the greatest challenges facing the program today is ensuring that patients in need of a transplant can actually access one. That’s because flawed Medicare payment policies often hamper the true effectiveness of our nation’s transplantation infrastructure, putting vulnerable Americans with blood diseases at risk. While we have seen steps in the right direction in recent weeks, we have also been disappointed by the failure to act. And our nation’s policymakers must go even further to make critical changes in reimbursement if patients are to have the treatment they need.
Let’s start with the positives. The Centers for Medicare & Medicaid Services (CMS) recently unveiled its proposed hospital outpatient prospective payment system (HOPPS), which would increase Medicare reimbursement to partially address the deficits marrow and cord blood transplant centers incur in providing transplants in the outpatient setting.
I cannot emphasize enough how important these measures are and how vital it is that they are finalized later this year. That’s because—despite the fact that marrow transplants often represent a patient’s last hope—there is a chronic, almost unthinkable underfunding among bone marrow and cord blood transplant centers for Medicare beneficiaries seeking life-saving transplants. In fact, the current outpatient reimbursement formula does not even consider the cost of the marrow or cord blood acquisition in setting reimbursement. These costs alone can easily reach $45,000 or more.
The proposed HOPPS rule is a vital change that will provide a positive pathway to address underfunding. Among a number of changes, it reclassifies transplants in the outpatient setting, increases the payment rate nearly five-fold, and demands clear reporting for acquisition charges, including NMDP fees, human leukocyte antigen (HLA) typing, donor evaluation, collection of cells and other costs. The last is especially important as it will allow CMS to assess the costs and gauge how well the payment reflects the costs of providing these services.
But the improvements contained in the proposed outpatient rule will still significantly underfund the cost of a transplant in that setting. More important, the vast majority of allogeneic transplants are still done in the inpatient setting. Unfortunately, CMS released a final rule in early August for the inpatient prospective payment system (IPPS) that retains the current flawed reimbursement system without explanation for the omission of bone marrow and cord blood transplants reimbursed in the inpatient setting, which is where the vast majority of these transplants occur. Without resolution to this serious problem, patients 65 years and old are at risk for not being able to access life-saving transplants simply because of their age and type of insurance.
For those of us in healthcare, we understand that when the numbers do not add up, especially to this extent, limited access is the unfortunate result. But this just will not do—not when the stakes are this high. Not when transplant represents a patient’s last chance at survival.
I commend CMS on its work on the HOPPS Proposed Rule, and I urge the Agency not only to finalize the rule, but to also continue working on behalf of patients to eliminate barriers to transplant in the inpatient setting.
CMS needs to make robust changes to payments in all settings, as vast differences in the cost of care and rate of reimbursement persist. This also means addressing narrow networks and ensuring that patients can access transplant options in a timely, convenient and cost-effective manner. And it means reworking payment policies so older Americans will know whether or not Medicare will pay for their transplant.
Our nation’s transplant infrastructure has made incredible progress since 1987. Let’s keep moving forward, first with changes to the HOPPS, next with similar reforms in the inpatient setting, and then with more meaningful reforms in years to come.
The views expressed by authors are their own and not the views of The Hill.