1 / 32

Incorporating New Treatments & Technologies: Can Your Program Afford It? Can You Afford Not To?

Incorporating New Treatments & Technologies: Can Your Program Afford It? Can You Afford Not To?. Gary A. Goldstein Financial Coordinator Stanford Blood & Marrow Transplant Program. Case Studies. Kepivance (palifermin) Mozobil (plerixafor) Isolex (cell sorter) Defibrotide (anticoagulant).

johana
Download Presentation

Incorporating New Treatments & Technologies: Can Your Program Afford It? Can You Afford Not To?

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Incorporating New Treatments & Technologies: Can Your Program Afford It? Can You Afford Not To? Gary A. Goldstein Financial Coordinator Stanford Blood & Marrow Transplant Program

  2. Case Studies • Kepivance (palifermin) • Mozobil (plerixafor) • Isolex (cell sorter) • Defibrotide (anticoagulant)

  3. Payor Mix & Reimbursement Strategies • Commercial Insurance & HMO’s • Fee For Service • Case Rates • Medicare • Medicaid

  4. Commercial • Fee for service (% discount) • Case rate structure

  5. Medicare • Inpatient DRG • Outpatient Fee Schedule • Professional Fees

  6. Medicaid (Medi-Cal) • Inpatient per diems • Outpatient fee schedules • Professional Fees

  7. Transplant Case Rate Contracting • When does the case rate start? • Is mobilization included? • Is cell collection included? • How is the preparative regimen defined?

  8. Case #1 - Kepivance (palifermin) • Indicated “…to decrease the incidence and duration of severe oral mucositis in patients with hematologic malignancies receiving myelotoxic therapy requiring hematopoietic stem cell support.”

  9. Case #1 - Kepivance (cont) 3 doses should be administered prior to myelotoxic therapy, with the third dose 24 to 48 hours before myelotoxic therapy. 3 doses should be administered post myelotoxic therapy, starting after, but on the same day of hematopoietic stem cell infusion.

  10. Schema – Stanford Autologous HCT for Multiple Myeloma Day -7: Kepivance Day -6: Kepivance Day -5: Kepivance Day -4: BCNU Day -3: Rest Day -2: Melphalan Day -1: Rest

  11. Schema – Stanford Autologous HCT for Multiple Myeloma (cont) Day 0: Autologous hematopoietic cell infusion & palifermin Day +1: Palifermin Day +2: Palifermin

  12. Dollars & Cents • Cost, charge & reimbursement figures discussed today are generalizations and used for example purposes only. Actual figures may be proprietary. • Assumption – Cost of Kepivance may be offset by 1 or 2 less inpatient days due to mucositis.

  13. Reimbursement modeling – Commercial Insurance • Fee for service, Medicare & Medicaid • Is mark-up greater than or equal to discount provided? • Case rates • What is the case rate starting point? • Is Palifermin part of the preparative regimen? • When does the case rate end? • Are post-discharge days included in the case rate?

  14. Palifermin – The Stanford Experience • Drug was administered at the Transplant Center • Decision was made to consider this part of the transplant’s preparative regimen (therefore included in most case rates) • Minimal reduction in post-transplant inpatient LOS. • Patients had trouble coming to the transplant center several days early • Local housing, caregiver, & childcare were all issues

  15. Case #2 – Mozobil (plerixafor) Indicated “…in combination with G-CSF to mobilize hematopoietic stem cells to the peripheral blood for collection and subsequent autologous transplantation in patients with NHL and multiple myeloma.”

  16. Mozobil (plerixafor) • Once a patient is identified as a poor mobilizer, plerixafor injections are administered SQ/QD for 1 to 4 days, starting 11 hours prior to apheresis. • It is discontinued when adequate cells have been collected.

  17. Cost & Reimbursement Factors • Will patients self-inject or will patients receive the injection at the Transplant Center? • How soon can patients be identified as poor collectors (Mozobil candidates)? • Assumption – Cost of 1-2 doses equals that of a bone marrow harvest.

  18. Reimbursement modeling – Commercial Insurance • Fee for service (% discount) • Is mark-up greater than or equal to discount provided? • Case rates • Is mobilization included in the case rate? • Can patient get Mozobil through their prescription drug plan?

  19. Mozobil – The Stanford Experience • Drug is administered at the Transplant Center • Considered part of Mobilization phase (in some case rates, not in others) • Planned for 1-2 doses, but some patients have needed up to 4 injections. • All patients have collected adequate cell doses for transplant

  20. Mozobil – The Stanford Experience (cont) • All poor collectors have had higher than average charges. • Some Mozobil patients have been cost-neutral vs. those that went on to marrow harvest, but others had increased costs. • Over all, a slight negative impact on cost but clinically successful. The program is willing & able to accept additional costs in some cases.

  21. Case #3 – Isolex Cell Sorter • Used for positive cell selection • AKA Miltenyi device • No FDA approval in USA due to Baxter Isolex patent • FDA approval given to as an investigational device • Being used in haploidentical transplant trial

  22. Cost & Reimbursement Factors Significant cost factors include: • Initial capital investment for the device • Sorting kit (individual use) • Lab tech time

  23. Reimbursement modeling – Commercial Insurance • Charge is for the process (cell selection) and not for the device • Considered part of allogeneic cell collection • Related donor cell collection is usually within a case rate • Added charges but no cost offset

  24. Isolex – The Stanford Experience • Major capital outlay • Use cost is billed but doesn’t always increase revenue • Allows significant new protocols including allogeneic HCT using haploidentical donors • Increased patient numbers • Differentiates our program from the crowd • Could be a key to separate Graft vs Malignancy from GvHD • Dollar-based stop loss avoids major negative impact on bottom line

  25. Case #4 – Defibrotide • Anticoagulant used to treat or prevent a failure of normal blood flow (Veno-occlusive disease, VOD) in the liver of patients who have had HCT. • Used outside of the USA, but not FDA approved for open use within the USA. • FDA gave orphan drug designation in 2007. • Gentium is sponsoring research in the USA.

  26. Cost & Reimbursement Factors • Drug was provided at no cost by maker, but they will now start charging Transplant Centers. • Typically administered during inpatient hospital stays, often soon post-transplant. • Assumption – Cost will be significant, but VOD is a costly and deadly complication

  27. Reimbursement modeling – Commercial Insurance • Can a transplant provider charge for a non-FDA-approved medication? • Charges will almost always be within the BMT case rate. • Clinical need is tremendous. • Patients with VOD can turn into catastrophic cases that are major charge outliers.

  28. Defibrotide – The Stanford Experience • Clinically the drug appears very useful. • We are working with our Compliance Officers to see how this drug can be added to our Charge Master. • We must educate insurance companies in order to obtain authorizations when needed and avoid claim denials.

  29. Lessons learned • Medicare & Medical have rigid reimbursement schedules that may not cover costs. • Payor mix is extremely important. Nonmyeloablative allogeneic HCT has led to a significant increase in the percentage of Medicare patients. • Can Transplant Centers influence Medicare reimbursement? Yes, but it’s not easy.

  30. Commercial Ins Contract Structures • Case rate contracts are the norm • What’s in a case rate can vary widely • Auto HCT • Should mobilization be included? • Should G-CSF (& Mozobil) be included? • Should apheresis or BMT harvest be included? • How long post-transplant should the case rate go?

  31. Case rate contracting • Should a Transplant Center negotiate carve-outs for new drugs & technologies? • A well-designed case rate structure can help with adoption of new treatments/technologies • Dollar-based stop-loss?

  32. In Closing • Failure to adopt new treatments & technologies and take advantage of new medicines (including biopharmaceuticals) will drag your program down clinically. HCT must move forward. • Failure to adequately structure contracts can leave a center financially unprotected. Programs can’t make clinical strides while going broke. At least not for long.

More Related