Perhaps the only thing worse than the fear of learning you have cancer is the frustration upon finding out that a life-saving treatment exists – but is completely out of reach.
It’s a harsh reality that has haunted some Medicare beneficiaries with blood cancers, for whom bone marrow, peripheral blood stem cell or cord blood transplant (cellular transplants) is the only treatment option. These transplants are able to effectively treat, and potentially cure, blood cancers like leukemia, myelodysplastic syndromes and lymphomas.
{mosads}Although these transplants are standard medical practice and routinely covered and reimbursed by commercial insurers, some Medicare beneficiaries have found them difficult – if not impossible – to access. That’s because, unlike solid organ transplants, current Medicare payment policy woefully fails to reimburse hospitals for the costs associated with performing cellular transplants. As a result, many hospitals have been forced to limit this care for Medicare beneficiaries – many of whom have no other treatment options.
No cancer patient should have to face the prospect of foregoing life-saving care – or struggling to finance it out-of-pocket – simply because Medicare policies have not kept pace with today’s treatment options.
Fortunately, lawmakers are taking long-awaited steps to bring reimbursement for cellular transplants up to where it should be. Reps. Doris Matsui (D-Calif.), Ron Kind (D-Wis.), Erik Paulsen (R-Minn.) and Gus Bilirakis (R-Fla.) recently introduced the Protect Access to Cellular Transplant (PACT) Act (H.R. 4215), which would allow Medicare to reimburse hospitals separately for the cost of acquiring donor cells and performing the transplant, and the lengthy inpatient stay. This bipartisan bill ensures these life-saving transplants are reimbursed just as Medicare reimburses solid organ acquisitions and transplants, like kidneys.
It’s a policy that makes sense and one that has been the standard for solid organ transplants, which are reimbursed on a reasonable cost basis for the organ acquisition costs and a separate Medical Severity Diagnosis Related Group (MS-DRG) payment for the transplant procedure and inpatient hospital stay. The Centers for Medicare & Medicaid Services (CMS) established this policy decades ago to ensure that reimbursement rates did not disincentivize hospitals from providing transplants. The same logic should apply to cellular transplants.
As it currently stands, hospitals that perform cellular transplants lose tens of thousands of dollars on every Medicare patient they treat. Because Medicare uses a single MS-DRG to reimburse transplant centers for transplant – which includes both hospital care and the cost of cell acquisition – it’s impossible for hospitals to cover their costs. Even though the current Medicare inpatient base reimbursement rate is $62,245, the average cost of cell acquisition can range between $40,000 and $60,000. Transplants not only include the cost of acquiring the cells, but typically a 20 to 30 day hospital stay, medically qualifying the selected donor, testing and typing, infectious disease screening and managing the complex donation process from start to finish.
Cellular transplants have been a game changer in cancer care for Medicare beneficiaries, and it’s crucial that payment policy is updated to support it. Before scientific advances made these treatments possible, the standard of care for patients with many blood cancers and other blood disorders was either chemotherapy or supportive therapy only.
The PACT Act is an important step in making sure Medicare beneficiaries can fight their disease – without fear of personal financial ruin.
I urge lawmakers in Congress to support this important legislation so that Medicare beneficiaries diagnosed with blood cancers have their best chance for survival.
Randal Mills, Ph.D., is the CEO of National Marrow Donor Program/Be The Match®.