Industry Voices—Medicare’s blood cancer patients need an assist from Congress

Every three minutes someone in the United States is diagnosed with a blood cancer like leukemia or lymphoma. For many of these patients, a bone marrow or cord blood transplant is their only hope for a cure.

Brian Lindberg

Seventy percent of patients do not have a fully matched donor in their family and rely on an unrelated donor to save their life. Yet, because of outdated Medicare payment policies, patients 65 and older who depend on Medicare face challenges accessing life-saving marrow and cord blood transplants. 

The Centers for Medicare & Medicaid Services (CMS) had an opportunity to implement common sense policies that provide adequate coverage for bone marrow and cord blood transplants. However, despite the growing use of transplant to cure blood cancers and other blood disorders, CMS continues to dramatically underfund the cost of cell acquisition and transplant for Medicare patients and the hospitals that perform transplants.  

The FY2019 Hospital Inpatient Prospective Payment System (IPPS) proposed rule represents obsolete Medicare payment policies that put blood cancer patients at risk of not being able to find hospitals to perform bone marrow and cord blood transplants, even though these transplants are the only curative therapy available to many patients.

Under current payment policy, inpatient reimbursement rates for solid organ transplants are treated differently than bone marrow and cord blood transplants. When a patient receives a kidney transplant, Medicare reimburses hospitals for the cost of the organ, as well as for the costs associated with identifying the donor, acquiring the organ, transporting the organ to the transplant center and performing the transplant surgery.

This payment structure protects patient access to life-saving treatments and covers considerable inpatient costs, making transplants financially sustainable. It’s a win-win.

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Regrettably, Medicare does not offer the same reimbursement structure for bone marrow and cord blood transplants. For patients with blood cancers, one cord blood unit can cost $60,000. Two cord blood units together, often needed for adults, can cost $100,000. Medicare only pays a reimbursement rate of approximately $70,000 for cord blood transplant, despite the actual costs incurred by the hospital. This rate does not fully account for the costs to acquire and transport the cells.

But it gets worse. Because the current reimbursement rate does not cover or barely covers the cost of cell acquisition, there are not sufficient dollars remaining to cover the cost of a patient’s typical 27-day post-transplant hospital stay. Faced with tremendous upfront costs and inadequate reimbursement rate, hospitals that choose to perform these life-saving transplants can lose tens of thousands of dollars when they preform transplants for Medicare patients.

As a result, many hospitals are forced to make the unthinkable choice between turning desperate patients away or incurring tremendous financial losses.

If CMS won’t do the right thing, then Congress must act. The Protect Access to Cellular Transplants (PACT) Act (H.R. 4215)—introduced by Representatives Erik Paulsen (R-MN), Ron Kind (D-WI), Doris Matsui (D-CA), and Gus Bilirakis (R-FL) —corrects this patient access issue once and for all. The PACT Act would give hope to the thousands of seniors and other Medicare patients with blood cancer by updating Medicare’s reimbursement rules so that bone marrow and cord blood transpalnts are reimbursed the same as solid organ transplants.

There is precedent for such action. Once policymakers recognized the negative impact not paying for solid organ acquisition costs had on access to transplants, CMS created rules to reimburse hospitals separately for solid organ acquisition costs and provide a separate Medical Severity Diagnosis Related Group (MS-DRG) payment to cover the actual transplant procedure and inpatient stay.

Because of this policy, millions of Americans have received life-saving solid organ transplants, allowing them to recover more quickly, spend more quality time with their families, and lead longer, fuller lives.

I urge Congress to pass H.R. 4215 to protect Medicare patient access to bone marrow and cord blood transplants.  

Brian Lindberg is the chief legal officer and general counsel and chief policy officer for the National Marrow Donor Program/Be The Match.