A Word from President Krishna Komanduri, MD
Dear colleagues,
As I write this, midsummer is upon us, with only another four weeks or so before our children’s summer vacations come to a close. In Miami, the relative heating of the Florida peninsula and the resulting differential of land and ocean temperatures in the afternoons bring offshore breezes and towering cumulonimbus clouds (photo), with thunderclaps punctuating our afternoons. The Atlantic Ocean and Caribbean Sea also warm, and we learn to keep watch for the possibility of tropical storms. As Andrew and Katrina taught all of us, the underestimation of threats can have serious, if not deadly, consequences. Fortunately, proper preparation for hurricanes can limit the destruction of homes and property, and avert most loss of life. A few weeks ago, with my son’s Boy Scout troop, I had the privilege of visiting the National Hurricane Center (NHC) in Miami. I learned how the NHC identifies threats, disseminates watches (and warnings) and facilitates community action to minimize threats to life and property.
Florida Storm Clouds from Airplane, Krishna Komanduri, MD
Like the NHC, the ASBMT must also monitor environmental changes that can threaten our academic centers, clinical programs, and the patients we serve. This past week, the US Senate debated how to repeal the Affordable Care Act (ACA) with the goal of reforming our health care system without success. We are glad the repeal did not move forward, as all estimates suggest it would have eliminated health care access for millions of Americans. The ASBMT Board has taken a principled stand to oppose the reform proposals to date, given their direct threats to access to hematopoietic transplantation and cellular therapies. In addition, the potential loss of protections for pre-existing conditions is a critical concern for our patients. Separately, the ASBMT has strongly opposed the first draft of the current administration’s budget proposal, which threatens to seriously damage the NIH. Despite temporary reprieve from these perils, the turbulence will remain—health care costs are still rising at an unsustainable rate and the ACA as it currently stands does not address this issue.
While these dangers are clear and visible, less obvious threats also loom. A major issue facing the financial health of our centers is an increase in the proportion of our patients insured by Medicare. The simple explanation for this fact relates to our collective scientific and clinical success in developing safer and more efficacious approaches to apply cellular therapies including transplantation to Medicare-aged patients. Approximately 15% of the US population (20% in Florida) is over the age of 65, with Medicare covering over 16% of the US population in 2015. Our younger members will not remember a time when allogeneic and even autologous transplants were confined to those under 60. It is my belief that the dramatic expansion of transplantation for our seniors, based on strong clinical evidence, is one of the best illustrations of the success and impact of our members and programs.
While we should celebrate the ability to perform transplants in the very patients with the highest incidence of diseases we treat, it is critical our members recognize that current reimbursement for Medicare patients inadequately covers costs of providing transplant care. Furthermore, despite the existing or impending expansion of allogeneic transplant coverage to include MDS, sickle cell disease, myelofibrosis and myeloma, transplant indications do not yet extend to lymphoma, despite abundant evidence for the curative potential of allogeneic SCT. Relative to solid organ transplantation, rates of reimbursement for allogeneic hematopoietic transplantation remain low, despite typically longer hospital stays. Moreover, the significant costs of allograft procurement (typically $30-50,000 in the unrelated donor setting; higher when two cord blood units are used) must be absorbed by centers in the Medicare transplant episode payment for alloSCT. In contrast, similarly high solid organ procurement costs are separately reimbursed. While the impact of these inequities has historically been modest, due to the relative infrequency of allogeneic transplantation in Medicare-aged patients, these issues now loom large as all of us (appropriately) expand access to a growing population of seniors. The NMD is advancing legislation to change the way acquisition costs are reimbursed, an initiative we will support during our visits to Capitol Hill in September.
A critical part of our increasingly improved response to hurricanes has been an investment in predictive modeling that allows us to assess risks and potential storm impacts. To similarly allow us to monitor and react to our environmental risks, the ASBMT decided to establish a formal health policy effort, independent of our partners (e.g., the NMDP, which has been a strong and wise advocate in this space). The addition of our first health policy staff member has increased our ability to respond to critical advocacy needs. Just this past week, at the invitation of ASH and ASCO, Stephanie Farnia and I met with medical directors of Medicare Administrative Contractors to discuss issues of access, including potential approaches to expand access to lymphoma patients. We also discussed the importance of reimbursement for donor grafts, an issue Dr. Jim Gajewski and I directly raised with US Senate Finance committee staffers on the same trip. Our team worked together to coordinate a response to the latest proposed Medicare inpatient rule changes, yielding a 12-page response that covered financial issues critical for our Society ranging from potentially decreased inpatient reimbursement to impacts on emerging T cell immunotherapies. We should know by early August if these efforts were successful or if additional actions will be needed.
Just as storm prediction and preparation has dramatically improved, I am confident that these initiatives will improve our ability to detect threats to patient access, and have already improved our ability to communicate these issues to you and to facilitate your actions. It will be critical moving forward to further educate members so that we have more individuals who can be informed advocates at the local and national level. We also need to develop processes by which our members and our patients can be alerted to respond directly to their elected representatives on issues we identify to be critical for our ongoing success. I look forward to directly hearing from all of you who would like to learn more.
Until next month, be well and please contact Stephanie Farnia, Ken Luurs or me with questions or if you would like to be engaged in these efforts.
All the best,
Krishna
Read the entire August 2017 ASBMT eNews here.