ORLANDO--An ongoing debate within the health care industry is
focusing on whether bone marrow and peripheral blood stem cell
transplants (BMT/PBSCT) should be regionalized in academic centers or
diffused to community hospitals.
At a transplant seminar, sponsored by IBC/Infoline, two consultants
specializing in oncology consulting and program development, said
that academic transplant centers must make their programs more
efficient to compete with community centers.
Ultimately, however, they recommend cooperation between academic and
community centers, with the goal of forging partnerships for
performing transplant procedures.
Thomas A. Paivanas, MHSA, founding director of Thomas A. Paivanas
& Associates, Annandale, Virginia, and Patti Jamieson, MSSW, MBA,
administrator of the Oncology Service Line at the University of
Illinoiss Chicago Medical Center, said that despite much
interest, relatively few community centers have been able to develop
high-volume transplant programs to date.
"Of more than 500 Association of Community Cancer Centers (ACCC)
member institutions, 115 (23%) report having BMT programs, but only
16% have annual volumes of 50 patients or more, 45% have annual
volumes of fewer than 25 patients, and nearly 30% report no volume at
all!" Mr. Paivanas said.
His firm has conducted a number of oncology-specific surveys, one of
which includes the BMT/PBSCT industry. This phone survey of academic
and community-based BMT/PBSCT programs with volumes greater than 70
patients per year solicited opinions and information regarding
operations, changing clinical indications, and the fiscal impact of
managed care contracting on BMT/PBSCT.
The survey showed an average global price for autologous transplants
of $65,000 to $90,000 and for allogeneic transplants, $115,000 to
$125,000. The amount allotted for professional services ranged from
about 10% to 15% of the global price. For autologous transplants, the
average length of stay is 8 to 20 days and for allogeneic
transplants, 18 to 45 days, the survey found.
The ratio of autologous to allogeneic transplants averaged 70 to 30.
"Generally, more autologous bone marrow transplants are done in
the community setting and more allogeneic transplants are done in an
academic setting," Ms. Jamieson said, "but we see that
changing in the future."
In global contracting, some payers have requested that services be
included from pretreatment to 360 days post-transplant. However, the
study suggests that those clinically and financially viable programs
have successfully negotiated more realistic time frames; defined
services that are included and excluded; and installed stop loss and
outlier provisions. Additionally, the consultants said, retaining the
option to re-negotiate and the ability to effect continuous contract
management are critical for leveling the managed care playing field.
Academic bone marrow transplant programs did not fare well overall in
the survey. They were characterized by higher costs and prices and
higher inpatient average length of stay.
"These programs often do not do a good job of integrating
clinical control and financial revenue," the consultants said.
"They may suffer from disjointed contracting; an unclear mission
for oncology services; a mosaic of reimbursement and
compensation arrangements; an adversarial decision-making process
exacerbated by personalities and politics; and organizational
paralysis preventing the development or evolution of efficient
They said that academic institutions need to learn the "tricks
of the trade" from their private sector colleagues, particularly
in terms of contracting and patient management. Managed care contract
negotiations are particularly challenging, as each contract is
different, all are complicated, and programs may take significant
financial risk, often without accurate clinical and accounting
"The administrator must have superlative talent and be truly
empowered in order to work effectively with the program, referring
physicians, and payer representatives," Mr. Paivanas said.
Competition for transplant services will increase in the future, and
forming partnerships is almost always preferable to competing, they
said, especially with community programs. They cited the success of
the H. Lee Moffitt Cancer Center in combining the best of
community-based oncology care with the academic resources of its
affiliate, the University of South Florida College of Medicine.
They noted a trend toward payers approaching academic institutions
directly to discuss partnership arrangements. [See Oncology News
International, July, 1998,] for a description of a community outreach
program involving the Hutchinson Cancer Research Center and 16
community transplant centers.]
"However, you have to successfully partner internally before you
can successfully partner with anyone externally," Mr. Paivanas
cautioned. "And dont compete exclusively on price.
Instead, focus on setting the standard of care in your region."