Keys to Success of BMT Programs in Managed Care Era

Although creating and sustaining a successful bone marrow transplant (BMT) program poses tricky challenges in today’s rapidly evolving managed care environment, it can be done, says Albert B. Einstein, Jr., MD, associate director for clinical affairs of the H. Lee Moffitt Cancer Center and Research Institute in Tampa, Florida. But “the window of opportunity for establishing major new BMT programs” will close within the next 2 years, added Thomas A. Paivanas, mhsa, director of integrated delivery systems at the consulting division on ELM Services, Inc, in Rockville, Maryland. Institutions hoping to set up BMT centers must therefore move promptly and carefully and “be careful of their hopes and aspirations,” he said during a joint presentation at the 24th Annual National Meeting of the Association of Community Cancer Centers.

Blueprint for Building Effective Relationships With Managed Care
Drawing on Moffitt’s experience, Einstein outlined what he called a workable strategy for building effective relationships with managed care organizations, which pay for many of the 160 BMTs done at Moffitt each year. Several years ago, he said, “we realized that our volumes were dropping off” as local competition for transplant patients increased. At that time, antagonism was the keynote of Moffitt’s approach to managed care. Increasing and stabilizing the center’s transplant volume required changing that attitude and working to educate managed care companies about the features that make transplantation “a unique medical procedure” and Moffitt an appropriate place to have it done.

“Small and medium companies were ignorant about transplants,” he said, and big companies “have their own ideas” about transplanting that “may not fit” with a center’s procedures and philosophy. The large companies want “centers with high quality and high volume” that are willing to “trade price for volume.” This encourages the large companies to deal with transplantation at “the national level,” designating a small number of regional centers to which they send patients from a wide area. At one time, for example, all of Florida’s managed care transplant patients went out of state for their procedures.

Cooperation of Medical Staff Is Crucial
This trend toward regionalization poses a major threat to many existing transplant centers, Paivanas said. A program’s prospects under managed care “start, operate, and conclude” with the cooperation of its medical staff. “National contracts are very sophisticated” and require the active involvement of a center’s physicians if the goals of achieving quality and cost containment are both to be met. “Medical staff need to be aware of contract negotiations,” Einstein agreed, because the details of the contract control what costs and procedures will be reimbursed.

Furthermore, only physicians can work to develop new treatment regimens, Einstein noted, which are needed because today’s “standard of care is not good enough” and “working off protocols [specified by pay0rs] is not good.” In addition, both speakers agreed that physicians must take the lead in educating company officials about what makes transplantation so variable and ambulatory management so difficult.

Negotiating Strategies
In working out a deal with a managed care organization, “everything is negotiable,” Paivanas said, but to negotiate effectively, Einstein added, “you have to know your costs.” And given how greatly transplant costs vary from patient to patient, centers should work to keep as many items as possible outside of any global fees in order to reduce their financial risk. Stop-loss mechanisms are another very important means of limiting risk, Paivanas said. From a provider’s point of view, he added, “capitating for oncology is very difficult.”

Still, he noted, managed care companies tend not to refuse requests to allow BMTs, especially those involving breast cancer, because they fear adverse publicity. But they may insist on sending to distant regional centers patients who prefer to have their transplants close to home. To keep such individuals from having to travel, local centers can sometimes convince a managed care company to allow them to perform the transplant for the same rate that the regional center would receive.